Premature menopause
Download
1 / 56

Premature Menopause - PowerPoint PPT Presentation


  • 472 Views
  • Updated On :

Premature Menopause. Michael Savvas King’s College Hospital,London. Premature Menopause . Menopause before the age of 40 Affects 1% of women. Loss of Ovarian Function. May not be permanent Spontaneous recurrence of ovarian function and even pregnancy are possible.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Premature Menopause' - emily


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Premature menopause l.jpg

Premature Menopause

Michael Savvas

King’s College Hospital,London.


Premature menopause2 l.jpg
Premature Menopause

  • Menopause before the age of 40

  • Affects 1% of women


Loss of ovarian function l.jpg
Loss of Ovarian Function

  • May not be permanent

  • Spontaneous recurrence of ovarian function and even pregnancy are possible


Six months of amenorrhoea l.jpg
Six months of amenorrhoea

  • Less than 1% return of fertility


Diagnosis l.jpg
Diagnosis

  • Amenorrhoea

  • Climacteric Symptoms

  • Raised FSH - Reduced Oestradiol

  • Biopsy unhelpful


Causes of premature menopause l.jpg
Causes of Premature Menopause

  • Idiopathic

  • Chromosomal abnormalities

    Turner’s syndr., X chromosome deletions

  • Autoimmune

  • Galactosaemia

  • Radiotherapy / Chemotherapy

  • Surgery – TAH, BSO, Ovarian Cystectomy

  • Infection - Mumps, TB.


X chromosome deletion rossetti et al 2004 l.jpg
X chromosome deletionRossetti et al 2004

  • Inherited deletion of X chromosome in mother and two daughters

  • Mother menopause at 43 years

  • Daughters menopause at 17 and 22 years

  • Role of environment


Pof the role of pelvic surgery l.jpg
POF - The role of pelvic surgery

  • Hysterectomy

  • Uterine Artery Embolisation

  • Ovarian surgery

  • Other Pelvic surgery


Anastomoses in pelvic circulation razavi et al 2004 l.jpg
Anastomoses in pelvic circulationRazavi et al 2004

76 patients undergoing UAE

10 (6.6%) main blood supply to the ovary was from the UA


Consequences of pof l.jpg
Consequences of POF

  • Symptoms

  • Infertility

  • Bone Loss

  • Heart Disease


Pof psychological symptoms l.jpg
POF - Psychological Symptoms

  • Depression

  • Low levels of self esteem and Life satisfaction

  • Sexual Dysfunction


Pof symptoms baber abdalla and studd 1991 l.jpg
POF-SymptomsBaber, Abdalla and Studd (1991)

  • Vasomotor 76%

  • Loss of libido 31%

  • sexual enjoyment reduced 37%

  • Most Distressing symptom

    Loss of fertility 54%

    Feeling Older 27%


Premature ovarian failure l.jpg
Premature Ovarian Failure

May present with infertility


Pof subfertility l.jpg
POF & Subfertility

  • 12 women aged 35-40 with poor ovarian response to stimulation

  • 11 developed menopausal symptoms within 7 years

  • Only 4 out of 24 controls

    (Nikolaou et al 2002)


Pof osteoporosis l.jpg
POF- Osteoporosis

  • Rate of bone loss same as following natural menopause

  • But consequences more severe as longer life expectancy


Premature menopause16 l.jpg
Premature menopause

  • Associated with significantly higher incidence of osteoporotic fractures

    Van Der Voort DJ et al Osteoporosis Int 2003


Premature menopause17 l.jpg
Premature Menopause

  • Increased incidence of heart disease


Age at menopause and heart disease l.jpg
Age at menopause and heart disease

  • 12115 women aged 50-65 attending for breast screening

  • Risk of heart disease higher in women with early menopause

  • For each year delay in menopause mortality from heart disease decreased by 2%

    Van der Schouw et al Lancet 1996


Premature menopause and endothelial function kalantaridou et al 2004 l.jpg
Premature menopause and endothelial functionKalantaridou et al 2004

  • 18 women with premature menopause

  • Endothelial function assessed using flow mediated dilatation of the the brachial artery in response to hyperaemia of the hand

  • Before and after six months CEE 0.625 and cyclical MPA


Endothelial function l.jpg
Endothelial function

  • Flow mediated dilatation lower in women with prem. Menopause.

  • After six months HRT flow mediated dilatation was improved and reached normal values

  • GTN induced (endothelial independent) dilatation no difference in two groups


Premature menopause21 l.jpg
Premature Menopause

  • 19,731 post menopausal women studied

  • All cause mortality

  • Inversely related to age at menopause

    Jacobsen et al Am J epidemiol. 2003


Premature menopause hrt l.jpg
Premature MenopauseHRT

  • Need HRT at least until the age of 51

  • Compliance usually very good

  • Results of WHI and HERS studies not applicable to this age group

  • But what is the most appropriate HRT?


Premature menopause hrt23 l.jpg
Premature MenopauseHRT

  • Oral

  • Patches, Gels

  • Implants

  • COC


Choice of hrt for women with premature ovarian failure l.jpg
Choice of HRT for women with premature ovarian failure

UK Soc Paediatric Endocrinology 42 questionnaires (28 responses)

  • COCP 18 (64%)

  • Oral HRT (sequential) 5 (18%)

  • Transdermal HRT (sequential) 3 (11%)

  • Ethinyloestradiol (sequential) 2 (7%)


Premature menopause25 l.jpg
PrematureMenopause

  • Combined pill

    • Convenient

    • “Peer Friendly”

    • Free


Premature menopause and the coc l.jpg
Premature Menopauseand the COC

  • Combined Pill v HRT

    • Guttman et al 2001 Clin Endocrinol

    • 0.625mg v 30mcg EE in 17 adult women with Turner’s Syndrome

    • FSH most suppressed by EE, BUT HRT was superior at minimising hyperinsulinaemia & bone turnover


Hormone implants l.jpg
Hormone Implants

  • Higher Circulating oestradiol

  • More effective Symptom control

  • Better skeletal effects

  • Better effects on uterus?


Slide28 l.jpg

1.0

0.9

0.8

0.7

spine

prox femur

0.0

Pre treat

Oral

Implant

Mean (+SEM) spine and femoral neck bone density in post menopausal women untreated and oral and implant therapy

Savvas et al. 1988


Slide29 l.jpg
Percentage change in bone density on 3 different doses of hormone implants after 1 yearStudd et al BJOG (1994)


Testosterone l.jpg
Testosterone hormone implants after 1 year

  • Can improve mood and libido

  • Particularly helpful following oopherectomy


Hrt and breast cancer l.jpg
HRT and Breast cancer hormone implants after 1 year

  • Fear of breast cancer important factor deterring women from taking HRT


Incidence of breast cancer from 50 to 70 years of age beral et al 1997 l.jpg
Incidence of Breast Cancer from 50 to 70 years of age hormone implants after 1 yearBeral et al 1997


Women s health initiatve jama 2002 288 321 333 l.jpg
Women’s Health Initiatve hormone implants after 1 yearJAMA 2002;288:321-333

  • Two parallel RCT

  • Study 1

  • 8506 women received HRT

  • (0.625mg CEE+2.5mg MPA)

  • 8102 received placebo

  • Study 2

  • Oestrogen alone Vs placebo

    Women with menopausal symptoms or osteoporosis needing HRT not recruited into study.


Whi e p study l.jpg
WHI E+P Study hormone implants after 1 year


Whi study study 1 l.jpg
WHI Study hormone implants after 1 yearStudy 1

  • Due to run for 8.5 years

  • Halted at a mean 5.2 years

  • Incidence of Breast cancer reached pre-specified safety limit


10 000 women receiving hrt per year l.jpg
10,000 Women receiving HRT hormone implants after 1 yearper year

  • 8 additional cases of Ca breast (RR 1.26)

  • 7 heart attacks (RR 1.29)

  • 8 strokes (RR 1.41)

  • 8 pulmonary embolism (RR 2.13)

  • 6 fewer cases of bowel cancer

  • 6 fewer hip fractures

  • overall mortality not affected


Problems with whi e p study l.jpg
Problems with WHI (E+P) study hormone implants after 1 year

  • Patients were old

  • Even younger women were many years past the menopause

  • Patients were overweight

  • Risks may be related to progestagens in general or specifically to MPA

  • Related to Continuous combined regimen


Whi and heart disease l.jpg
WHI and Heart Disease hormone implants after 1 year

  • Backround Incidence of cardiac events in this group is 53/10 000 per year

  • Study thus underpowered to detect change in this group

  • Larger numbers in this age group may have revealed significant reduction in risk


Since the whi study july 17 th 2002 l.jpg
Since the WHI Study hormone implants after 1 yearJuly 17th 2002

  • 50% of American women have stopped HRT

  • 30% of British women have stopped HRT


Whi oestrogen alone jama 2004 291 1701 1712 l.jpg
WHI oestrogen alone hormone implants after 1 yearJAMA 2004 ;291:1701-1712

  • Mean age 63.6

  • Study terminated at 6.8 years

  • Increased risk

    CVAs

  • No increased risk

    Breast Cancer

    CHD

    Pulmonary Embolus


Whi oestrogen alone l.jpg
WHI Oestrogen alone hormone implants after 1 year

  • CVAs

    12 extra cases per 10 000 woman years

  • Breast cancer

    7 fewer cases per 1000 woman year but not statistically significant


Whi oestrogen alone43 l.jpg
WHI oestrogen alone hormone implants after 1 year

  • Data suggest more favourable findings in 50-59–year-old women

  • Absolute risk small


Whi oestrogen alone breast cancer and age l.jpg
WHI oestrogen alone hormone implants after 1 yearBreast Cancer and age


Hrt and risk of breast cancer l.jpg
HRT and risk of breast cancer hormone implants after 1 year

  • Survey of 600 doctors in 2004

    203 Gynaecologist

    145 Physicians

    219 GPs

  • Correct estimate of risk 28%

  • Overestimated risk 67%

    Gynaecologist more likely to accurately estimate risk

    Williams et al 2005


Hrt and estimated risk of breast cancer coombs et al bmj 2005 l.jpg
HRT and Estimated Risk of Breast Cancer hormone implants after 1 yearCoombs et al BMJ 2005

50 yr old woman cumulative risk to 79 yrs

No HRT 6.1%

Oestrogen alone 6.3%

Combined HRT 6.7%

  • Additional breast cancer risk for an individual is very small


Premature menopause47 l.jpg
Premature Menopause hormone implants after 1 year

  • Impact of WHI and HRT in women with Premature Menopause

    • Ng C., Reddy N., Panay N. 2004 ESHRE Berlin

  • Awareness of Recent HRT Publicity 100%

  • 7 (16%) had stopped HRT as a result of publicity

  • 5 sought advice before stopping

  • 37% were considering stopping HRT because of breast cancer fears

  • Less than half realised that risks did not apply to their age group


Premature ovarian failure48 l.jpg
Premature ovarian failure hormone implants after 1 year

Fertility Treatment


Fertility l.jpg
Fertility hormone implants after 1 year

  • Spontaneous pregnancy very rare

  • Ovulation induction unsuccessful


Oocyte donation l.jpg
Oocyte Donation hormone implants after 1 year

IVF Using donated oocytes


Oocyte donation kings college hospital l.jpg
Oocyte Donation hormone implants after 1 yearKings College Hospital

2002-2004

  • 20 Cycles with fresh ET

  • 8 pregnancies

  • 40% per ET

  • Independent of recipient age


Oocyte donation the lister hospital 2001 l.jpg
Oocyte donation hormone implants after 1 yearThe Lister Hospital 2001

  • Patients 213

  • Cycles 210

  • Pregnancies 95

  • 45% per cycle


Obstetric outcome abdalla et al 1998 l.jpg
Obstetric outcome hormone implants after 1 yearAbdalla et al 1998

Higher incidence of

  • Miscarriage

  • PIH

  • small for gestational age

  • PPH


Premature menopause and hrt conclusion l.jpg
Premature Menopause and HRT hormone implants after 1 yearConclusion

  • Encourage HRT at least until 51 yrs

  • No increased risk of breast cancer


Thank you for your attention l.jpg

Thank you for your attention! hormone implants after 1 year


Pof and sub fertility l.jpg
POF and sub fertility hormone implants after 1 year

  • 31 women who required induction of ovulation

  • 200 controls

  • Menopause at 46.4 years

  • Menopause at 50 years in controls