Transcript Menopause and HRT - Home Page | York General Practice

Sharan Pobbathi
Alena Billingsley
Will cover:
 What is the menopause?
 Diagnosing the menopause
 Management
 Non-hormonal
 HRT
 Premature menopause
Programme
 Patient experience
 Presentation
 Case Studies (CSA style)
 Quiz
Menopause – what and when
 The menopause may be
 Natural or induced
 Natural menopause is the permanent cessation of the
menstrual cycle due to loss of ovarian follicular activity
 Only known retrospectively one year after the last
period
 Average is 51 years
Induced menopause
 Specific treatment e.g. chemotherapy or radiotherapy
 Oophorectomy
 Treatment with gonadotrophin-releasing hormone
(GnRH) analogues
Diagnosis - symptoms
 Short Term
 Vasomotor



Flushes
Night sweats
Insomnia
 Sexual dysfunction
 Vaginal dryness
 Dyspareunia
 Decreased libido
 Musculoskeletal
 Joint aches
 Fat redistribution
 Psychological
 Depressed mood
 Anxiety
 Irritability
 Mood swings
 Lethargy
 Difficulty concentrating
Consequences of the menopause
 Long term
 Osteoporosis
 1 in 3 increase in risk of fracture
 Cardiovascular disease
 MI and stroke most common cause of death >60y
 Oophoretomised women have 2-3 fold risk of CHD
 Urogenital
 Lower urinary tract and pelvic floor atrophy leading to frequency,
urgency, nocturia, incontinence, recurrent infections
 Vaginal atrophy
Investigations
 FSH is only used if diagnosis is in doubt
 FSH >30 iu/L
 Don’t do LH, oestradiol and progesterone as not
helpful
 TFTs if confusion about symptoms
 BMD if significant risk of osteoporosis
Management – Non-hormonal
• Lifestyle advice
– Avoid hot drinks especially caffeinated ones, and alcohol
– Stop smoking
– Fans and layering
– Use of vaginal moisturisers e.g. Replens MD® and Sylk ®
• No evidence that diet (phytoestrogens) affects
symptoms
Management – Non-hormonal
 OTC remedies
 Black cohosh



Oestrogen like effect
May help with emotional symptoms
Interacts with antihypertensives and risk of liver failure
 St John’s Wort


Recognised anti-depressant effects
Lots of interactions
Management – Non-hormonal
 Licensed
 Clonidine for hot
flushes
 SEs insomnia, dry
mouth, dizziness,
constipation,
drowsiness
 Unlicensed
 SSRIs/SNRI
(venlafaxine) for mood
swings, vasomotor
symptoms
 Gabapentin for
musculoskeletal; SEs
dizziness, fatigue,
tremor, weight gain
HRT
 Counselling about risks and benefits
 Contraindications to HRT
 Different routes/types of HRT
 Deciding on appropriate HRT (systemic or local)
 Following up patients on HRT
 Stopping HRT
Benefits of HRT
 Proven
 Relief of menopausal
symptoms
 Prevention/treatment of
osteoporosis
 Reduced risk of
colorectal cancer
Risks of HRT
• Breast cancer
– Increased by 26% in ♀ > 50 years taking combined HRT
for > 5 years
– Returns to baseline 5 years after stopping
• VTE
– 2-3x with oral HRT, highest in first year
– Absolute risk remains small
•  risk of acute coronary events in women with pre-
existing CVD in first year
•  risk of CVA
Women’s Health Initiative
 Launched in 1991
 Effect of
postmenopausal HRT,
diet modification, and
calcium and vitamin D
supplements
 heart disease
 Fractures
 breast and colorectal
cancer.
 Combined HRT
 ↑ MI, CVA, VTE, breast
cancer
 ↓ colorectal cancer and
fractures
 Oestrogen alone
 ↔ MI, colorectal cancer
 ↑ CVA, VTE
 ? Breast cancer
 ↓ fractures
Million Women Study
• National study involving over a million women aged 50
and over
• Main focus is effect of HRT use
• Over 1 in 4 women in target age group are in study
–  risk breast cancer in women using HRT, particularly
with combined HRT
–  risk breast if HRT peri- rather than postmenopause
Contraindications to HRT
* specialist initiation
 Hormone dependent
 Severe active liver
cancer – endometrial
cancer, current or past
breast cancer*
 Active or recent arterial
thrombotic disease
(CVD, CVA)*
 VTE*
 Otosclerosis*
disease (oral oestrogen)
 Undiagnosed breast
mass
 Undiagnosed abnormal
vaginal bleeding
 Dubin-Johnson and
Rotor syndromes
Relative contraindications
 May require extra supervision
 Uterine fibroids
 Endometriosis
 Hypertension
 Migraine
HRT
Local symptoms
Vaginal oestrogen
Systemic symptoms
Uterus
No uterus
Combined HRT
Oestrogen only
Oral or non-oral
Perimenopausal
Sequential or cyclical HRT
Postmenopausal (>12 months since
LMP)
Continuous combined HRT (no bleeds)
Tibolone
Local symptoms
• Vaginal dryness, soreness, dyspareunia, urinary
frequency/urgency
• Various preparations
– Pessaries e.g. Ortho-Gynsest®
– Creams e.g. Gynest ®, Ovestin ®
– Tablets e.g. Vagifem ®
– Rings e.g. Estring ®
• Some damage latex condoms/diaphragms
Non-oral oestrogens
• All estradiol 17 beta
• Avoid first pass
• Potentially more suitable
metabolism in liver
• Available as
– With liver disease or
– Patches
– Gels (less irritating than
a patch)
– Implants (last resort)
• Low, medium and high
doses
for women:
–
–
–
–
gallstones
At risk of VTE
With DM and others
with raised TGs
On enzyme inducers
First line for women
with migraine and
malabsorption
Oral oestrogens
 Three types
 Conjugate equine oestrogens (CEEs)
 Estradiol 17 beta
 Estradiol valerate
 Low, medium, high doses
 Start at low dose
Progestogens – three types
• Testosterone analogues (C19 - androgenic SEs)
– Norethisterone, levonorgestrel (Mirena®), Norgestrel
• Progesterone analogues (C21)
– Dydrogesterone, medroxyprogesterone acetate (MPA)
• Newer (derivates of norgestrel)
– Desogestrel, norgestimate, gestodene
Why bother about type?
 Oral (combined or alone), transdermal (combined)
and intrauterine
 If patient gets PMS-type symptoms
 Can alter progestogen to less androgenic type
 Can alter route of progestogen (e.g. to IUS)
HRT
Local symptoms
Vaginal oestrogen
Systemic symptoms
Uterus
No uterus
Combined HRT
Oestrogen only
Oral or non-oral
Perimenopausal
Postmenopausal (>12 months since
LMP)
Sequential or cyclical HRT
Continuous combined HRT (no bleeds)
Tibolone
• Perimenopausal
– Sequential if regular
period or cyclical if
infrequent (Tridestra®)
– Progestogen 12-14
days/month
– 5% - 15% have no
monthly bleed
– Tridestra® gives 3
monthly bleed
 Postmenopausal
 Continuous (no bleed
HRT)
 Require investigation if
persistent bleeding



> 6 months
Heavier bleeding
Bleeding after a period of
amenorrhoea
 Tibolone
Tibolone
 Synthetic steroid that properties of oestrogen,
progestogen & testosterone
 For prevention of osteoporosis in postmenopausal
women
 For short term use in pre-menopausal ♀ being treated
with GnRH
 Increases risk of stroke in ♀ > 60 years, similar to
conventional HRT in younger ♀
Side Effects of HRT
 Nausea, vomiting,
 Altered blood lipids
abdominal cramps,
bloating
 Weight changes
 Breast tenderness
 PMS-like syndrome
 Sodium and fluid
retention
 Glucose intolerance
 Mood changes
 Headache, migraine,
dizziness
 Leg cramps
 And more…
Testosterone?
• Women who have had TAH+BSO may experience
testosterone deficiency (abrupt rather than gradual fall
in levels)
• Can offer replacement
– Implants (need to monitor levels before each change)
– Patches
– SEs: hirsutism, deep voice, clitomegaly
• Must be on oestrogen, but not CEE
Questions to ask…
• Does patient want HRT?
• Is the patient informed about risks and benefits?
• Are symptom local or systemic?
• Does the patient have a uterus?
• Is the patient peri- or postmenopausal
• Which oestrogen?
• Which progestogen?
Premature menopause
 Classification
 Normal: 45 – 55 years (average 51 years)
 Early:
40 – 45 years
 Premature:
< 40 years
 Unpredictable, so need to continue contraception
 Diagnosis
 Minimum of two FSH >30 iu/L at least one month apart
Other Investigations
 Pregnancy test!
 TFTs
 Prolactin for hyperprolactinaemia
 Auto-antibodies (ovarian/thyroid/adrenal)
 Karyotyping if < 30 years for mosaic Turner’s Syndrome
 Baseline DEXA, then repeat every 2 - 5 years
 Baseline fasting lipids (yearly, depending on RFs)
 Follicle tracking on USS (fertility)
Risks of premature menopause
 Life expectancy is reduced (2 years)
 Untreated,
 50% higher risk of osteoporotic fracture between 50-70
years
  risk of CVD compared to woman of same age
 260%  risk of dementia following removal of a single
ovary by age 38
  risk Parkinson’s
Treating premature menopause
 Oestrogen replacement with progesterone
 Given most conveniently as COCP
 Continue until aged 50 years
Follow up on HRT
 Three monthly until stabilised, then yearly
 At follow up, check:
 Symptom control
 bleeding control
 Side effects
 BP, BMI
 Reassess risk vs. benefits
 Breast awareness
Duration of use
• Minimum dose for shortest period
– Symptoms last between 2-5 years, so try stopping at 3-5
years
– Woman can continue longer as counselled re risks…
Stopping
 Ensure progestogen dose offers endometrial protection
if ↓ing slowly (high dose oestrogens only)
 No evidence of how best to stop i.e. gradual versus
sudden
 When stopping HRT, warn patient of 2-3 months
rebound vasomotor symptoms
HRT
 Sudden severe chest pain
 Hepatitis, jaundice,
 Sudden dyspnoea
hepatomegaly
 Systolic BP > 160,
diastolic >95 mmHg
 Prolonged immobility
 Detection of RF that is
contraindication
 Stop 4-6 weeks before
any major surgery
 Unexplained
swelling/severe calf pain
 Severe stomach pain
 Neurological effects
Summary
 HRT is good for menopausal symptoms and
osteoporosis prevention
 Non-hormonal treatments can help with symptoms
 HRT is not necessarily systemic
 Treatment must be regularly reviewed
Stopping contraception around
the menopause - 1
 Contraception may be stopped at 55 years
 Women using hormonal contraception, and have
regular bleeding at 55 years should continue with
contraception
 Ideally women over 50 years should switch to POP,
implant, LNG-IUS or barrier method until aged 55, or
until menopause confirmed
Stopping contraception around
the menopause - 2
 FSH is not a reliable indicator of menopause in women
using combined hormonal contraception
 Women with premature menopause may need
specialist contraceptive opinion (ovarian activity may
return spontaneously)
Stopping contraception around
the menopause - 3
 If using non-hormonal methods of contraception,
 Women over 50 years can stop after 1 year of
amenorrhoea
 Women under 50 years can stop after 2 years
 Women over 40 yeas with a copper IUD (≥ 300 mm2
copper) inserted at or over age 40 can retain the device
until the menopause
 FSH is best used in women aged over 50 on
progestogen only methods
 Need 2 x FSH ≥ 30iu/L, 6 weeks apart, and then
contraception can be stopped after a year
HRT and Contraception
 Women should not rely on HRT for contraception
 POP can be used to provide contraception with
combined HRT
 Women using oestrogen replacement may use LVGIUS (Mirena®) to provide endometrial protection.
 When IUS is used as progestogen component, it must be
changed no later than 5 years (license says 4 years)
Resources
• eLFH learning modules
• Menopause and HRT InnovAiT, Vol.2, No. 1, pp 10 – 16,
2009.
• Common problems of the menopause InnovAiT first
published online May 16, 2012 doi:10.1093/innovait/ins075
• http://www.menopausematters.co.uk/
– http://www.menopausematters.co.uk/tree.php
• http://www.millionwomenstudy.org
• http://www.nhlbi.nih.gov/whi/
• FSRH Guidance: Contraception for women ages over 4o
years (July 2010)
QUIZ
Question 1
 Which one of the following conditions is least
likely to be the cause of post menopausal
bleeding?
a. Atrophic vaginitis
b.Cervical intraepithelial neoplasia (CIN)
c. Hormone replacement therapy
d.Tamoxifen therapy
e. Urethral caruncle
Question 2
 The age at which a woman reaches the menopause is
related to:
a. Age at menarche
b. Ethnic group
c. Family tendency
d. Parity
e. Regularity of cycle
Question 3
 A 52-year-old post-
menopausal woman comes
to see you regarding her
menopausal symptoms.
She is suffering with
intrusive hot flushes and
these vasomotor symptoms
are getting her down. She
does not want to take HRT
but would consider
another medicine, if it
would help.
 Which one of the following
have an evidence base for
its use in this situation?
a. Amitriptyline
b. Flupentixol
c. Mirtazapine
d. Phenelezine
e. Venlafaxine
Question 4
 A post-menopausal
woman comes to see you
complaining of frequent
intrusive hot flushes. She
does not wish to take
HRT and is keen to try
'natural alternatives'.
 Which one of the following
alternatives has the most
evidence base for its use in
this situation?
a. Dong quai
b. Evening primrose oil
c. Ginkgo biloba
d. Kava kava
e. Red Clover
Question 5
 A 54-year-old lady comes to see
 Which one of the following is
you to discuss treatment for the
menopause. Her last period was
18 months ago. She has no
significant past medical or
surgical history and is keen to
try HRT as she is getting
troublesome hot flushes and
vaginal dryness.
 Following full discussion and
counselling she has no
contraindications to hormonal
treatment and is keen to try a
suitable regimen.
the most appropriate to
prescribe?
a. Continuous combined HRT
b. Low dose COCP
c. Oestrogen only HRT
d. Sequential HRT
e. Topical vaginal oestrogen
Question 6
 A 52-year-old lady comes to see you. Her periods had
become light and infrequent for several years and then
stopped about five months ago. She has no other
significant past medical or surgical history.
 Her family history reveals no significant cardiovascular or
thromboembolic disease. She is a lifelong non-smoker. She
has had two pregnancies both of which resulted in healthy
children.
 She currently feels well. On further questioning she has
had some mild flushes but these are not troublesome.
Examination reveals a BP of 118/76 and a BMI of 22.
Question 6
Which of the following pieces of advice should you give?
a.Blood tests for FSH, LH and oestradiol should be sent to confirm she is
post-menopausal and guide her management
b.Her periods have become irregular and ceased because of waning
oestrogen production, and that HRT is indicated as it will counteract this
and help with the flushes
c.If she is worried about pregnancy risk then a low dose COCP would be
her best option, as it would treat her flushes as well as provide
contraception
d.She is postmenopausal and therefore does not require any
contraception
e.She is probably postmenopausal but she should continue to use
contraception until 12 months have elapsed since her last period
Question 7
Menopausal
assessment
Symptoms but
does not wish
HRT:
• Clonidine
• (I)
• Gabapentin
• Alternative Rx
Decision to
start HRT
Urogenital
symptoms
only (II)
Systemic HRT
With uterus
Without
uterus
Postmenopausal
Perimenopausal
III
IV
Regular
cycle
V
Infrequent
cycle
VI
Question 7
Management of menopausal symptoms algorithm
• A – alendronate
• B – beta blockers
• C – continuous combined
•
•
•
•
•
•
•
oestrogen
D – danazol
E – local oestrogens
F – long cycle HRT
G – selective serotonin reuptake
inhibitor
H – sequential HRT
I – strontium ranelate
J – systemically absorbed
oestrogens
• For each of the following
stems relating to key
points in the algorithm,
select the correct option to
complete the algorithm
from the list given.
• Each option may be used
once, more than once or
not at all.
Question 8
 Which one of the following is true of the menopause?
a. All symptoms respond to counselling
b. Flushes should not be treated with systemic oestrogens
c. Hormone profiles are needed for confirmation in most
cases
d. Hot flushes may respond to clonidine
e. Loss of libido is due to oestrogen withdrawal
f. Phyto-oestrogens are as effective as HRT
g. Tibolone is not effective for loss of libido
Question 9
 A – Clonidine
 B - Combined hormone









replacement
C - Dietary modification
D - Hypnotic preparations
E - Mineral supplements
F - Oestrogen only HRT
G - Psychological support
H - Referral to psychiatrist
I - Regular exercise
J - Vaginal lubricant
K - Vaginal oestrogens therapy
(HRT)
 For each case below, choose the
single most appropriate
treatment from the given list of
options. Each option may be
used once, more than once, or
not at all.
Question 9
 A 52-year-old married woman who has a family history of breast cancer
has been experiencing mild dyspareunia for a few hours following
intercourse for the last month. She is worried about using hormones.
 A 45-year-old woman who has had a total abdominal hysterectomy
(TAH) and bilateral salpingo-oophorectomy (BSO) for fibroids and
menorrhagia complains of hot flushes, night sweats and mood swings.
She has no other medical problems
 A 72-year-old woman has experienced frequency of micturition
intermittently for the last few months. Mid-stream urine (MSU)
cultures have been persistently negative. She is well otherwise, but
would like the symptoms resolved.
 A 56-year-old woman whose periods stopped five years ago has become
increasingly depressed. She now feels life is no longer worth living and
threatens suicide.
END