MENOPAUSE & HRT

Nicola Stewart
Sarthak Timbadiya
28/02/2018
Physiology & Clinical Features
● 1.5 million oocytes at birth.
● 1/3rd lost by menarche.
● Peri-menopause – increased anovulatory cycles.
● Clinical Features: (affects 2/3rd woman)
● Menstrual irregularity
● Vasomotor
● Musculoskeletal
● Psychological
● Urogenital
● Cardiovascular
● Osteoporosis
● Breast disease
Case Study 1
● 43 year old
● Mirena coil for 2 years
● Presenting with:
● Inter menstrual and post coital bleeding
● Increased anxiety, snapping
● No hot flushes or night sweats, not low in mood, no
change to libido
● No FH of early menopause
● Asking if she is peri-menopausal?
● Asking to have a blood test?
Diagnosis
● Diagnosis should be based on clinical symptoms if
>45
● Perimenopause – vasomotor Sx & irregular periods
● Menopause – no period for 12m & not taking contraception
(Sx if no uterus)
● Consider FSH if…
● >45 years with atypical symptoms
● 40-45 years with Sx and change in periods
● <45 years and suspecting premature menopause
● Laboratory results
● Consistently raised FSH >30IU/l.
● Raised LH
● Low serum oestrdiol.
Assessment of Menopause
● Assess symptoms and their severity
● Assess risk of cardiovascular disease (Qrisk)
● Assess risk of osteoporosis
● Discuss her expectations
● Only carry out investigations if…
● Sudden change in menstrual pattern (IMB, post coital)
● Personal or FH of DVT
● High risk of breast cancer
● Evidence of arterial of other gynaecological disease
Case Study 2
● 34 year old
● Has not had a period for 7 months
● FH of premature menopause
● Nil other symptoms
● Asking if she should be tested for this?
● Asking what management might be required?
Premature Menopause
● Menopause <40 years (1%).
● Risk of osteoporosis and IHD
● Diagnosis – FSH >30 with raised LH and low
oestrogen on two occasions 4-6 weeks apart
● Management
● Should have hormonal treatment with HRT or
combined hormonal contraceptive until age of
natural menopause & 5-10 yrs after
● HRT can benefit BP/ CVS risks, but both HRT and
combined contraceptive offer bone protection.
● HRT not a contraceptive
Case Study 3
● 52 year old
● Suffering from hot flushes, night sweats and loss of
libido
● Last period was 8 months ago
● Would like to discuss HRT.
● Benefits and risks?
● If there are things she can also adjust herself?
● What she should start?
HRT
● Indications
● Relief of vasomotor or other menopausal
symptoms
● Prevention of osteoporosis
● Premature ovarian failure
● Contraindications
● Pregnancy, undiagnosed abnormal PV bleeding
● Active thromboembolic disorder or MI
● Breast disease or endometrial cancer
● Active liver disease
HRT
● Modifiable lifestyle factors
● Healthy balanced diet
● Calcium supplements
● Smoking, alcohol and caffeine
● Optimise management of their co-morbidities
● Benefits
● Reduce vasomotor symptoms
● Improved sleep, joint pain, quality of life
● Reduced psychological symptoms
● Reduce vaginal dryness and improve sexual function
● Improve bone mineral density
Counselling Points
● Irregular bleeding is common in first 3-6
months
● (Bleeding > 6mnths/ after amenorrhoea requires Ix)
● Importance of adherence with treatment
● Remind peri-menopausal women that HRT is
not a contraceptive
● Can stop contraception at 1 year after period if >50
yrs and 2 years if <50yrs or 56yrs
● No evidence that HRT causes weight gain
Risks (over 5 years)
● Breast cancer
● <50yrs on HRT no extra risk
● Background risk is 15/1000. 2-6/1000 extra cases
● Ovarian cancer
● Background risk is 2/1000. <1 extra case over 5 yrs
● Endometrial cancer
● Combined HRT protects endometrium
● B/G risk is 2/1000. 4 extra cases over 5 yrs (oestrogen only)
● Venous thromboembolism
● Background risk is 5/1000. 2 extra cases over 5 yrs
● Cardiovascular disease
● No increased risks
Risks (in perspective)

● Breast cancer
● <>2-3 units alcohol per day increases risk by 1.5x
● Post menopausal obesity increases risk by 1.6x
● First pregnancy >30 years increases risk by 1.9x
● 5 years of HRT increases risk by 1.35x
Management Algorithm

● HRT Guidance and Treatment Pathway

Case Study 4
● 54 yr old has read the PIL on HRT and
decided that she does not want to accept the
potential risks.
● Suffers from hot flushes and would like to know
what she can try?
● Finding sex uncomfortable, would like to know what
she can try?
Alternative Treatments
● Vasomotor symptoms
● Fluoxetine, citalopram, venlafaxine or clonidine
● Vaginal dryness
● Vaginal lubricants
● Sexual dysfunction
● Seek specialist advice re; testosterone
● Psychological symptoms
● CBT, antidepressants
● Tibolone
● Beta blockers, gabapentin, complementary
therapies
Case Study 5
● 57 year old
● Menopausal symptoms
● LMP: 2 yrs ago.
● PMH: DVT following laparotomy.
● Asking if she can start HRT?
Management of Co-Morbidities
● With or high risk of breast cancer
● Non-hormonal and non-pharmacological treatment
● St Johns Wart (Tamoxifen)
● Refer for further specialist input
● Risk of VTE
● Transdermal rather than oral
● Refer to haematologist if high risk
● Cardiovascular disease
● Can use HRT. Manage risk factors
● Type 2 diabetes
● Can use HRT. No effect of glucose control
Case Study 6
● 51 year old
● Presenting with mastodynia (worse over 3-4
months) and symptoms of hot flushes, night sweats
and tearfulness
● Estradiol for 15 months. Mirena for 3 years.
● No periods
● Has tried St Johns Wort and primrose oil

● What options would you give her?

Poor Symptom Control
● Check compliance and allow time
● Usually 3 months before making any changes
● Poor patch adhesion or skin irritation
● Change brand
● Inadequate oestrogen dose
● Increase dose or change route
● Unrealistic expectations
● Counsel
● Drug interactions
Side Effects
When to Refer
● Persistent side effects
● Difficulty in diagnosis
● Loss of libido causing significant distress
● Premature menopause
● Patient request
● Difficulty in knowing when to stop HRT
● (usually consider at 5 yrs as they enter
menopause)
● Complex medical history
Review
● Follow up at 3 months
● Then annual review
● Effectiveness, s/e, dose, route, pros and cons
● BP, cervical and breast screening, osteoporosis
● Roughly for around 5 years after onset of
symptoms
● There is no mandatory limitations
● HRT should be withdrawn slowly