Menopause and HRT. John Smiddy and Alistair Ledsam

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1 Menopause and HRT John Smiddy and Alistair Ledsam

2 Menopause The cessation of menstruation Diagnosed retrospectively after 1 year of amenorrhoea Average age 51 in the UK

3 Normal physiology - Menstruation Born with limited number of oocytes Menstrual cycle sees oocyte numbers reduce through ovulation Image: By Lyrl CC-BY-SA-2.5 ( via Wikimedia Commons

4 Normal physiology - Perimenopause Often referred to as the menopause Early (short term) symptoms Due to reduced response of diminished numbers of FSH Estradiol remaining oocytes May be sporadic menstruation and symptoms

5 Normal physiology - Menopause Cessation of menstruation The maturation of follicles stops completely despite increased FSH production Without follicle maturation, oestrogen production does not increase as in the normal cycle

6 Normal physiology Post Menopause Not experienced any menstrual flow for a minimum of 12 months Intermediate symptoms Late symptoms

7 Early Symptoms Vasomotor instability Hot Flushes Thermoneutral zone? Insomnia Irritability Memory loss Fatigue Poor concentration

8 Intermediate Symptoms Less oestrogen leads to less collagen in tissues Generalised atrophy (skin and hair) Fragile and dry skin Dyspareunia Urethral atrophy Dysuria (urethral syndrome)

Late Symptoms Osteoporosis Cardiovascular system Oestrogen is protective before menopause Similar incidence of cardiovascular disease to men by 70 Less active somatotropic axis Oestrogen increases

9 Late Symptoms Osteoporosis Cardiovascular system Oestrogen is protective before menopause Similar incidence of cardiovascular disease to men by 70 Less active somatotropic axis Oestrogen increases HDL and lowers LDL (thought to) Redistribution of body fat Image: "615 Age and Bone Mass" by Anatomy & Physiology, Connexions Web site. Jun 19, OpenStax College. Licensed under Creative Commons Attribution 3.0 via Wikimedia Commons -

10 Diagnosis of the Menopause Usually based on history and retrospective diagnosis of last menstrual period after 1 year of amenhorrea Measure FSH + Anti Mullerian Hormone levels FSH rises above 40 IU AMH undetectable Diagnosis used in premature menopause

11 Early Ovarian Dysfunction Experiencing menopause between the ages of 40 and 45 Usually Idiopathic Iatrogenic

12 Premature Ovarian Dysfunction Menopause before 40 years of age Genetic Turners syndrome Fragile x syndrome Idiopathic Iatrogenic Autoimmune Image: "45,X". Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons -

13 Hormone replacement therapy (HRT) Aims to reduce the vasomotor symptoms associated with the menopause. Hot flushes Night sweats With or without awakening HRT is indicated when these menopausal symptoms affect the quality of life.

14 Additional benefits of HRT Reduces fracture risk Improves vaginal dryness Improved sexual function May also improve sleep muscle aches and pains Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women s Health Initiative randomiszed controlled trial. JAMA 2002;288: Welton AJ, Vickers MR, Kim J, Ford D, Lawton BA, MacLennan AH, et al. Health related quality of life after combined hormone replacement therapy: randomised controlled trial. BMJ 2008;337:1190

15 Types of HRT Oestrogen only For women who have undergone a hysterectomy Combined oestrogen and progesterone For women who still have their uterus Provides endometrial protection Sequential For women who LMP was less than a year ago Continuous More than a years since their LMP

16 Other types Tibolone oestrogenic, androgenic, progesteronic actions when the above are not suitable Testosterone can be added to the HRT regimen Improves libido

Preparations Oestrogen Oral Intravaginal Transdermal Progesterone Oral Transdermal Intrauterine device Image - http://img.webmd.

17 Preparations Oestrogen Oral Intravaginal Transdermal Progesterone Oral Transdermal Intrauterine device Image - s/menopause_slideshow/getty_rm_photo_of_hormone_replacement_treatements.jpg

18 Does it work? HRT can reduce the frequency of hot flushes by around 18 a week, and reduces the severity of hot flushes by 87% when compared with placebo. Maclennan AH, Lester S, Moore V. Oral oestrogen and combined oestrogen/progesteron therapy versus placebo for hot flushes. Cochrane Database Syst Rev 2004;4:CD002978

Homeopathic options Black cohosh Dong Quai Red clover (pictured) Soy No firm evidence Image - http://img.webmd.

19 Homeopathic options Black cohosh Dong Quai Red clover (pictured) Soy No firm evidence Image - ow/getty_rf_photo_of_red_clover.jpg

20 Contra-indications for HRT Pregnancy and breast feeding Abnormal vaginal bleeding undiagnosed Venous thromboembolic disease Coronary heart disease Suspected, current or past breast cancer Endometrial cancer Uncontrolled hypertension

21 Side-effects Oestrogen Breast tenderness Leg cramps Bloating Nausea Headaches Progesterone PMS-like symptoms Breast tenderness Backache Depression Pelvic pain Bleeding

22 Useful studies that you might get asked about Women s Health Initiative Showed a number of adverse outcomes Excess risk of CHD, stroke, venous thromboembolism and breast cancer. Million Women Study Current users of HRT are more likely to develop breast cancer than those not on HRT

23 Royal College of Obstetricians and Gynaecologists (RCOG) Key recommendations: HRT dosage, regimen and duration should be individual for each woman Monitor the risks and benefits annually. Women with Premature Ovarian Insufficiency (POI) are encouraged to use HRT at least until the average age of menopause In women over 60, using HRT, the dose should be lowered, with a transdermal route of administration

24 References NICE (2013). Menopause: Clinical Knowledge Summary. Available online:

Menopause & HRT. Rosie & Alex. Image:

Menopause & HRT. Rosie & Alex. Image: Menopause & HRT Rosie & Alex Image: http://www.keepcalm-o-matic.co.uk/ Menopause The permanent cessation of menstruation for 12 months When does it happen? Average age 51 Image: Nature Medicine - 12, 612-613