Menopause and Hormone replacement therapy

 

Menopause And Hormone Replacement Therapy

Dr Funmi Odusoga DFRSH MRCOG

Table of content

1. Definition

2. Incidence/Epidemiology

3. Physiological effect of menopause

4. Management

5. Information for General practitioners

6. Which HRT regimen

7. Long term benefit and Risk

8. Premature ovarian Insufficiency

9. Reference

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Definition

• Menopause-Cessation of menstrual period for 12 months or more
• It marks the end of a woman’s reproductive capacity
• Premenopausal-means before menopause
• Post menopause- means after menopause
• Climacteric/Perimenopausal period –It is the transition period during which the woman’s reproductive function gradually diminishes and disappears

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Incidence / Epidemiology

• Mean age is 51yrs
• 97% of women are menopausal by 58years
• 0.3-0.9% are menopausal before 40years (Premature Ovarian failure)
• Gene not yet found
• Socioeconomic status (lower is linked to earlier earlier)
• Higher parity is linked to Late menopause
• Smoking is linked to early menopause

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Diagnosis

• Women aged over 45 -Perimenopause  is diagnosed based on vasomotor symptoms and irregular periods not with blood test as hormone levels are erratic and unpredictable
• Menopause is diagnosed in women who have not had a period for at least 12 months and are not using hormonal contraception
• Menopause  diagnosis is based on symptoms in women without a uterus

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Clinical Features Of Perimenopause

• Lasts between 2-5 years
• Changing period, mood swings, low self-esteem, vasomotor symptoms headache, premenstrual syndrome, insomnia, palpitations, tiredness, irritability, poor concentration, poor cognitive function, foggy head, difficulty in making decisions

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Physiological Effect of Menopause

• Cardiovascular-Increased Cardiovascular risk
• Endometrium-Bleeding problems
• Musculoskeletal-Joint and muscle ache, Osteoporosis (remember importance of detection, prevention & treatment)
• Brain-Memory & Cognition difficulties
• Vasomotor symptoms-night sweats, hot flashes, flushing
• Urogenital -Vaginal atrophy, Urinary symptoms and Sexual problem

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Management

• Individualised care-Identify and manage patients need
• Do not do Anti Mullerian Hormone, inhibin A or B, oestradiol, antral follicle count, ovarian volume to diagnose perimenopause or menopause in women over age 45. Manage patients symtomatically
• Do not check Follicle Stimulating Hormone (FSH) if on Combined Oral Contraceptives or high dose progestogen
• Check FSH only in women aged 40-45 with symptoms including change in menstrual cycle and in women aged under 40 with menopausal symptoms

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• Explain stages of menopause, common symptoms, lifestyle changes and intervention, benefit and risk of treatment, long term health implication of menopause
• Information about types of treatment, HRT, non-hormonal e.g. Clonidine, non pharma, Cognitive behavioural therapy
• Offer information to women who are likely to go through menopause due to surgical and medical intervention.
• Refer to Menopause specialist if in doubt

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Lifestyle Intervention

• Loose cotton layers
• Fans
• Avoid spicy foods
• Avoid hot drinks especially caffeine
• Reduce alcohol intake
• Stop smoking
• Increase exercise
• Lose weight
• Improve glucose tolerance

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Management Of Abnormal Bleeding

• Obtain endometrial lining biopsy if indicated on scan
• Tranexamic and mefenamic if periods are more frequent
• Progestogen is useful for irregular cycle, give longer than the luteal phase ( Beware or norethisterone , Medroxyprogesterone is better)
• Mirena- you can add estrogen
• COCP is underrated but useful (Check UK medical eligibility criteria)
• Consider extended pill regimen

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Regimen (see chart above)

• For patient requiring unopposed oestrogen give oestrogen from day1 to day 28
• For sequential combined therapy- oestrogen is given from day 1 to day 28, progestogen is given from day 14 to day 28
• For continuous combined oestrogen and progesterone are given from day 1 to day 28

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Managing Short Term Symptoms

❑ Vasomotor-Oestrogen and progesterone to women with uterus

❑ Oestrogen alone to women without a uterus

❑ SSRIs, SNRIs and clonidine should not be used as 1st line treatment

❑ Isoflavone and black cohosh-

• Beware as safety is uncertain
• Different preparation may vary
• May interact with other drugs

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Psychological Symptoms

• Give HRT to alleviate low mood that arises as a result of the menopause
• Offer Cognitive behavioural therapy for low mood & Anxiety
• There is no clear evidence for SSRIs and SNRIs if not diagnosed with depression

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Altered Sexual Function

❑ Consider Testosterone

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Urogenital Atrophy

• Vaginal oestrogen- even if they are on systemic HRT
• If systemic HRT is contraindicated seek advice from menopause expert

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Complimentary Therapy And Unregulated Preparations

• Efficacy and safety of unregulated compounded bioidentical hormones are unknown
• St John wort may relief vasomotor symptoms but there is uncertainty about dosage,variation in nature and potency, persistence of effect, interaction with drugs e.g. tamoxifen, anticoagulant and anti-convulsant

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Review And Follow Up Of Women On HRT

• Women must keep up to date with national health screening
• Review treatment 3 months after commencing HRT to assess efficacy and tolerability
• Review patient Annually
• Refer to specialist if no improvement of symptoms or side effects or contraindications to HRT
• Unscheduled bleeding is common side effect within 3 months of treatment and should be reported at 3-month review. If bleeding occurs after 3 months refer for endometrial screening

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Stopping HRT

Gradually reducing may limit recurrence of symptom in short term but makes no difference in the long term

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Women With High Risk Of Breast CA

• Refer women to specialist (Gynaecologist with special interest in managing menopause)
• Do not offer SSRIs

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Long Term Benefits And Risk

• Venous Thromboembolism- risk of HRT is greater in oral than transdermal
• Consider transdermal if BMI >30
• Refer to haematologist if high risk of Venous thromboembolism, strong family history or hereditary thrombophilia

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Cardiovascular

• Does not increase CVS risk in women <60
• Does not affect risk of dying from CVS disease
• HRT with oestrogen is associated with no or reduced risk of coronary heart disease
• Oestrogen and progesterone has little or no increase in risk of coronary heart disease
• Oral but not transdermal is associated with small increase in the risk of stroke.
• Diabetes- HRT does not have adverse        effect on blood glucose control

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Breast CA

• Oestrogen alone –little or no change in risk of breast ca
• Oestrogen and progesterone-Increase in risk of breast CA
• Increase in risk is reduced after stopping HRT

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Osteoporosis

Risk of fragility fracture is decreased whilst taking HRT

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Dementia

❑ It is not known f HRT affects the risk of dementia

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Colorectal

Reduces risk

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Premature Ovarian Insufficiency

Cessation of periods due to ovarian failure under 40 years

Aetiology

Most are idiopathic

• Take into account previous medical (10-30% have concurrent autoimmune disease such as hypothyroidism), surgical(previous oophorectomy/endometrioma) and family history (5-30%) have another affected relative
• Associated with fragile X, turner’s and down syndrome
• Associated with Chemotherapy, radiotherapy or ischaemia after uterine artery embolisation

Diagnosis

• (Under 40)
• Infrequent or no periods
• Elevated FSH levels on 2 blood samples taken 4-6 weeks apart. FSH>30IU and high LH
• Chromosomal analysis and autoimmune screening may help to identify underlying causes

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Management Of Premature Ovarian Insufficiency

• COCP or HRT except contraindicated e.g. women with hormone sensitive Cancer
• Continue to age 50
• HRT may have beneficial effect on BP compared with COCP
• HRT/COCP offer bone protection
• HRT should not replace effective contraception as unpredictable spontaneous return of ovarian function does occur in a few women
• Dual X-ray absorptiometry should be arranged for a baseline bone density measurement

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Side Effect Of Systemic HRT

• Oestrogen related- fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps and dyspepsia
• Progestogen related- fluid retention, breast tenderness, headaches or migraines, mood swings, depression, acne, lower abdominal pain, backache.
• Combined – irregular, breakthrough bleeding.
• All types- weight gain

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Reference

• NICE guideline November 2015