Transcript No Slide Title

Hormone Replacement
Therapy
Dr Annice Mukherjee
Consultant and Lecturer in Endocrinology
Salford Royal NHS
Definition of Menopause
Failure of steroid
production and ovulation
and the final cessation of
menstruation
 Average age 51 yrs
 Incidence of natural
premature ovarian failure
before age 40 is estimated
as 1%

Menopause facts
70% women suffer with
symptoms
 Symptoms may occur before
menopause is biochemically or
clinically evident
 Symptoms spontaneously
improve over 2-5 years

Symptoms of Menopause


Menstrual irregularity indicating failing
ovulation
Vasomotor symptoms

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Sleep disturbance
Vaginal symptoms
Mood changes
Joint pains
Physical


- hot flushes/flashes, night sweats
Skin/body habitus/weight changes
Sexual dysfunction
Eleanor
46, menopause began last year
 Has had fractured humerus and pelvis after
trivial injuries in past
 Otherwise very healthy
 BMI 19, FH osteoporosis
 Tolerating menopause well with few
symptoms

The Effect of Age on Peak Bone Mass
Attainment of
peak
bone mass
Consolidation
Age-related bone
mass
Males
Females
Fracture threshold
Menopause
0
10
20
30
40
Years
50
60
70
Eleanor

Has she had BMD checked??

High risk of osteoporosis from history

Would benefit form HRT even in absence of
symptoms in terms of bone protection
Vicky
33 year old female, married, no children
 Menses stopped 18 months ago, several
pregnancy tests negative,
 Bloods LH 70, FSH 50, Oestradiol 42
 She wants to know if she can have children
 She also complains of vaginal dryness and
itching even thought she has had treatment
for thrush

Premature Menopause
Requires estrogen replacement until age of
natural menopause
 Symptoms may be more severe than natural
menopause
 Urogenital and sexual problems also impact
 Cardiovascular risk increased
 Osteoporosis
 Fertility

Vicky
Consider doing autoantibody screen
 ?Family history prem. menopause/
behavioural problems in boys (-fragile X
syndrome)
 Estrogen replacement required for well being
and bone protection-risk of osteoporosis
 Can use high doses of HRT in this context
 Pregnancy possible with egg donation

Menopause
Aims of Management
To maximise the quality of life of
hypogonadal women by:
Reducing the impact of menopausal
symptoms
 Addressing the increased risk of
osteoporosis

Treatment options

Lifestyle
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Natural herbs & remedies
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Exercise, stop smoking, limiting alcohol, caffeine &
stress, adopting a healthy diet
Placebo treatment reduces hot flushes by 50%
HRT
Other prescription therapies
Natural herbs & remedies

Phytoestrogens (Red clover)
 Structural
 Efficacy

similarity to oestradiol
data insufficient
Black cohosh

Buttercup family

Flushes & other symptoms

Data insufficient to date

Progesterone creams

Acupuncture
Yvonne
62 year old housewife
 Severe MSK pain, hot flushes, sleep
disturbance low libido, mood swings
 Despirate for symptom control!
 BMI 40, BP 160/95
 Tx for hyperlipidaemia
 Strong FH of IHD & 2 sisters with
breast cancer
 Biochemistry- post-menopausal

Prescription Remedies
 HRT
preparations
 Progestogens
 Venlafaxine and Paroxetine
 Clonidine
 Gabapentin
Yvonne
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62 year old housewife
Identify ranking of symptoms
Is she depressed?
Would significant weight loss help well
being?
If main symptom is flushing consider SSRIupto 70% improvement in flushes/sweating
She may wish to start with a natural remedy
The Role of HRT
Natural menopausal symptoms
 Premature menopause
 Surgical menopause
 Other causes of oestrogen deficiency
under age of 50 yrs
 Menopausal women at significant risk of
osteoporotic fracture
 Consider contraindications risks carefully

Risks of combined
HRT
Risks of oestrogen
Only HRT
•Breast Cancer (0.77)
Breast cancer (1.24)
•Stroke
(1.39)
After
women’s Health
Initiative
Study
 Stroke(1.41)
•DVT (1.47)
 the
DVT (1.95)
number of women
using HRT
•IHD (0.77)
 IHD (1.24)
fell by almost
half
•Billiary disease (1.67)
 Billiary disease (1.59)
•Ovarian cancer (1.2)
 Ovarian cancer (1.2)
•Malignant melanoma ?
 Malignant melanoma ?

Benefits of HRT
 Vasomotor
symptoms
 Mood changes and insomnia
 Osteoporosis
 Urogenital symptoms
 Sexual dysfunction
Use of HRT
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Start during perimenopause in natural
menopausal (earlier the better)
Most women use HRT for less than 5 years
Vaginal oestrogen is effective for urogenital
symptoms
Merits of long term HRT should be assessed for
each individual
 Premature
menopause
 Osteoporosis
HRT
preparations/combinations
 Oestrogen

oral/patches/gels
With progestogen for women with an intact
uterus
 Sequential
preparations (bleed)
 Continuous combined preparations (non-bleed)
 Intrauterine
progestogen
HRT; Dose and route
Use lowest dose for the shortest possible
time in women with natural menopause
 Women with premature menopause will
need higher doses
 Transdermal has less metabolic effect and
probably safer

Tibolone
Synthetic steroid with oestrogenic,
progestogenic and androgenic actions
 Relieves symptoms
 Protects bones
 Improves sexual function
 Shares some of HRT risks although
possibly not all

Jenny
50 yr old police officer
 Menopausal symptoms++
 Had TAH for endometriosis 4 years before
 Now feels so bad that she can’t work, thinks
she will lose her job soon. Can’t afford to be
un-employed
 Has maternal aunt who died of breast cancer
age 45

Relative contraindications
Breast cancer
 Thromboembolic disease
 Coronary heart disease
 Stroke
 Gall bladder disease
 Dementia
 Migraine

Jenny
Difficult problem
 Quality of life vs. uncertain cancer risk
 Could have trial of low dose oestrogen only
transermal HRT with close monitoring &
referral to breast cancer family history clinic
 Spell out risks versus benefits

Joan
52 year old cleaner
 Menses stopped 1 year ago
 Reduced libido, low mood no flushes
 Worried her partner is going to leave
her
 Tried HRT no benefit

Sexual Dysfunction
(PHSDS)
p=0.0008
p=0.009
p=0.0004
p=0.0006
p=0.008
Hormone Therapy (HT) vs.
HT + Testosterone
on sexual function
p=0.0007
p=0.0008
Somboonporn W et al. Testosterone for periand postmenopausal women (review), Oct
2005, Cochrane Library
p=0.002
Indications for Androgen
Therapy

Progressive loss of libido and sexual
enjoyment associated with non specific
tiredness, loss of drive, motivation and
sense of well being
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Exclude clinical depression or other
explanation
Joan
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52 rear old cleaner management?
Is she depressed?
Is the reduced libido lack of interest or physical
(vaginal discomfort/pain) or both
If complex psychosexual issues consider referral
to specialist clinic
Consider topical oestrogen
Consider testosterone/HRT combination

Oral restandol/intrinsa patches
Urogenital Atrophy
10 - 40% of hypogonadal women are
symptomatic
 Oestrogens effective in the management
 Most convincing evidence being in support
of local treatment
 Doses lower than conventionally used

Conclusions
HRT has well recognised benefits
and well publicised risks
 Consider the indications and risk
carefully and discuss them with the
patient
 Tailor the treatment offered to the
needs of the individual patient

Thank-You!