Real life issues & answers: The hormonal patient Defining best practice, 5 key issues & case study

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Gerald Mosley
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1 Real life issues & answers: The hormonal patient Defining best practice, 5 key issues & case study Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP

2 Case Number 1 - Claire Age 38 Generally feels dreadful

3 Claire More tired and less energy Worsening migraines History of premenstrual migraine with aura Seen in migraine clinic Given pregabalin, topiramate and gabapentin All led to side effects UTIs and urinary symptoms Occasional palpitations FH of CVD and stroke

4 Numerous hospital appointments Bloods +++ / MSUs / CT / Ultrasound/ MRI / ECG / Echo / 24 Hour tape Cardiologist / Neurologist / Urologist All investigations normal

5 Review of last consultation More anxious Sleep not good Irritable at times Low mood at times Early morning wakening Likely diagnosis: Depression Given citalopram

6 Even further questioning reveals LMP 13 months ago Hot flushes around 8 a day Night sweats and poor sleep Vaginal dryness and irritation Post coital UTIs Last smear really uncomfortable and painful No libido

7 So what is the diagnosis?

8 Issue Number 1 Menopause care should be undertaken in primary care for as many women as possible

9 Do you think you should be managing the menopause in primary care? % % 0 Yes 82 No 2 Not applicable 5 6% Yes No Not applicable

10 Are you confident in prescribing HRT to younger women (under 45 years)? % % % 0 Yes 59 No 26 Not applicable 4 Yes No Not applicable

11 Still confusion in primary care 25% were not aware of any differences between various modes of administration and doses of HRT 62% incorrectly thought that transdermal oestrogen should not be given to women with diabetes 26% thought that any type of HRT increases risk, while 33% thought there is an increased risk in any aged woman Newson L, Mair R. BJFM 2018, 12-22

13 Psychological symptoms of the menopause Anxiety Irritability Panic attacks Feeling low Mood swings Feeling frustrated Tearful Loss of self-esteem Loss of self-confidence

14 Issue Number 2 Guidelines exist but are often not referred to in practice

15 NICE / IMS / ESHRE

16 Issue Number 3 Many perimenopausal and menopausal women are incorrectly being diagnosed with depression and being given or offered antidepressants

Making a diagnosis No tests in otherwise healthy women >45 years with menopausal symptoms: Perimenopause based on vasomotor symptoms and irregular periods Menopause in

17 Making a diagnosis No tests in otherwise healthy women >45 years with menopausal symptoms: Perimenopause based on vasomotor symptoms and irregular periods Menopause in women who have not had a period for at least one year (not on contraception) Menopausal symptoms in those without a uterus Approx 9.6 million wasted by unnecessary FSH testing

18 Issue Number 4 Many doctors, nurses and healthcare professionals are scared of prescribing HRT

21 Breast cancer Breast cancer is common Increased risk of breast cancer with: Increasing age Family history Obesity Alcohol Reduced exercise

22 Breast cancer and HRT No increased risk of breast cancer in women: Who only take oestrogen (hysterectomy) Who are young Appears to be lower risk with micronised progesterone and dydrogestone No risk with micronised progesterone for first five years Modifiable risk factors need to be addressed Stute P, Wildt L, Neulen J.Climacteric 2018;21(2):

24 Issue Number 5 There are health risks from not adequately managing the menopause

25 Risks to health with menopause Bone loss Osteoporosis Central obesity Raised cholesterol Cardiovascular disease Dementia Depression

26 Doing nothing is not an option

27 Polypharmacy

28 Antidepressants and menopause Current guidance: No clear evidence for SSRIs or SNRIs to ease low mood 1 For depression or depressive disorders that occur during the menopausal transition, oestrogen therapy may improve affective symptoms or increase the likelihood of remission 2 However: 70% had given or offered antidepressants to women who have symptoms of low mood and / or anxiety 3 1. NICE guideline NG23 Menopause:diagnosis and management IMS Recommendations on women s midlife health and menopause hormone therapy. Climacteric 2016;19(2): Newson L, Mair R. BJFM 2018, 12-22

29 How to prescribe HRT Oestrogen Pill / patch / gel Oestrogen and micronised progesterone (Utrogestan) / Mirena if she has a womb Cyclical HRT for first year or so +/- Testosterone Consider need for local (vaginal) oestrogen +/- vaginal moisturisers and lubricants Keep it simple!

30 Optimal HRT for most women

Type of oestrogen matters Transdermal oestrogen Patches or transdermal gels Few contra-indications Reliable absorption Oral oestrogen can lower libido by increasing SHBG Safer with respect to VTE

31 Type of oestrogen matters Transdermal oestrogen Patches or transdermal gels Few contra-indications Reliable absorption Oral oestrogen can lower libido by increasing SHBG Safer with respect to VTE risk No VTE risk at standard doses Can be used in women with h/o VTE Consider transdermal oestrogen for women: Who are obese With diabetes / history of migraine / gallbladder or liver problems Canonico M, Oger E, Plu-Bureau G, et al. Circulation 2007;115:840-5

Type of progestogen matters Micronised (natural) progesterone Utrogestan: Can improve cardiovascular risk / lipids Neutral effect on BP / may reduce BP No VTE risk No breast

32 Type of progestogen matters Micronised (natural) progesterone Utrogestan: Can improve cardiovascular risk / lipids Neutral effect on BP / may reduce BP No VTE risk No breast cancer risk for first 5 years (when over 51 years old) MPA can negate cardioprotective effects of oestradiol Mirena coil Stute P, Wildt L, Neulen J. Climacteric 2018;21:

Testosterone prescribing Consider in women with reduced libido despite HRT * Mood, energy and concentration often improve Tostran / AndroFeme Younger women Post TAH and BSO

33 Testosterone prescribing Consider in women with reduced libido despite HRT * Mood, energy and concentration often improve Tostran / AndroFeme Younger women Post TAH and BSO *Testosterone does not have a UK marketing authorisation for women. The prescriber should follow relevant professional guidance, taking full responsibility for the decision

34 Claire Needs to have hormones in view of her age Oral HRT not suitable in view of migraines Discuss choice of patch or gel for oestrogen Patch can be preferable Likely to need high doses Choice of progestagen Mirena or micronised progesterone Remember contraception Vaginal mositurisers / lubricants Consider local oestrogen

35 Before and after HRT!

Sex, hormones and the heart

Sex, hormones and the heart Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP www.menopausedoctor.co.uk #IandA2017 Declaration I have had financial relationships (lecturer, writer, member of advisory boards