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MANAGING THE MENOPAUSE

MANAGING THE MENOPAUSE. 2007. SUMMARY. HRT appropriate for moderate to severe symptoms HRT should not be used for disease prevention Lowest dose for shortest time necessary to control symptoms Must advise about increased risk of CVA, DVT, and gall bladder disease

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MANAGING THE MENOPAUSE

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  1. MANAGING THE MENOPAUSE 2007

  2. SUMMARY • HRT appropriate for moderate to severe symptoms • HRT should not be used for disease prevention • Lowest dose for shortest time necessary to control symptoms • 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

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

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

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

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

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

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

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

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

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

  12. Bleeding patterns • Sequential regimes • Withdrawal bleed near end of progesterone dose • Combined continuous • 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

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

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

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

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

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