Menopause and HRT

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 Naturalprogesterones from yams Blackcohosh Red clover *avoid with warfarin* Foods containing phyto-oestrogense.g soy Dongquai, 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 derrangedLFT’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 : • 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 1st, reduced in cold weather • STOP immediately if : CP/signs of PE/DVT, severe headache, hepatitis, hepatomegaly, BP>160 systolic or >100 diastolic

Menopause and HRT