11/15/2017. Update on HRT. Highgate Private Hospital (Barnet Hospital) Women s Health. Menopause

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1 Update on HRT Miss Moneli Golara Consultant Obstetrician and Gynaecologist MBBS, FRCOG Highgate Private Hospital (Barnet Hospital) E: Women s Health Life expectancy of a woman in UK is 81 Live 30 years post menopause Extremely important this period is handled carefully Menopause The Change By definition is the last menstrual period No periods for one year Average age is 51- life expectancy is 81 1

2 Menopausal Transition (MT) Or Perimenopause Transition from normal ovulatory menstrual cycle to cessation of ovulation & menstruation Ovarian Follicular depletion resulting in Hypoestrogenemia & raised FSH levels Usually lasts 4 years (2-8 years) Gradual change Not ON/OFF switch Average age : 47 yrs (39 51 yrs) Menopause Because of timing, often coincides with other life changes: Ill relatives/ Parents Children moving out Relationship problems/ Divorce The Menopause No periods for one year average age 51.4 yrs worldwide 80% of women experience (30% seek help): hot flushes and night sweats (the most common symptoms) vaginal dryness/urinary problems Joint pain tiredness and sleep disturbance mood swings lack of concentration loss of libido. 2

3 Diagnosis of Menopause After age of 45, clinical diagnosis only, unless other problems coexist NICE 2015 FSH levels unreliable in this age group years clinical (Hot flushes, no periods) & BHCG, FSH, Prolactin, TSH FSH indicated Under 40 years ( premature menopause (primary ovarian insufficiency) Refer, needs specialist input and tests FSH indicated Hormone Replacement Therapy HRT provides low doses of estrogen and progestogens (rarely testosterone) HRT is available as tablets, skin-patches gels or nasal spray. A cream, pessary, or vaginal ring containing estrogen best for local vaginal symptoms Hormone Replacement Therapy Replacing Estrogen and Progesterone Does what it says on the pack! Useful for relief of symptoms Hot flushes Night sweats Vaginal dryness? Mood/ libido Will not change your life circumstances Stress maybe due to other factors- HRT not the answer to everything 3

4 Menopause and Hormone Replacement Only use if symptoms adversely effect life Start with lowest dose Need both Estrogen and progesterone if woman has uterus intact Should be assessed yearly Good practice is to give for 2 years and see how things improve Better to wean off gradually Practical Tips If less than one year since last period, best to use cyclic as mimics normal cycle If more than one year- then better to use constant combined Pulsed rarely used in UK If Hysterectomy then Estrogen alone. GSM (GenitoUrinary symptoms of menopause) Long term Local oestrogen can reverse the urogenital atrophy - Even in women who are on HRT (NICE 2015) Low-dose vaginal Estrogen in recurrent UTI once pathology ruled out. Urgency/urge incontinence/frequency/nocturia may be improved by oestrogens but not usually stress incontinence. No need to monitor endometrial thickness in women who are using vaginal estrogen Encourage women to report unscheduled bleeding 4

5 Vaginal Dryness Lack of Estrogen causes changes in vaginal mucosa Thinning Dryness Pain on sex Bleeding Local Estrogen very effective Very small amount gets absorbed therefore very safe Urinary symptoms such as recurrent water infections and dryness can be helped Tablet or Cream Alternatively can use vaginal moisturisers ie Replens or Sylk Others NICE Consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective.- Testim Gel HRT prevents osteoporotic fractures but benefit declines soon after stopping, hence do not use for this alone. Raloxifene, a selective oestrogen receptor modulator (SERM), reduces the incidence of vertebral fractures in women with osteoporosis. Reduced risk of breast cancer but increased incidence of vasomotor symptoms. 5

6 Risks of HRT Breast Cancer Risk increase only after 5 years Risk higher with combined preparation After 5 years 6 extra cases per 1000 Women taking HRT Contraindications of HRT HRT is contraindicated in women with previous breast cancer personal history of VTE Current/recent use of HRT increases breast cancer risk. Returns to background risk soon after stopping Risk directly related to duration of therapy, not to dose. Combined oestrogen and progestogen increase the risk of breast cancer more than oestrogen alone. Breast aware and regular mammograms.. Cardiovascular Disease nice 2015 HRT does not increase cardiovascular disease risk when started in women aged under 60 years Does not affect the risk of dying from cardiovascular disease. Presence of cardiovascular risk factors is not acontraindication to HRT as long as they are optimally managed. HRT with oestrogen alone is associated with no, or reduced risk of coronary heart disease 6

7 Elite Trial NEJM- March 2016 Studied 643 women on 17 b estradiol 1. Mg per day vs placebo Stratified to < 6 years (early) or >10 years (late) since menopause Carotid artery Intima- Media thickness (CIMT) Measured every 6 months atherosclerosis Significant reduction in early group no change in late group. Golden window for prevention of heart disease Who should not take HRT Personal history of breast cancer Personal history of DVT/ PE Genetic testing shows positivity for BRCA genes? Strong family history of breast Remember Risk can return to background after stopping HRT Risk related mainly to duration of treatment Combined Estrogen and progesterone risk higher than Estrogen alone Breast awareness important. Risks of HRT Stroke Numbers very small Safe if no other risk factors Patches better than tablets 7

8 Before starting HRT Counsel re risk of VTE, assess risk, educate re signs and symptoms, highest risk in 1st year Suggest Patch over oral, less VTE risk Thrombophilia testing should be available for women with a personal or family history of VTE. HRT does not require to be routinely stopped prior to surgery provided that appropriate thromboprophylaxis, is used. HRT not effective treatment of established Alzheimer's disease or improving cognitive function or depression. Use of HRT in women > 75 years may increase the risk of developing dementia. Preparations Estrogen Conjugated Equine Premarin Plant derived- Estradiol Valereate 1mg oral Transdermal- 50 mcg 17 beta estradiol Ethinylestradiol- 5 mcg Progesterone Medroxyprogesterone acetate-5-10 mg Natural micronised progesterone Uterogestan mg/day Levonorgestrel- Mirena Norethisterone- Drospirenone- (Angelique) Practical tips Start with patch Evorel mcg if Estrogen only Evorel sequi or conti if combined (has NET ) Or Fem Seven (contains LNG) If < 1 year amenorrhoea then cyclical HRT Evorel sequi If > 1 year amenorrhoea then continuous combined Evorel conti Bleeding common with patches, investigate if continues greater than 6 months of HRT use 8

9 Alternatives to HRT? Herbal medicine Red clover Black cohosh St. John s wort Preparations may have different doses Interactions Relaxation techniques Acupuncture Aromatherapy Lifestyle changes Meditation and mindfulness Yoga Medical treatments Antidepressants and Clonidine- poor side effect profile CBT Tibolone Synthetic steroid which breaks down and has active by products Estrogenic, progestogenic and androgenic activity Useful for treatment of hot flushes Given continuously- not cyclically Effective in reducing vasomotor symptoms Beneficial effect on bone mineral density However increase risk of Stroke Data on breast cancer conflicting Clonidine Centrally active alpha-2 adrenergic agonist Relief of hot flushes in some but not all trials Orally or patch Poor side effect profile Dry mouth Dizziness Constipation Sedation 9

10 Vasomotor symptoms Antidepressants (SNRIs,SSRIs) venlafaxine, paroxetine and fluoxetine are options for women with hot flushes along with mood disorders, who are not candidates for oestrogen therapy. Not first line therapy (NICE 2015) Not contraindicated in women with breast cancer. May have loss of libido/nausea. Topical natural progesterone cream cannot be recommended. Vasomotor symptoms Lifestyle measures Low intensity Exercise Yoga Pilates Healthy Diet Soya Seeds, nuts, legumes Avoid caffeine and reduce alcohol Keep hydrated Phytoestrogens: Soy and Red Clover Phytoestrogens are plant substances that have similar effects to estrogens. The most important groups are called isoflavones and lignans. The major isoflavones are genistein and daidzein, found in soy beans, chick peas, red clover, legumes, beans. The major lignans are enterolactone and enterodiol, found in Flaxseed, whole cereals, fruit. Cereal bran 10

11 Prevention/Treatment of Osteoporosis Weight bearing exercises, under supervision Walking 30 min/day, esp while sunny Improves mood, posture and balance Diet -1000mg of calcium Supplement of Calcium and Vit D -500mg -1000mg depending on diet Calcum Content of Foods Case Studies: 38 year old lady no periods for 1 year? 42 year old erratic cycles, hot flushes? 53 year old menopausal lady, fit and well, terrible hot flushes, can t function normally 51 year old lady, periods stopped, low mood, hot flushes, wishes to avoid HRT 49 year old, history of breast cancer, wishes HRT As a GP, what would be your advice? 11

12 HRT Treatment Consider if quality of life affected, esp if natural alternatives not helping Use for 2-3 years, upto 5 years to minimise risk Combine with natural methods Counsel re risks and benefits Use in premature menopause (< 40) Role in surgical menopause Oral vs patches vs implants patches better than tablets Stopping HRT -? Weaning vs stopping If woman accepts risks, some need for much longer Clonidine? Lifestyle changes Start new hobbies Languages Dance New skills Join a club Sports Yoga Pilates Golf Sleep modification Avoid caffeine Maybe take short nap if lack of sleep Exercise daily o Brisk walk o Swim in early evening Reading Join/ start a book club Miss Moneli Golara Consultant Obstetrician and Gynaecologist MBBS, FRCOG E: lauren@medicaladministration.co.uk 12