Transcript MANAGING THE MENOPAUSE

MANAGING THE
MENOPAUSE
2007
SUMMARY
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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
Indications for HRT
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Menopausal symptoms
Night Sweats
 Hot flushes
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75% reduction compared 50% reduction placebo
Vaginal dryness
 No evidence for cognitive or mood disturbance
 Urogential symptoms
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Incontinence worsened by HRT
 Dyspareunia and UTI improved with vaginal oestrogen
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Beneficial Effects
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Reduced incidence of osteoporotic fracture with
combined and oestrogen only therapy
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Reduced incidence of colorectal cancer with
combined therapy
Osteoporosis Prevention
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Adequate intake calcium
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Adequate intake Vit D
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Regular weight bearing exercise
Osteoporosis Prevention
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DEXA recommended for
Age > 40 with fragility fractures
On systemic steroids > 3/12
 Age < 65 with risk factors
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Family history of osteoporotic fractures
Age . 65yrs
Treat
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T score -2.5 or -1.5 + 1 major risk factor
Contraindications for HRT
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Personal history of
Breast cancer
 CVD
 CVA
 Venous thromboembolism
 Dementia
 Untreated gallbladder disease
 Ostosclerosis
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Pre treatment assesment
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Full personnel history
Gynae
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IMB, PCB or PMB needs investigating
Risk assessment for CVD
BMI
 BP
 Blood lipids
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Treatment
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Available preparations
Oral tablets
 Transdermal patches
 Gels
 Nasal sprays
 Implants
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Regimes
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Uterus present
Oral
Combined sequential
 Combined continuous post menopause
 Oestrogen only +Mirena
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If still menstruating start oestrogen on 1st day
of period and progesterone 14 days later
Regimes
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Transdermal patch
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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
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Bleeding patterns
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Sequential regimes
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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
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Stopping treatment
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No evidence on best way to stop
Suggest
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Stop at end of packet
Women for whom severe flushes return
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Restart therapy and slowly decrease over 3-6/12
Other treatments for menopause
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Tibolone
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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%)
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Previous Breast Cancer
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Often have severe flushes due to
Chemotherapy
 Ovarian ablation
 Tamoxifen/aromatase
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HRT causes increasein recurrence compared to
placebo
All hormonal treatments contraindicated
Other treatments
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Clonidine – transdermal 0.1mg/day
SSRI
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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