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MENOPAUSE & HRT

MENOPAUSE & HRT. Nicola Stewart 28/02/2018. Physiology & Clinical Features. 1.5 million oocytes at birth . 1/3 rd lost by menarche. Peri-menopause – increased anovulatory cycles. Clinical Features : (a ffects 2/3 rd woman) Menstrual irregularity Vasomotor Musculoskeletal Psychological

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MENOPAUSE & HRT

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  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

  3. Case Study 1 • 43 year old • 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.

  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 • 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

  8. Case Study 3 • 52 year old • 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 • 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 • 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 • <50yrs on HRT no extra risk • Background risk is 15/1000. 2-6/1000 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 2/1000. 4 extra cases over 5 yrs (oestrogen only) • Venous thromboembolism • Background risk is 5/1000. 2 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

  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 • 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 Wortand 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

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