Menopause occurs when a woman's ovaries stop releasing eggs and estrogen levels decline. Common symptoms include hot flashes, night sweats, and mood changes. Hormone replacement therapy (HRT) can effectively treat many menopausal symptoms but also has some risks, including a small increased risk of blood clots, heart disease, and breast cancer. It is important for clinicians to evaluate each woman's individual risks and benefits when considering HRT.
Menopause is a biological stage in a woman's life that occurs when she stops menstruating and reaches the end of her natural reproductive life. This is not usually abrupt, but a gradual process during which women experience perimenopause before reaching post-menopause”
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
causes ,aetiology of pain during menstrual cycle and treatment.
causes and treatment for anxiety before menstrual cycle
non pharmacological treatment of anxiety before periods
different gynaecological problems
pscycological aspects of the dysmenorrhoea
pharmacological management of dysmenorrhoea
Case Based Panel Discussion on Menopausal healthSujoy Dasgupta
Dr Sujoy Dasgupta moderated a panel on "Case Based Panel Discussion on Menopausal health" in the CME on Menopausal Health, organized by the AICC RCOG (All India Coordinating Committee) East Zone, held in Kolkata in March, 2022
Menopause is a biological stage in a woman's life that occurs when she stops menstruating and reaches the end of her natural reproductive life. This is not usually abrupt, but a gradual process during which women experience perimenopause before reaching post-menopause”
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
causes ,aetiology of pain during menstrual cycle and treatment.
causes and treatment for anxiety before menstrual cycle
non pharmacological treatment of anxiety before periods
different gynaecological problems
pscycological aspects of the dysmenorrhoea
pharmacological management of dysmenorrhoea
Case Based Panel Discussion on Menopausal healthSujoy Dasgupta
Dr Sujoy Dasgupta moderated a panel on "Case Based Panel Discussion on Menopausal health" in the CME on Menopausal Health, organized by the AICC RCOG (All India Coordinating Committee) East Zone, held in Kolkata in March, 2022
There are a lot of misconceptions out there when it comes to PCOS. People often make assumptions and it can be hard to work out fact from fiction. Here are some important points that every Doctor should be aware of.
Menopause is signaled by 12 months since last menstruation.
Common symptoms include hot flashes and vaginal dryness. There may also be sleep disturbances. The combination of these symptoms can cause anxiety or depression.
Menopause is a natural process with treatments that focus on symptomatic relief. Vaginal dryness is treated with topical lubricants or estrogen. Medications can reduce the severity and frequency of hot flushes. In special circumstances, oral hormone therapy may be used.
The menopause may be
Natural or induced
Natural menopause - the permanent cessation of menstruation for 12 months caused by failure of ovarian function with elevated gonadotropins (FSH, LH).
Average is 51 years
@women health , #menopause ,#DEFINITION OF MENOPAUSE
● @STAGES OF MENOPAUSE
● #MENOPAUSAL SYMPTOMS
● @TREATMENT OPTIONS
12 months of amenorrhea
without any other obvious
pathological cause or
physiological cause.
Why menopause
occurs in old women?
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. How to diagnose Menopause?
In a woman > 45 years of age, diagnose
• Perimenopause
• If she is having vasomotor symptoms and irregular periods
• Menopause (with uterus)
• If her last menstrual period was >12 months ago and she is not
using hormonal contraception
• Menopause (without uterus)
• If she has climacteric symptoms
NICE guideline : Menopause: diagnosis and management, 2015
3. FSH measurement
Consider using FSH to diagnose menopause only in:
• Women aged 40-45 years with menopausal symptoms +
change in menstrual cycle
• Women aged <40 years in whom menopause is suspected
• FSH > 35miu/ml in 2 separate occasions 6 weeks apart
NICE guideline : Menopause: diagnosis and management, 2015
4.
5. Average age of Menopause
• Mean age of menopause in Malaysia = 50.7 years
• Average life expectancy of Malaysian women = 74 years
First Consensus Meeting on Menopause in the East Asian Region – Menopause
and HRT in Malaysia
6. Physiology of Menopause
• Menopause occurs when the ovary runs out of eggs
• This results in reduced estradiol (E2) and increased FSH
• Therefore, symptoms of menopause relate to estrogen
deficiency
During perimenopause,
• There can be wide variation in hormone levels
• Women can present with a mixture of both estrogen excess
and estrogen deficiency symptoms
• Symptoms of estrogen excess include breast tenderness,
menorrhagia, migraine, nausea, shorter cycle length, shorter
follicular phase
7. Climacteric Symptoms
MUM’S Vagina
• Musculoskeletal symptoms
• Joint and muscle pain
• Urogenital symptoms
• Vaginal dryness / itching, dyspareunia, urinary frequency/urgency
• Mood changes
• Irritability, depressive sx, sleep disturbance, reduced
concentration
• Sexual difficulties
• Loss of libido
• Vasomotor symptoms
• Hot flushes, night sweats
8. Symptom Prevalence
In the US
• African-American > Caucasian > Chinese > Japanese
In the UK
• 1 in 4 experience severe VMS
• 1 in 3 experience severe psychological symptoms (anxiety,
depression)
• 1 in 2 experience moderate to severe symptoms of sleep
disturbance, joint pain or headache
• 1 in 4 have sexual problems
F. M. Jane & S.R. Davis (2014) A Practitioner’s Toolkit for Managing the
Menopause, Climacteric 17:5, 564-579, DOI: 10.3109/13697137.2014.929651
9. Symptom Prevalence
In Malaysia
• 52% felt that symptoms affected their quality of life
• Only 2.7% reported severe symptoms
Bahiyah Abdullah et al, Prevalence of menopausal symptoms, its effect to quality of life
among Malaysian women and their treatment seeking behaviour, Med J Malaysia Vol 72
Symptom Prevalence
Joint pains / Muscular discomfort 24%
Fatigue / Irritabiliry 60%
VSM symptoms 55%
Depression / Anxiety 45%
Vaginal dryness 41%
Sexual problems 35%
10. Symptom Duration
• There is no age limit at which menopausal symptoms cease
• 10% of women have VMS 10 years after menopause
• 16% of 85 year olds continue to experience VMS
F. M. Jane & S.R. Davis (2014) A Practitioner’s Toolkit for Managing the
Menopause, Climacteric 17:5, 564-579, DOI: 10.3109/13697137.2014.929651
11. Other Health Consequences of
Menopause
Metabolic
• Central abdominal fat deposition
• Insulin resistance / T2DM
Cardiovascular
• Impaired endothelial function
• Increased cholesterol
Skeletal
• Accelerated bone loss
• Increased fracture risk
12. Neurological
• ? Cognitive performance decline
Urogenital
• Atrophic vaginitis
• Urinary tract – frequency, cystitis, urge incontinence, dysuria
Cancer
• Breast / cervical / colon
Other Health Consequences of
Menopause
13. Indications for starting HRT
• Management of menopausal symptoms
• VSM symptoms
• Mood disorders
• Altered sexual function
• Urogenital atrophy
• Prevention of Osteoporosis
14. Indications for Treatment
Complaint 1st line treatment 2nd line treatment
Vasomotor symptoms HRT SSRI, SNRI, Clonidine
Black cohosh
Low mood HRT CBT
SNRI/SSRI only for
diagnosed depression
Reduced libido HRT / Tibolone Add on Testosterone
Urogenital atrophy Vaginal estrogen Add on moisturisers,
lubricants
High risk of osteoporosis HRT ( <60 yo) Bisphosphonates,
Denosumab, SERM
NICE guideline : Menopause: diagnosis and management, 2015
15. Treatment options
HRT
• Estrogen only – ERT (Only to be used in women w/out uterus)
• Oral / Patch / Vaginal
• Estrogen + Progestogen – E+P
• Oral / Patch
• Continuous HRT or Sequential HRT
Other options
• Tibolone
• TSEC (Tissue-selective estrogen complex therapy)
• Estrogen + SERM
• SSRI / SNRI
16. Contraindication for HRT
• History of breast cancer
• History of VTE / stroke
• Undiagnosed uterine bleeding
• Significant cardiovascular disease
• Hypersensitivity to estrogen
• Active liver disease
• Fibroids / endometriosis (Relative contraindications)
17. Timing of Initiation
• Best to start within 10 years of menopause
• Should NOT start HRT above 60 yo without STRONG indication
• In premature menopause, HRT is recommended until at least
age of ‘natural’ menopause ie 50yo
18. Dosages
Use the LOWEST EFFECTIVE dose
of estrogen consistent with
TREATMENT GOALS
• All women with an intact uterus will require progestogen.
• Younger women generally require higher doses than older
women
20. Which is better?
• CEE and Micronised Estradiol found to have lowest risk of
increase in VTE
• Micronised progesterone and Dydrogesterone found to have
lower risk of breast cancer
21. Pre-treatment evaluation
General examination
• Medical history
• Family history
• Weight/Height/BMI
• Blood pressure
• Breast examination
• Bimanual
examination
• Papsmear
Optional Investigations
• Lipid profile
• FBS
• FBC
• Buse/Cr
• LFT
• TFT
• BMD
• Mammogram
Mammography screening should be done 2 yearly from 50-74 yo – US
Preventive Task Force (USPTF) 2009
22. Duration of use
• NO MANDATORY duration
• HRT can be given for AS LONG AS THE WOMAN WANTS IT
• Ensure adequate supervision – annual risk-benefit assessment
• Ensure woman aware of risks and benefits
23. Clinical Side Effects of HRT
Estrogen excess
• Nausea, headache, breast tenderness
• May be reduced by transdermal estrogen
• Try changing to a different preparation
E+P HT
• Heavy bleeding, low mood
• Micronised progesterone may have less mood side effects
24. Long Term Effects of HRT
• VTE
• Stroke
• Cardiovascular disease
• Breast cancer
• Type 2 diabetes
• Osteoporosis
NICE guideline : Menopause: diagnosis and management, 2015
25. VTE and HRT
• Micronised progesterone has lower risk of CTE compared to
other types of progesterone
• Estradiol may have lower risk of VTE compared to other types
of estrogen
• E only – 4 additional cases per 10 000 woman years
• E+P – 6 additional cases per 10 000 woman years
• Transdermal estrogen patch is NOT SHOWN to increase VTE
• Patch should be used in women with increased risk of VTE
R. J. Baber, N. Panay & A. Fenton the IMS Writing Group (2016) 2016 IMS Recommendations on women’s
midlife health and menopause hormone therapy, Climacteris, 19:2, 109-150, DOI: 10.3109-
13697137.2015.1129166
26. Stroke and HRT
• HRT in women <60 years of age and <10 years since
menopause is not shown to increase risk in stroke
• WHI study
• Small increased risk of stroke in women taking oral estrogen
>60 yo (but not transdermal estrogen!)
27. Cardiovascular disease & HRT
• HRT does NOT increase cardiovascular disease risk when
started in women <60 yo
• Risk of cardiovascular disease depends largely on other factors
• HRT with estrogen alone is associated with no, or REDUCED
risk of coronary heart disease
• HRT with E+P is associated with little or no increase in the risk
of coronary heart disease (up to 5 more women per 1000
women)
• DOPs study – reduction in risk of CVD present up to 16 years
later
NICE guideline : Menopause: diagnosis and management, 2015
28. Breast cancer & HRT
• Estrogen ALONE is associated with little or NO CHANGE in the
risk of breast cancer
• E+P is associated with a small increase in risk of breast cancer
• Up to 5 more cases per 1000 women
• Any increase in risk will reduce after stopping HRT
• Micronised progesterone may have lower risk
NICE guideline : Menopause: diagnosis and management, 2015
29. Type 2 diabetes & HRT
• No contraindication for HRT
• Not shown to have any impact on DM
30. Osteoporosis and HRT
• T-score
• Osteopenia -1 to -2.4
• Osteoporosis -2.5 or lower
• Osteoporosis depends on multiple factors including genetics
and lifestyle
• HRT significantly reduces the risk of fragility fracture but the
benefits decrease once treatment is stopped
• 23 fewer fractures per 1000 women
NICE guideline : Menopause: diagnosis and management, 2015
31. Summary of Long Term Effects
of HRT
E only E+P
VTE
Baseline risk 1:1000
+4 per 10 000 women
No increase in transdermal
+6 per 10 000 women
Stroke
Baseline risk 11:1000
No increase in transdermal +6 per 1000 women
CHD
Baseline risk 26:1000
-6 per 1000 women +5 per 1000 women
Breast cancer
Baseline risk 22:1000
-4 per 1000 women +5 per 1000 women
Osteoporosis
Baseline : variable
-23 per 1000 women -23 per 1000 women
NICE guideline : Menopause: diagnosis and management, 2015
32. Summary of Long Term Effects
of HRT
E only E+P
VTE
Baseline risk 1:1000
+ / = +
Stroke
Baseline risk 11:1000
+ / = +
CHD
Baseline risk 26:1000
+
Breast cancer
Baseline risk 22:1000
+
Osteoporosis
Baseline : variable
33. Perimenopausal Women
GOALS – Cycle control, Contraception, Symptom control
• OCP
• Rule out CI eg smoking, hypertension, dyslipidaemia, migraine,
thrombosis risk, CVS risk
• Consider switching to estradiol containing OCP rather than EE
• Progestogen only contraception
• Oral progestogens may be helpful in cycle control but not
symptoms
• LNG-IUS can be combined with oral estrogen for symptom control
• Cyclical MHT
• MHT does not suppress ovulation hence there may be symptoms
of estrogen excess eg mastalgia, erratic bleeding
36. Tibolone
• Estrogenic, progestogenic and androgenic action
• Contraindicated for breast cancer patients
Improvement Increased Risk
Libido /
Osteoporosis /
Stroke >60yo – 2x risk
Breast cancer Reduced risk
Colon cancer Reduced risk
Endometrial
hyperplasia
No impact
F. M. Jane & S.R. Davis (2014) A Practitioner’s Toolkit for Managing the
Menopause, Climacteric 17:5, 564-579, DOI: 10.3109/13697137.2014.929651
37. TSEC – Tissue-selectiveestrogencomplextherapy
• SERM + Estrogen
• CEE 0.45mg/day + Bazedoxifene 20mg /day
• Reduces VMS
• Improves urogenital atrophy
• Preserves bone mass
• Does not stimulate the endometrium
• No evidence to increase VTE
• No increase in breast cancer
F. M. Jane & S.R. Davis (2014) A Practitioner’s Toolkit for Managing the
Menopause, Climacteric 17:5, 564-579, DOI: 10.3109/13697137.2014.929651
38. SSRI / SNRI
• Second line treatment for VMS
• May also improve mood and well-being
• Not indicated for low mood without clinical depression
39. HRT available in Malaysia
Brand name Hormonal content Dosage
Angeliq Estradiol hemihydrate
+ Drosperinone
1.0mg
2.0mg
Climen - 16 pills
- 12 pills
Estradiol valerate
Estradiol valerate
+ cyproterone acetate
2.0mg
2.0mg
1.0mg
Divigel gel
(28 sachets)
Estradiol 1mg/g
41. HRT available in Malaysia
Brand name Hormonal content Dosage
Oestrogel gel 17ẞ estradiol 1.5mg/2.5g gel
Permarin Conjugated equine
estrogen
0.3mg, 0.625mg
Premarin vaginal cream Conjugated equine
estrogen
0.3mg/0.625mg/42.5g
Premelle 2.5 CEE
+ MPA
0.625mg
2.5mg
Premelle 5.0 CEE
+ MPA
0.625mg
5mg
42. HRT available in Malaysia
Brand Name Hormonal content Dosage
Progynova Estradiol valerate 1.0mg or 2.0mg
Progyluton - 11 pills
- 10 pills
Estradiol valerate
Estradiol valerate
+ norgestrel
2.0mg
2.0mg
500mcg
43.
44.
45.
46.
47.
48.
49. Summary
• Current evidence indicates that HRT BENEFITS OUTWEIGHS
HARM
• HRT should be given to symptomatic women / women at high
risk of osteoporotic fractures
• Clinicians have an important role to offer HRT after
appropriate counselling and ruling out any contraindications
• The lowest dose of estrogen consistent with treatment goals
should be used
• HRT can be given for as long as the woman wants
• Review women on HRT 6-12 monthly TRO any new
contraindications
• All menopausal women should be given advice on healthy
lifestyle and ideal weight.