Menopause & HRT Matt McKenna Elliot Davis
Menopause Before age 40: Premature Menopause After 12 months clinical diagnosis made Depletion of Ovarian Follicles Oestrogen Progesterone LH FSH Spontaneous Amemorrhoea Perimenopausal Stage Final Menstrual Period between 40-58 (51 avg)
Sleep disturbance Common subjective symptom May be secondary to vasomotor symptoms Can contribute to depression Mood changes Anxiety, irritability, memory loss, depression and poor concentrations Loss of libido Perimenopausal Stage Menstrual irregularity Can last up to 4 years Increase in blood loss common Hot Flushes & Sweats Hallmark symptoms Hot flushes affect face, head, neck and chest Vasomotor symptoms in 80% of women Caused by loss of homeostasis in central thermoregulatory centre Urinary and vaginal symptoms Trophic effect of oestrogen lost Dyspareunia, discomfort & dryness, recurrent UTI Can manifest 5-10 years post Menopause
Induced Menopause Radiotherapy Chemotherapy Surgical Excision GnRH analogues
Associated Diseases Cardiovascular Disease Stoke, MI, PAD Osteoporosis Due to low oestrogen Alzheimer s Disease Two to three times more common in women Early HRT shows a reduction in long-term risk Others Redistribution of fat to the abdomen Urogenital atrophy (above)
Hormone Replacement Therapy Two types: A combination of oestrogen and progesterone Oestrogen only in those patients without a womb Considered in those with: Significant menopausal symptoms Surgical/irradiation oophorectomy Premature menopause
Post-menopausal Symptom Control Use for the smallest amount of time Short term oestrogen replacement at lowest effective dose Usually cyclical for the 1 st year Induces withdrawal bleed Progesterone prevents endometrial hyperplasia Continuous for 2+ years post-menopause
Premature Menopause Treating symptoms and preventing osteoporosis Cyclical oestrogen with progesterone Continuous combined also available to remain completely amenorrhoeic
Surgery or Irradiation of Ovaries Longer term therapy to prevent osteoporosis Usually if procedure before 50
Delivery of HRT Orally (most common) Compliance issues Transdermal patches Oestrogen & progesterone easily absorbed through skin Oestrogen Implants Abdominal wall/thigh lasting 6months Progesterone PO in latter half to promote withdrawal bleed (if required) Commonly used by those with hysterectomy (progesterone not required) Mirena coil Vaginally Spray, cream
Side Effects of HRT Abdominal bloating Breast tenderness Nausea Leg cramps Hirsutism Headaches Mood Changes Weight gain is NOT associated with HRT
HRT and Malignancy Endometrial Neoplasia risk with unopposed oestrogen Adding progesterone appears to reduce this risk to near normal Breast Breast cancer stimulated by higher oestrogen levels Increase risk of breast cancer from 1% to 1.3% with HRT Council patients with a family history of breast cancer Ovarian 1 extra case of ovarian cancer, for every 1000 patients taking HRT for 5 years
Stroke and Heart Disease Slight increase in CV risk in those on combined therapy There is an increased risk of ischaemic stroke and VTE However, women starting HRT <60years are not at increased risk of stroke HRT is not recommended in those with a history of stroke or DVT
Withdrawing HRT 40-50% of women stop HRT within 1 year 65-75% stop within 2 years Tapering Vs abrupt cessation of treatment Unsure which is best Rarely, patients may experience vasomotor symptoms after stopping
Alternatives to HRT Healthy lifestyle Vaginal lubricants SSRI/SNRI Gabapentine Tibolone Synthetic hormone mimicking oestrogen & progesterone Bezedoxifene (Selective oestrogen receptor modulator) Oestrogen oral contraceptive Peri-menopausal women to relieve light symptoms
References UpToDate: http://www.uptodate.com/contents/treatment-ofmenopausal-symptoms-with-hormonetherapy?source=search_result&search=hormone+replacemen t+therapy&selectedtitle=3~150 RCOG: https://www.rcog.org.uk/globalassets/documents/guidelines/ scientific-impact-papers/sip_6.pdf Crash course: Obstetrics & Gynaecology 3 rd Ed; Onwere, Vakharia; 2014
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