1. MANAGING THE MENOPAUSE 2007

2. SUMMARY HRT appropriate for moderate to severe symptoms HRT appropriate for moderate to severe symptoms HRT should not be used for disease prevention HRT should not be used for disease prevention Lowest dose for shortest time necessary to control symptoms Lowest dose for shortest time necessary to control symptoms Must advise about increased risk of CVA, DVT, and gall bladder disease Must advise about increased risk of CVA, DVT, and gall bladder disease Combined therapy also associated with increased risk of breast cancer and dementia in women > 65yrs Combined therapy also associated with increased risk of breast cancer and dementia in women > 65yrs

3. Indications for HRT Menopausal symptoms Menopausal symptoms Night Sweats Night Sweats Hot flushes Hot flushes 75% reduction compared 50% reduction placebo 75% reduction compared 50% reduction placebo Vaginal dryness Vaginal dryness No evidence for cognitive or mood disturbance No evidence for cognitive or mood disturbance Urogential symptoms Urogential symptoms Incontinence worsened by HRT Incontinence worsened by HRT Dyspareunia and UTI improved with vaginal oestrogen Dyspareunia and UTI improved with vaginal oestrogen

4. Beneficial Effects Reduced incidence of osteoporotic fracture with combined and oestrogen only therapy Reduced incidence of osteoporotic fracture with combined and oestrogen only therapy Reduced incidence of colorectal cancer with combined therapy Reduced incidence of colorectal cancer with combined therapy

5. Osteoporosis Prevention Adequate intake calcium Adequate intake calcium Adequate intake Vit D Adequate intake Vit D Regular weight bearing exercise Regular weight bearing exercise

6. Osteoporosis Prevention DEXA recommended for DEXA recommended for Age > 40 with fragility fractures Age > 40 with fragility fractures On systemic steroids > 3/12 On systemic steroids > 3/12 Age < 65 with risk factors Age < 65 with risk factors Family history of osteoporotic fractures Family history of osteoporotic fractures Age. 65yrs Age. 65yrs Treat Treat T score -2.5 or -1.5 + 1 major risk factor T score -2.5 or -1.5 + 1 major risk factor

7. Contraindications for HRT Personal history of Personal history of Breast cancer Breast cancer CVD CVD CVA CVA Venous thromboembolism Venous thromboembolism Dementia Dementia Untreated gallbladder disease Untreated gallbladder disease Ostosclerosis Ostosclerosis

8. Pre treatment assesment Full personnel history Full personnel history Gynae Gynae IMB, PCB or PMB needs investigating IMB, PCB or PMB needs investigating Risk assessment for CVD Risk assessment for CVD BMI BMI BP BP Blood lipids Blood lipids

9. Treatment Available preparations Available preparations Oral tablets Oral tablets Transdermal patches Transdermal patches Gels Gels Nasal sprays Nasal sprays Implants Implants

10. Regimes Uterus present Uterus present Oral Oral Combined sequential Combined sequential Combined continuous post menopause Combined continuous post menopause Oestrogen only +Mirena Oestrogen only +Mirena If still menstruating start oestrogen on 1 st day of period and progesterone 14 days later If still menstruating start oestrogen on 1 st day of period and progesterone 14 days later

11. Regimes Transdermal patch Transdermal patch With or without progesterone ? Lower thrombotic risk With or without progesterone ? Lower thrombotic risk Implants Implants Specialist centres only Specialist centres only Those with surgical menopause whose symptoms can’t be controlled by other means Those with surgical menopause whose symptoms can’t be controlled by other means Avoid if uterus present risk of prolonged stimulation Avoid if uterus present risk of prolonged stimulation

12. Bleeding patterns Sequential regimes Sequential regimes Withdrawal bleed near end of progesterone dose Withdrawal bleed near end of progesterone dose Combined continuous Combined continuous Irregular spotting for first 6-12 months by end of year most women do not bleed Irregular spotting for first 6-12 months by end of year most women do not bleed If irregular bleeding persists, check compliance. Cervical malignancy/infection should be ruled out before referring for investigation If irregular bleeding persists, check compliance. Cervical malignancy/infection should be ruled out before referring for investigation

13. Stopping treatment No evidence on best way to stop No evidence on best way to stop Suggest Suggest Stop at end of packet Stop at end of packet Women for whom severe flushes return Women for whom severe flushes return Restart therapy and slowly decrease over 3-6/12 Restart therapy and slowly decrease over 3-6/12

14. Other treatments for menopause Tibolone Tibolone Synthetic steroid weak oestrogenic prostogenic and androgenic effects no data on breast cancer and CVD Synthetic steroid weak oestrogenic prostogenic and androgenic effects no data on breast cancer and CVD Progesterones Progesterones Depo-provera (90% vs 25% fewer flushes than placebo) Depo-provera (90% vs 25% fewer flushes than placebo) Oral medoxyprogestrone acetate 20mg (83% vs 19%) Oral medoxyprogestrone acetate 20mg (83% vs 19%)

15. Previous Breast Cancer Often have severe flushes due to Often have severe flushes due to Chemotherapy Chemotherapy Ovarian ablation Ovarian ablation Tamoxifen/aromatase Tamoxifen/aromatase HRT causes increasein recurrence compared to placebo HRT causes increasein recurrence compared to placebo All hormonal treatments contraindicated All hormonal treatments contraindicated

16. Other treatments Clonidine – transdermal 0.1mg/day Clonidine – transdermal 0.1mg/day SSRI SSRI 60% less flushes vs 30% with placebo 60% less flushes vs 30% with placebo Gabapentin Gabapentin Red clover small reduction in flushes Red clover small reduction in flushes Phyto oestrogens no effect Phyto oestrogens no effect Vit E 1 less flush/day Vit E 1 less flush/day Magnets Magnets