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Setting the scene

Menopause and HRT- made easy Anita Juliana MBBS, MD, FRCOG Consultant Obstetrician and Gynaecologist Menopause Lead for NUH. Setting the scene. ‘ They thought I was a hypochondriac. It’s taken me years to convince them that there was something else besides neurosis’

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Setting the scene

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  1. Menopause and HRT- made easyAnita Juliana MBBS, MD, FRCOGConsultant Obstetrician and GynaecologistMenopause Lead for NUH

  2. Setting the scene ‘They thought I was a hypochondriac. It’s taken me years to convince them that there was something else besides neurosis’ ‘I didn’t feel like a ‘real woman’. I felt inferior’ ‘I felt like a new person. I was reborn, even though they were brought on by tablets’ ‘Most people say; ‘At my age’, ‘I’m at the age’ and I think, ‘well, I’m not, not at all, I’m half the age’………………

  3. Refresh and strengthen the basics • Clarify myths • NICE Update • Case discussions Objectives

  4. What is Menopause? Symptoms Treatment – Yes or No Myths around HRT Menopause- Basics

  5. Meno - pause ( Cessation of periods) • 12 months after last Menstrual period • Average age in UK is 51 years Peri Menopause – Irregular periods +Symptoms (45-55 age range) Premature Menopause – Below 40 years (1% of women) Early Menopause is below 45 years (Around 5%-20%) What is Menopause?

  6. Fixed number of eggs when a girl baby is born. 2,000,000 oocytes at birth 25000 at 37 years 1000 oocytes at the age of 50 Rate of decline is variable Menopause – Why ?

  7. Menopause - Process

  8. Menopause

  9. Aetiology - Various • Elevated FSH levels > 30 IU/L (two samples 4-6 weeks apart) • Fertility issues • Osteoporosis - Increased risk • Need HRT until 51 years • Refer for expert opinion Premature menopause

  10. Primary care challenges • One third of women's life is post menopause • Post cancer survivors • Quality is priority • Risks versus Benefits • Role of Media • Time limit • Too many visits....

  11. Yes You Can • Prescribe HRT in 45+ year old women • Symptoms obvious • No contraindications • Initial investigations • Premature Menopause

  12. Primary care Dilemmas • Premature / Early menopause • Not so obvious peri -menopause • Post cancer, post surgical menopause • Older women • Unsettled with HRT • Contraindication for HRT • Increased risks • Media wise customers ( Bio-identicals, Natural hormones)

  13. Not everybody suffers with symptoms • 70% - Vasomotor symptoms (Hot flushes, sweats) • Varies – familial , Ethnicity • Duration – 6 months – 20 years (Average 7.4 years) • Crucial time (45 -55 years) • After 60, requirement for estrogen reduced Menopause-How does it affect?

  14. Awareness Coping mechanisms (Diet, lifestyle, Exercises) If severe, consider HRT What to do?

  15. Diet – Healthy eating ( Fruit, Veg, Dairy, Fish, Low fat, high fibre) • Managing Optimal weight and BMI ( Reduces risk of CHD, Type 2 diabetes, Osteoporotic Fracture) • Exercise (Weight bearing, Fast walking, Tai chi, Pilates ) Helps to reduce risk of heart disease, osteoporotic fractures by increasing bone mineral density • Stop smoking • Limited alcohol Diet, Exercise, Lifestyle

  16. Estrogen (Main), Progestogens (Endometrial protection) and Testosterone (Rarely used) • Truly effective to reduce symptoms and long term benefits for bones • Variable preparations More than 50 different types, doses, routes) Hormone Replacement Therapy - HRT

  17. HRT - Continued Women with uterus Estrogenand Progesterone Still having periods or within 1 year of LMP Cyclical/Sequential More than one year of LMP or after 54 years Continuous Combined After 1 year of Cyclical Change to Continuous Combined Women without uterus Estrogen only

  18. HRT - Continued Estrogen preparations Ethinylestradiol Conjugated estrogen Estradiol Estriol Estrone Progestogen preparations Norethisterone Levonorgesterol Dydrogestrone MPA Mirena IUS Micronised Progesterone – Utrogesterone ( Natural)

  19. Oral 0.5mg, 1mg, 2mg (once a day) • Patches 25, 37.5, 50, 75, 100 mcg (twice weekly) – below waist • Gel/Pessary/Cream • Progestogens - variable • Mirena (20mcg LNG/day) • Natural progestogen (utrogestan) 100 or 200mcg • Testosterone (gel, cream) Implants no longer available in UK Doses & routes

  20. Headaches Breast tenderness Fluid retention Bloating Nausea Mood swings HRT – Side effects

  21. Very few category of women • Estrogen dependant malignant tumor ( Breast, Endometrial) • Undiagnosed vaginal bleeding • Current DVT/PE • Pregnancy HRT – Contraindications

  22. Myths Increases Breast cancer risk Increases Coronary heart disease Published by Media widely in 2003 Is this true? HRT - Concerns

  23. Two studies in early 2000 • Women's Health Initiative (WHI) • Million Women study (MWS) HRT – Risks

  24. HRT – Risks Women's Health Initiative (WHI) • USA (1993-2002) • 16600 women (50-79) • Average age 63.2, BMI 28.5 • Randomised HRT Vs Placebo • Increase in Breast cancer and coronary events, stroke, DVT in HRT group • Study stopped early in 2002 • HRT in under 60 – Protective • In over 70, not beneficial could be increased risk • Risk is duration dependant, more risk with combined than for estrogen only. Million Women study (MWS) • UK (1996-2003) • One million women attending NHS Breast screening clinic over 50 years old • Questionnaire sent out • Large number of drop outs • Screening women are already high risk • Study methodology has been criticised • Oestrogen only increases risk of breast, womb and ovarian cancer • Combined more risk than estrogen only

  25. Breast cancer risk – 4 extra cases /1000 women after 5 years (This is less risk than smoking 10 cigs/day) 45/1000 – population risk 49/1000 – HRT (5 years) 51/1000 – HRT (10 years) • Ovarian cancer – No increased risk • Endometrial cancer – Adding progestogen decreases risk HRT – Risks ( Latest analysis)

  26. Risk of heart disease not increased if started between 50 and 59 • Stroke – not increased if started under 60. More risk with Smoke and Over weight • Weight gain – RCT no evidence • Osteoporosis – Useful more in Premature menopause, but not a first line for prevention in older Do not use HRT In Breast or Endometrial cancer, Stroke or DVT, Severe liver disease. HRT – Risks ( Latest analysis)

  27. Tibolone(Livial) – oestrogenic, progestogenic & androgenic properties SERM - Raloxifene SSRI/SNRI - Venlafaxine/Fluoxetine/Paroxetine Clonidine - not very effective Complementary - soya, red clover, black cohosh, evening primrose, acupuncture, homeotherap Insufficient data for safety & effectiveness Non –Pharmacological - CBT Alternative options

  28. Identical to those produced by body 17 – beta estradiol or Micronized progesterone Claimed to be safe than traditional hormones Same risk and benefit as traditional Not regulated Not enough evidence for safety Salivary hormones – not representative of serum levels Bio-identical Hormones

  29. Menopause – Diagnosis and Management Nov 2015 NICE

  30. Challenge is to reduce the use of FSH in diagnosing perimenopause and menopause No periods for at least 12 months & not using hormonal contraception = menopause Women without uterus but has menopausal symptoms = menopause DO NOT use FSH test to diagnose menopause if on COCP or high dose progestogen Consider using FSH test as a diagnostic test for menopause: Age 40-45 years with menopausal symptoms including irregular periods < age 40 with a suspicion of early onset of menopause Diagnosis of perimenopause and menopause

  31. DO NOT use the following test to diagnose menopause • > 45 years old • Inhibin A and inhibin B • Estradiol • Anti-Mullerian hormone • Antral follicle • Ovarian volume Diagnosis of perimenopause and menopause

  32. Can be used in HRT contraindicated women after expert advice Increase dose if needed after expert advice (Up to 5 times a week) Used along with vaginal lubricants and moisturisers Vaginal oestrogens

  33. HRT • If HRT alone not effective, consider testosterone supplementation • In younger women where ovaries are absent, testosterone is considered. Altered sexual function

  34. Age 40 • Women using HRT should not rely on this as contraception • POP can be used with HRT to provide effective contraception (must be combine HRT) • Can use oestrogen replacement therapy + MIRENA to provide endometrial protection HRT and Contraception

  35. Give information on all treatment options • Paroxetine and Fluoxetine should not be offered to patients with breast cancer on tamoxifen • Refer for expert advice Women with, or at high risk of breast cancer

  36. Advice regarding stopping HRT • 2 choices – gradually reducing or immediate cessation • Gradually reducing HRT may reduce the recurrence of symptoms in the short term • No difference of symptoms in long term Stopping HRT

  37. Case discussion

  38. 52 year old secondary school teacher No relevant medical history Always calm and organised Recently irritable and struggling to cope with minor challenges Exploited by school children of her weakness Unable to sleep, asking GP for more sleeping tablets Case study

  39. Relevant history LMP 6/12 ago, before that 3/12 ago Night sweats with severe chills sometimes, occasional day time flushes Often wakes then sweats No interest in sex, often it hurts How to approach?

  40. Explanation Information www.menopausematters.co.uk www.womens-health-concern.org.uk www.menopause-health-concern.org.uk www.daisynetwork.org.uk What to do next?

  41. Sequential combined HRT Ellesteduet 1mg Estradiol 1mg plus NET 1mg from day 17-28 NHS cost £9.72 for 3 months What do we choose now?

  42. Persistence of symptoms Any new symptoms/side effects? When do they occur in the cycle? Bleeding pattern BP Review of risk analysis Review in 3 months

  43. Symptoms and sleep better in the first 2 weeks of the pack Not so good and tearful when pill colour changes Bleeding is fine 2- 3 days in to the new pack Would like to improve things 3 months later

  44. Increase estrogen Change progestogen preparation Femoston 2:10 ( 17B estradiol 2mg plus 10mg dydrogesterone) Cost £13.47 for 3 months Modify treatment

  45. More Case Discussions HRT- Dilemmas

  46. 33 year old, Aplastic anemia ( when she was 25), had chemo, No periods for many years. Now, random periods, terrible menopausal symptoms Case 1

  47. Possible Premature Ovarian Insufficiency Confirm with FSH Combined, sequential HRT until 51. Case 1 - Discussion

  48. 52 years old, post Lap BSO for BRAC2. On Tamoxifen for Chemo prevention of breast Cancer Low mood, tiredness, night sweats, Vaginal dryness, No sex drive Type 1 diabetic, high BMI, High BP Case 2

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