Menopause and HRT

AIMS

• Menopause : How to diagnosis • Symptoms • Treatments• Premature menopause• HRT : indications/contraindications

Menopause

• Average age 50yrs• Smoking brings forward by 2 yrs• Impact -> cultural, health and social factors

Diagnosis

• = >12 months amenorrhea with no other cause >50yrs

OR

= >24 months amenorrhea in <50yrs

If diagnosis in doubt-CHECK LH/FSHe.g. • post hysterectomy with conservation of ovaries• If amenorrhea <45yrs• Or Having regular bleeds due to cyclical HRT/COC pill

*check at beginning of pill packet or end of pill free week, COC/HRT can decrease FSH/LH

OR stop preparation and check levels at 6 and 12 wks post stopping

• FSH >30IU/L and amenorrhea suggests post menopausal

Differential Diagnosis

• Need to exclude : physical illness e.g. thyroid disease, anemia,

DM, CKDSE of medication e.g. calcium antagonists

cause flushing social problems or psychiatric illness

Symptoms

• Changes in menstrual pattern -common yrs before-cycle shortens after 40yrs by 7-10d-cycle then lengthens, periods can occur at 2-

3monthly intervals then stop -DUB common leading up (IX if post

menopausal)

• Psychological symptoms-controversial ; depression/anxiety

• Flushes and sweats-80% have symptoms, 20% seek help-+/- palpitations

• Sexual dysfunction-vaginal dryness and atrophy common-loss of libido ( responds to androgens i.e.

testosterone + HRT until libido returns)

• Urinary problems -incontinence, nocturnal, urgency = common

• Ischemic heart disease-Risk is 2x after menopause

• Osteoporosis-consider HRT in premature menopause

Treatment Options

• Flushes/sweats/psychological exercise (reduced flushes by 50%), wearing natural

fibers, decrease stress, avoid spicy foods/caffeineHRT SSRI’s/SNRI’s e.g. fluoxetine 20mg OD reduces in

>50yrsNorethisterone (5mg OD), megestrol acetate

*may cause vaginal bleeding on withdrawal* 40mg OD decrease flushes in >80%

• Complimentary therapiesNatural progesterones from yamsBlack cohosh Red clover *avoid with warfarin*Foods containing phyto-oestrogens e.g soyDong quai, evening primrose oil, vitamin E and

ginseng no better than placebo

• Sexual dysfunction systemic or topical oestrogentesosterone implants in combination with HRT

• Urinary problems -Topical oestrogen may improve outcome of

surgery

• Osteoporosis-HRT in premature menopause

Premature Menopause• Woman <40yrs• Increased risk of osteoporosis and CVD

Causes : • Idiopathic• Radiotherapy/chemotherapy• Surgery : bilateral oophrectomy-> instant menopause, hysterectomy

without oophrectomy can induce• Infection -> TB, mumps• Chromosome abnormalities –particularly X chromosome• Autoimmune endocrine disease e.g. DM, hypothyroid, Addisons’s• FSH receptor abnormalities• Disruption of oestrogen synthesis

Treatment

• HRT until average age of menopause e.g. 50yrs

HRT

• Short term use recommended for relief of symptoms related to oestrogen deficiency peri and post menopausally

• Carefully balance risks/benefits per individual

Indications : -Early menopause, continue till age 50yrs-Hysterectomy pre menopause even if ovaries preserved :

1:4 have early menopause-Second line Rx osteoporosis

Contraindications -Breast Cancer-Endometrial Cancer-Thromboembolic disease (includ. AF)-Liver disease with derranged LFT’s-In those with PMH liver disease, gallstones,or

taking liver-enzyme inducing drugs transdermal therapy

*stop HRT 4-6wk prior to surgery, restart after full mobilization

Pre starting HRT

• HX : establish expectations, bleeding pattern, abnormal bleeding

• Risk factors : osteoporosis ,DVT ,CVD ,FH of breast Ca

• Contraceptive assessment• Drug hx e.g. may need to increase dose of

levothyroxine, steroids ( HRT decreases effectiveness), antiepileptic (increase elimination of oestrogen)

Risks

• Breast Ca : 1 in 1000 per annum• Stroke : only women > 60yrs Tibolone 2x risk stroke > 60yrs• VTE : risk increased 2-3x with oral HRT• Endometrial Ca : substantially increased with

oestrogen only • Cervical Ca : Currently conflicting data likely no

increased risk

• Exam : BP/weight , breasts, smear• Discuss Side effects : -oestrogen related : fluid retention, breast

enlargement, nausea, headaches-progesterone related : weight gain, bloating,

depression-Bleeding may be erratic for 2-3m

Preparations

• Start with low dose and provide 3m supply

-No uterus : oestrogen alone unless PMH endometriosise.g. Climaval, Evorel

-Intact uterus : 1) If still having periods/just finished periods Cyclical combined preparationoestrogen + progesterone for last 12-14d cycle to prevent

endometrial proliferation,)e.g. Climagest

2) Periods ceased >1yr agoConsidered to be post menopausal -Continuous combinede.g. Premique

• E.g. • Oestrogen + progesterone – Premique estradiol + progesterone – Angeliq, climagest• Tibolone SERM – Oestrogenic, progestogenic

and androgenic action *not within 12m of last period*

• Topical – Oestrogen pessaries,creams or rings. Use limited to 3-6months if uterus present

HRT review

• Review every 6-12m if any problems recheck weight, BP, breasts, bleeding pattern

• Risks and benefits• On stopping ½ dose for 1m 1st, reduced in cold

weather• STOP immediately if : CP/signs of PE/DVT,

severe headache, hepatitis, hepatomegaly, BP>160 systolic or >100 diastolic

Risks Short term benefits Long term benefits

Breast Ca (rr1.43) Alleviate flushes/sweats/vaginal dryness Recurrent UTI

Osteoporosis

DVT (rr1.45) Colorectal CaStroke (rr1.15)

Gallbladder diseaseOvarian Ca if oestrogen only may increase CHD risk in 1st year of use