Menopause

1. MENOPAUSE & HRT
Nicola Stewart
28/02/2018

2. Physiology & Clinical Features
 1.5 million oocytes at birth.
 1/3rd lost by menarche.
 Peri-menopause – increased anovulatory cycles.
 Clinical Features: (affects 2/3rd woman)
 Menstrual irregularity
 Vasomotor
 Musculoskeletal
 Psychological
 Urogenital
 Cardiovascular
 Osteoporosis
 Breast disease

3. Case Study 1
 43 year old
 Mirena coil for 2 years
 Presenting with:
 Inter menstrual and post coital bleeding
 Increased anxiety, snapping
 No hot flushes or night sweats, not low in mood, no
change to libido
 No FH of early menopause
 Asking if she is peri-menopausal?
 Asking to have a blood test?

4. Diagnosis
 Diagnosis should be based on clinical symptoms if
>45
 Perimenopause – vasomotor Sx & irregular periods
 Menopause – no period for 12m & not taking contraception
(Sx if no uterus)
 Consider FSH if…
 >45 years with atypical symptoms
 40-45 years with Sx and change in periods
 <45 years and suspecting premature menopause
 Laboratory results
 Consistently raised FSH >30IU/l.
 Raised LH
 Low serum oestrdiol.

5. Assessment of Menopause
 Assess symptoms and their severity
 Assess risk of cardiovascular disease (Qrisk)
 Assess risk of osteoporosis
 Discuss her expectations
 Only carry out investigations if…
 Sudden change in menstrual pattern (IMB, post coital)
 Personal or FH of DVT
 High risk of breast cancer
 Evidence of arterial of other gynaecological disease

6. Case Study 2
 34 year old
 Has not had a period for 7 months
 FH of premature menopause
 Nil other symptoms
 Asking if she should be tested for this?
 Asking what management might be required?

7. Premature Menopause
 Menopause <40 years (1%).
 Risk of osteoporosis and IHD
 Diagnosis – FSH >30 with raised LH and low
oestrogen on two occasions 4-6 weeks apart
 Management
 Should have hormonal treatment with HRT or
combined hormonal contraceptive until age of
natural menopause & 5-10 yrs after
 HRT can benefit BP/ CVS risks, but both HRT and
combined contraceptive offer bone protection.
 HRT not a contraceptive

8. Case Study 3
 52 year old
 Suffering from hot flushes, night sweats and loss of
libido
 Last period was 8 months ago
 Would like to discuss HRT.
 Benefits and risks?
 If there are things she can also adjust herself?
 What she should start?

9. HRT
 Indications
 Relief of vasomotor or other menopausal symptoms
 Prevention of osteoporosis
 Premature ovarian failure
 Contraindications
 Pregnancy, undiagnosed abnormal PV bleeding
 Active thromboembolic disorder or MI
 Breast disease or endometrial cancer
 Active liver disease

10. HRT
 Modifiable lifestyle factors
 Healthy balanced diet
 Calcium supplements
 Smoking, alcohol and caffeine
 Optimise management of their co-morbidities
 Benefits
 Reduce vasomotor symptoms
 Improved sleep, joint pain, quality of life
 Reduced psychological symptoms
 Reduce vaginal dryness and improve sexual function
 Improve bone mineral density

11. Counselling Points
 Irregular bleeding is common in first 3-6
months
 (Bleeding > 6mnths/ after amenorrhoea requires Ix)
 Importance of adherence with treatment
 Remind peri-menopausal women that HRT is
not a contraceptive
 Can stop contraception at 1 year after period if >50
yrs and 2 years if <50yrs or 56yrs
 No evidence that HRT causes weight gain

12. Risks (over 5 years)
 Breast cancer
 <50yrs on HRT no extra risk
 Background risk is 15/1000. 2-6/1000 extra cases
 Ovarian cancer
 Background risk is 2/1000. <1 extra case over 5 yrs
 Endometrial cancer
 Combined HRT protects endometrium
 B/G risk is 2/1000. 4 extra cases over 5 yrs (oestrogen only)
 Venous thromboembolism
 Background risk is 5/1000. 2 extra cases over 5 yrs
 Cardiovascular disease
 No increased risks

13. Risks (in perspective)
 Breast cancer
 <>2-3 units alcohol per day increases risk by 1.5x
 Post menopausal obesity increases risk by 1.6x
 First pregnancy >30 years increases risk by 1.9x
 5 years of HRT increases risk by 1.35x

14. Management Algorithm
 HRT Guidance and Treatment Pathway

15. Case Study 4
 54 yr old has read the PIL on HRT and
decided that she does not want to accept the
potential risks.
 Suffers from hot flushes and would like to know
what she can try?
 Finding sex uncomfortable, would like to know what
she can try?

16. Alternative Treatments
 Vasomotor symptoms
 Fluoxetine, citalopram, venlafaxine or clonidine
 Vaginal dryness
 Vaginal lubricants
 Sexual dysfunction
 Seek specialist advice re; testosterone
 Psychological symptoms
 CBT, antidepressants
 Tibolone
 Beta blockers, gabapentin, complementary
therapies

17. Case Study 5
 57 year old
 Menopausal symptoms
 LMP: 2 yrs ago.
 PMH: DVT following laparotomy.
 Asking if she can start HRT?

18. Management of Co-Morbidities
 With or high risk of breast cancer
 Non-hormonal and non-pharmacological treatment
 St Johns Wart (Tamoxifen)
 Refer for further specialist input
 Risk of VTE
 Transdermal rather than oral
 Refer to haematologist if high risk
 Cardiovascular disease
 Can use HRT. Manage risk factors
 Type 2 diabetes
 Can use HRT. No effect of glucose control

19. Case Study 6
 51 year old
 Presenting with mastodynia (worse over 3-4
months) and symptoms of hot flushes, night sweats
and tearfulness
 Estradiol for 15 months. Mirena for 3 years.
 No periods
 Has tried St Johns Wort and primrose oil
 What options would you give her?

20. Poor Symptom Control
 Check compliance and allow time
 Usually 3 months before making any changes
 Poor patch adhesion or skin irritation
 Change brand
 Inadequate oestrogen dose
 Increase dose or change route
 Unrealistic expectations
 Counsel
 Drug interactions

21. Side Effects

22. When to Refer
 Persistent side effects
 Difficulty in diagnosis
 Loss of libido causing significant distress
 Premature menopause
 Patient request
 Difficulty in knowing when to stop HRT
 (usually consider at 5 yrs as they enter
menopause)
 Complex medical history

23. Review
 Follow up at 3 months
 Then annual review
 Effectiveness, s/e, dose, route, pros and cons
 BP, cervical and breast screening, osteoporosis
 Roughly for around 5 years after onset of
symptoms
 There is no mandatory limitations
 HRT should be withdrawn slowly