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Published byJerome Goldrich Modified over 9 years ago
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Menopause and HRT
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AIMS Menopause : How to diagnosis Symptoms Treatments Premature menopause HRT : indications/contraindications
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Menopause Average age 50yrs Smoking brings forward by 2 yrs Impact -> cultural, health and social factors
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Diagnosis = >12 months amenorrhea with no other cause >50yrs OR = >24 months amenorrhea in <50yrs
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If diagnosis in doubt -CHECK LH/FSH e.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
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Differential Diagnosis Need to exclude : physical illness e.g. thyroid disease, anemia, DM, CKD SE of medication e.g. calcium antagonists cause flushing social problems or psychiatric illness
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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)
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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)
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Urinary problems -incontinence, nocturnal, urgency = common Ischemic heart disease -Risk is 2x after menopause Osteoporosis -consider HRT in premature menopause
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Treatment Options Flushes/sweats/psychological exercise (reduced flushes by 50%), wearing natural fibers, decrease stress, avoid spicy foods/caffeine HRT SSRI’s/SNRI’s e.g. fluoxetine 20mg OD reduces in >50yrs Norethisterone (5mg OD), megestrol acetate *may cause vaginal bleeding on withdrawal* 40mg OD decrease flushes in >80%
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Complimentary therapies Natural progesterones from yams Black cohosh Red clover *avoid with warfarin* Foods containing phyto-oestrogens e.g soy Dong quai, evening primrose oil, vitamin E and ginseng no better than placebo
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Sexual dysfunction systemic or topical oestrogen tesosterone implants in combination with HRT Urinary problems -Topical oestrogen may improve outcome of surgery Osteoporosis -HRT in premature menopause
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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
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Treatment HRT until average age of menopause e.g. 50yrs
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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
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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
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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)
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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
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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
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Preparations Start with low dose and provide 3m supply -No uterus : oestrogen alone unless PMH endometriosis e.g. Climaval, Evorel -Intact uterus : 1)If still having periods/just finished periods Cyclical combined preparation oestrogen + progesterone for last 12-14d cycle to prevent endometrial proliferation,) e.g. Climagest
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2) Periods ceased >1yr ago Considered to be post menopausal -Continuous combined e.g. Premique
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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
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HRT review Review every 6-12m if any problems recheck weight, BP, breasts, bleeding pattern Risks and benefits On stopping ½ dose for 1m 1 st, reduced in cold weather STOP immediately if : CP/signs of PE/DVT, severe headache, hepatitis, hepatomegaly, BP>160 systolic or >100 diastolic
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RisksShort term benefitsLong term benefits Breast Ca (rr1.43)Alleviate flushes/sweats/vaginal dryness Recurrent UTI Osteoporosis DVT (rr1.45) Colorectal Ca Stroke (rr1.15) Gallbladder disease Ovarian Ca if oestrogen only may increase CHD risk in 1 st year of use
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