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 (2006) doi:10.1038/nm0606-612
Image: http://www.britannica.com/ebchecked/topic/375292/menstrual-cycle
My body clock is ticking... A woman is born with 1.5 million oocytes. 1/3 are lost through menarche Remainder lost during reproductive life Aging has a big role Menopause occurs when the supply of responsive oocytes runs out
Case 1: Teri A 49-year old actress presents to her GP 1 year history of: Irregular periods Weight gain Intermittent hot flushes Loss of libido Image: http://terihatcheronline.com/gallery/thumbnails.php?album=374
Perimenopause The period of time leading up to the menopause Characterised by an increased number of anovulatory cycles Progesterone production Symptoms: Periods become irregular Gain weight Lower abdomen, buttocks, thighs
Case 2: Nigella 54 year old chef presents to GP 2 year history of amenorrhoea 4 year history of: Hot flushes Depression Dyspareunia FH: osteoporosis (mother) SH: smoker (15 pack years) Image: http://www.nigella.com/about-nigella
Post-menopause Oestrogen production falls Due to absence of ovarian follicles Reduced negative feedback by oestrogen on pituitary production of FSH and LH Serum levels of FSH and LH rise (>40 IU/I)
Symptoms of menopause Vasomotor instability Osteoporosis Genital atrophy Mood disturbances Image: http://www.cardiachealth.org/menopause-and-palpitations
Image: http://www.examiner.com/slideshow/hotflash-humor#slide=1 Vasomotor instability Hot flushes Sudden increase in body temp. Due to declining oestrogen levels
Osteoporosis Post-menopausal women experience: Increased bone resorption Diminished bone formation Resultant bone fragility Effects: Loss of height Kyphosis Spinal compression fractures Hip fractures Image: http://www.wastrongbones.org/
Genital Atrophy Common symptoms: Dyspareunia Vaginismus Dysuria Urgency Urinary incontinence Image: http://womenshealthency.com/articles/atrophic-vaginitis/
Mood disturbances Common symptoms: Fatigue Nervousness Headaches Insomnia Depression Irritability
Management
Investigation + management Treatment can be started upon clinical picture Investigation is only necessary for women < 40 or women with unusual bleeding patterns Counsel Lifestyle advice Medical treatment
Treatment Most women who seek medical therapy for menopausal symptoms in their late 40s or 50s Hormone replacement therapy (HRT) Replaces Oestrogen Used to relieve symptoms of menopause - mainly vasomotor symptoms (hot flushes) - mood liability/depression - vaginal atrophy - Joint aches and pains
Porphyria cutanea tarda History Breast cancer suspected oestrogensensitive cancer Pregnancy Contra indications Untreated endometrial hyperplasia Acute liver disease History DVT, Thrombotic events Uncontrolled hypertension Undiagnosed PV bleeding
Types Unopposed oestrogen For women who have undergone hysterectomy Oestrogen + progesterone For women with an intact uterus who need a progesterone to prevent oestrogen-associated endometrial hyperplasia
HRT regimes Oestrogen only (unopposed) Recommended for women who have had a hysterectomy Cyclical (sequential) Recommended for women who have menopausal symptoms but still have periods Premenopausal Monthly recommended for women having regular periods -Oestrogen every day and progestogen at the end of your menstrual cycle for 14 days, withdrawral bleeds every month Three monthly recommended for women having irregular periods - Oestrogen every day and progestogen for 14 days, every 13 weeks, withdrawal bleeds every 3 months Continuous combined Continuous combined (oestrogen +progestogen) HRT is usually recommended for women who are post-menopausal No menses
Mode of delivery Creams / gels pessaries Vaginal ring (Estring ) Oral Transdermal
HRT dosing Start Prescribe the lowest effective dose for the shortest time possible Older women may be less tolerant of oestrogen and need to start on a lower dose Younger women may require higher doses Tailor the dose to the symptoms Stopping Most women are able to stop taking HRT after their menopausal symptoms finish. Usually 2-5 years after they start. Gradually decreasing HRT dose is recommended Osteoporosis cover post
Side effects oestrogen fluid retention bloating breast tenderness or swelling nausea leg cramps headaches indigestion progestogen fluid retention breast tenderness headaches mood swings depression acne backache
Risks/ benefits of HRT Risks Breast cancer Increased risk with time taken Risk Combined > oestrogenonly HRT Taking combined HRT doubles the breast cancer risk compared to women who do not take HRT Ovarian cancer Endometrial cancer Stroke + heart disease Benefits Symptom relief improve QOL Osteoporosis protection
http://cks.nice.org.uk/menopause#!scenariorecommendation:3
Alternative treatments For vasomotor symptoms: paroxetine, fluoxetine, citalopram, venlafaxine, or clonidine For vaginal dryness: vaginal lubricant or moisturizer For psychological symptoms: self-help groups, psychotherapy, counselling, or antidepressants, according to the individual
References http://cks.nice.org.uk/menopause#!topicsum mary http://www.uptodate.com/contents/treatmen t-of-menopausal-symptoms-with-hormonetherapy?source=search_result&search=hrt&s electedtitle=3%7e150 http://www.womens-healthconcern.org/help/factsheets/fs_hrtrisksbenefi ts.html