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
Menstrual irregularity – cycle can lengthen or shorten. Period can be heavy. 10% have periods that suddenly stop.
Vasomotor – hot flushes, warmth, sleep disturbance. Affects 85% menopausal woman times per day lasting for 4-5 mins. Due to release of GnRH. Most improve within a few months, and 90% resolved within 4-5 yrs. Clonidine can help. MSK – joint aches and pains due to reduced oestrogen Urogenital – Oestrogen dependent organs thin causing dyspareunia, bleeding, increased vaginal and urinary dryness and infections, urgency, nocturia and dysuria, UTIs, low libido
Psychological – mood, depression, irritable, confused, lethargy, memory, libido, depresison, sleep disturbance.
Osteoporosis – bone density decreases, increased risk of fractures.
Breast Disease – rate increases with age, but rate of increase slows after menopause

3. Case Study 1 43 year old Asking if she is peri-menopausal?
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.
Cannot use blood tests to diagnose menopause if taking hormonal treatment. So, in this case unable to.

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 Asking if she should be tested for this?
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
Prior to diagnosing premature menopause, other helpful tests to exclude causes for secondary amenorrhoea include: Pregnancy test, TFTs, Prolactin, testosterone, Blood glucose, Blood cholesterol and triglycerides, Cervical screening and mammograms, A pelvic scan
Premature meonpause is elevated gonadotrophins and oestrogen deficiency.
Early menopause is years. Average age of menopause is 51.

8. Case Study 3 52 year old Would like to discuss HRT.
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 Contraindications
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 Benefits 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 Ovarian cancer Endometrial cancer
<50yrs on HRT no extra risk
Background risk is 15/ /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/ extra cases over 5 yrs (oestrogen only)
Venous thromboembolism
Background risk is 5/ 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
Clonidine S/E: Dry mouth, sedation, fluid retention and depression.
No clear evidence that anti-depressants help mood in woman who have not been diagnosed with depression.
Tibolone (SERM) – combines oestrogenic and progesteronic activity, with weak androgenic activity.
Complementary therapies: black Cohosh (risk?), evening primrose oil, acupuncture, phyto-oestrogen (nuts, wholegrain cereals, soy beans).

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 What options would you give her?
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