Menopause

1. Menopause Aysha Qureshi Consultant Obstetrician & Gynaecologist BMI Bath Clinic 12th July 2011

3. Vasomotor symptoms Urogenital symptoms Types of HRT Contraception Principles of prescribing

4. Vasomotor symptoms Transient & commonest 30-50% improve within months 85-90% improve within 4-5 years 10-15% continue long term Higher FSH is related to hot flushes History taking exclude organic causes

5. Poor vasomotor symptom control Check following potential causes: Compliance with treatment. Sufficient duration of treatment (3-6 months). Drug interactions, e.g. enzyme inducers, St. John’s Wort. Poor absorption, e.g. bowel disorder. Poor patch adhesion. Unrealistic expectations or incorrect diagnosis

6. Poor vasomotor symptom control Management options: Increase oestrogen dose. Different route of hormone delivery (e.g. from tablets to patch or vice versa). Counselling on compliance and expectations of therapy. Review diagnosis and indications for HRT. Review 6-12 months

7. Urogenital symptoms Persist and worsen with age 30% early and 47% later after menopause Dryness, dyspareunia, itching Frequent UTIs due to neutral vaginal Ph

8. Women with urogenital symptoms Local oestrogen preparations are best treatment Should have a pelvic examination to exclude other pathology prior to commencing topical treatment. Low-potency estriol cream or pessaries, estradiol vaginal tablets or vaginal ring (Estring®) are available. Long-term treatment usually required, as symptoms will return on discontinuation. Can be combined with systemic HRT if clinically indicated. Low-dose maintenance treatment (twice weekly) does not appear to increase endometrial thickness and endometrial cancer risk. No apparent adverse effect in women with a history of breast cancer or venous thrombosis.

9. Vaginal dryness remedies

10. Healthy Vagina, Healthy Vulva: Practical Tips Things to avoid: Harsh soaps, contact irritants (e.g., chemicals, perfumes) Over-bathing Dampness / bladder leakage Mini pads Recommended tips: Wear 100% cotton underwear Kegel, Pilates, Yoga exercises Weight loss DISCUSSION NOTES There are a number of simple lifestyle modifications which can help alleviate symptoms of urogenital aging. Lifestyle factors that accelerate the decline of estrogen levels should be avoided (e.g., smoking). Kegel’s exercises were named after Dr. Arnold Kegel Exercises designed to strengthen pelvic floor muscles Studies suggest that Kegel exercises may be beneficial for urinary incontinence, may help prevent prolapse of pelvic organs, and increase sexual pleasure Pelvic floor muscles may be localized by stopping the flow of urine or by inserting a finger into the vagina and squeezing the surrounding muscles As pelvic floor muscles are contracted, the vagina should tighten and the pelvic floor moves upward; when the muscles are relaxed, the pelvic floor moves down to the starting position Kegel exercises should be performed with an empty bladder Pelvic floor muscles should be tensed for 5 to 10 seconds at a time, 4 or 5 times in a row, relaxing for 10 seconds between contractions Perform sets of 10, 3 times a day DISCUSSION NOTES There are a number of simple lifestyle modifications which can help alleviate symptoms of urogenital aging. Lifestyle factors that accelerate the decline of estrogen levels should be avoided (e.g., smoking). Kegel’s exercises were named after Dr. Arnold Kegel Exercises designed to strengthen pelvic floor muscles Studies suggest that Kegel exercises may be beneficial for urinary incontinence, may help prevent prolapse of pelvic organs, and increase sexual pleasure Pelvic floor muscles may be localized by stopping the flow of urine or by inserting a finger into the vagina and squeezing the surrounding muscles As pelvic floor muscles are contracted, the vagina should tighten and the pelvic floor moves upward; when the muscles are relaxed, the pelvic floor moves down to the starting position Kegel exercises should be performed with an empty bladder Pelvic floor muscles should be tensed for 5 to 10 seconds at a time, 4 or 5 times in a row, relaxing for 10 seconds between contractions Perform sets of 10, 3 times a day

11. Management of loss of libido Investigate possible psychosexual causes and consider referral to psychosexual clinic. Tibolone (Livial®) has a beneficial effect on libido.

13. Mirena® Intra-uterine system (used in combination with oestrogen only HRT) No monthly bleeds. Provides contraception. IUS only licensed for 4 years if used as part of HRT. Possibly reduced breast cancer risk as minimal absorption of progestogen. Possibly reduced risk of endometrial cancer as with ccHRT.

14. Continuous combined HRT (ccHRT) Tablets and transdermal patches available. No monthly bleeds. Indicated for postmenopausal women and women over 54 years (80% postmenopausal by then). Women currently on sequential HRT may consider changing to ccHRT after 1-2 years (if 50 years or over) or after 4-5 years (if under 50 years). Suitable as ‘add-back HRT’ for women on long term GRHA treatment. Reduced risk of endometrial Ca

15. Tibolone Synthetic compound with oestrogenic, progestogenic and androgenic compounds. No monthly bleeds. Same indications as ccHRT, including ‘add-back HRT’ for women on long term GRHA. Unlike other ccHRT may not reduce the risk of endometrial cancer. May be less likely to increase breast cancer risk than other types of HRT. Beneficial effect on libido.

16. Women with intact uterus, after endometrial ablation or subtotalhysterectomy Sequential (cyclical) HRT Tablets and transdermal patches available. Use in perimenopause while woman still has periods. Most women have regular monthly withdrawal bleed. Absence of regular bleeds in 5% of women but no investigation needed if correct use and no unscheduled bleeding. 3-monthly bleed preparation (Tridestra®) suitable for women with infrequent periods.

17. Women without a uterus Oestrogen only HRT Tablets and transdermal products available – patches or gel. Transmucosal systemic products – nasal spray, vaginal ring (Menoring®). Subcutaneous implant – for intractable menopausal symptoms.Monitoring of oestrogen levels required – refer to secondary care.

18. Contraception in the perimenopause Women who start HRT before the menopause continue to require use of contraception. HRT is not contraceptive, as ovulation may not be reliably inhibited. Most contraceptive methods are suitable for perimenopausal women, unless there are specific medical contraindications or risk factors. Women on combined hormonal contraception should change to a different method (intrauterine contraception, progestogen-only or barrier method) from age 50 years. The contraceptive efficacy of progestogen only methods (except Mirena® IUS) if used concomitantly with HRT is unknown.

19. Contraception Intrauterine contraception is particularly useful for perimenopausal women and can be used together with HRT. A copper IUD inserted after age 40 years may remain in utero until the menopause (unlicensed use). A Mirena® IUS inserted after age 45 years may remain in utero until the menopause, if the woman remains amenorrhoeic (unlicensed use). If Mirena® IUS is used as part of HRT it should be changed after 4 years to comply with manufacturer’s advice regarding endometrial protection. Natural fertility control methods aimed at detecting ovulation are unreliable in women with erratic periods. Latex condoms may be damaged by topical vaginal oestrogen preparations.

20. General prescribing principles Use lowest effective dose for shortest duration to control menopausal symptoms. Tablets should be offered in preference to patches as they are more cost-effective and avoid problems with detachment from skin and local side effects. The transdermal route may be appropriate where there is a clinical need to avoid first-pass metabolism of oestrogens (e.g. liver disease, diabetes), if woman cannot tolerate tablets or if they express a strong preference for a non-oral preparation. Addition of a progestogen is required for protection against endometrial cancer in women with an intact uterus, including those with endometrial ablation or subtotal hysterectomy.

21. General prescribing principles Contraception is still required in perimenopausal women on HRT. The risks and benefits of long-term use of HRT should be assessed for each individual at regular intervals. HRT should not be used first line in asymptomatic postmenopausal women for primary prevention of osteoporosis

22. Commencing HRT (cont) Give life style advice on smoking, alcohol, exercise and diet. Measure baseline blood pressure and body mass index. Carry out cervical smear if indicated as per national Cervical Screening Programme. Discuss breast awareness and participation in National Breast Screening Programme. Pelvic and breast examination only if clinically indicated. Full blood count, thyroid function tests, genital swabs if clinically indicated. Assess contraceptive needs. Discuss HRT risks and benefits and provide a patient information leaflet. Follow-up appointment if necessary.

23. Commencing HRT Starting HRT Initial consultation Take symptom history, gynaecological history, past medical history and family history.

24. Endometrial cancer risk and HRT after >5 years of use (BMS 2006) Type of HRT product Odds ratio 95% CI Estradiol alone 6.2 3.1 – 12.6 Conjugated equine oestrogens 6.6 3.6 – 12.0 Oestrogen plus cycl prog for 10-15 days 2.9 1.8 – 4.6 Continuous oestrogen/progestogen 0.2 0.1 – 0.8 Low potency vaginal oestrogens e.g. 1.2 0.8 – 1.9* – Estriol cream (Ortho-Gynest®, Ovestin®) – Estradiol pessaries/ring (Vagifem®, Estring®) but not conjugated oestrogen cream (Premarin®) * not significant

25. Oestrogenic side effects Usually transient and subsiding within three months. Fluid retention, nausea, headaches, breast tenderness, leg cramps. Management options: Check blood pressure and compare with baseline measurement. Reduce oestrogen dose. Different route of hormone delivery (e.g. from tablets to patch or vice versa).

26. Progestogenic side effects Usually transient and subsiding within three months. Premenstrual symptoms. Androgenic effects – acne, facial hair, skin problems. Management options: Change of progestogen. Different route of hormone delivery (e.g. from tablets to patch). Intrauterine progestogens (Mirena® IUS).

27. Absolute contraindications Active breast cancer or endometrial cancer. Active venous thromboembolism. Pregnancy.

28. Uncertainties with HRT use Alzheimer’s disease – Oestrogen may delay or reduce risk of AD, but does not seem to improve established disease. Possibly two-fold increase in dementia in women >75 years using combined HRT. Ovarian cancer – Unresolved but possibly increased risk with very long-term use of oestrogen-only HRT. Cardiovascular disease – Tendency to reduction in coronary vascular events in younger oestrogen-only HRT users, but not statistically significant.

29. Alternatives to HRT Progestogen-only therapy (for vasomotor symptom control) Norethisterone (5-15mg daily) Medroxyprogesterone acetate (2.5 – 5mg bd) Non-hormonal alternatives (for vasomotor symptom control) Clonidine 50-75mcg twice daily Antidepressants (unlicensed use) e.g. fluoxetine 20mg daily, citalopram 20mg daily, or venlafaxine 37.5mg bd. antidepressants are associated with a withdrawal syndrome. Gabapentin (unlicensed use) 300-900mg daily

30. Cautions – refer for specialist advice if Undiagnosed abnormal vaginal bleeding. History of oestrogen dependant cancer (e.g. breast, endometrium, endometroid ovarian) or significant family history of breast cancer (refer for genetic testing). History of venous thromboembolism or significant family history of venous thromboembolism (thrombophilia screen advisable, but negative test does not completely exclude condition). Current anticoagulant use. Primary biliary cirrhosis (risk of osteoporosis) or acute porphyria

31. Thank you Any Questions