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/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

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

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/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%

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

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

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 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

2) Periods ceased >1yr ago Considered to be post menopausal -Continuous combined e.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 1 st, reduced in cold weather STOP immediately if : CP/signs of PE/DVT, severe headache, hepatitis, hepatomegaly, BP>160 systolic or >100 diastolic

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