T10

Menopausal symptoms in 52 year

old woman
Case scenario
◦ A 52 year old woman attends your clinic complaining of hot flush and night sweats. She
has had no periods for the last 14 months
Term & definition
◦ What is Menopause ?
◦ Menopause is a state of natural ovarian senescence with accompanying estrogen
deficiency.

◦ It also refers to states of ovarian failure and ovarian destruction/removal with

accompanying estrogen deficiency.

◦ - Occurred after 12 consecutive months of amenorrhea with no obvious pathological or

physiological cause present
Diagnosis of menopause
◦ Clinical :
1. Age around menopause ( around 50 years )
2. No periods for 12 months
3. Menopausal symptoms
NB: all 3 criteria need not be present for a diagnosis

◦ Laboratory :
1. FSH level > 35miu/ml
2. Estrogen< 20pg/ml
Type of Menopause Description
Premature Woman aged <40 years
Early Woman aged 50 -59 years
Late Woman aged >60 years
Surgical Surgical removal of both ovaries
in a woman
Medical Permanent damage to both
ovaries in a woman following
either
chemotherapy or radiotherapy
1) What other symptoms related to the climacteric might you elicit
on history taking?

◦Climacteric
◦ Transition from the reproductive state to non-reproductive state
◦ Results in hypoestrogenemia and high FSH concentrations
 Symptoms
Short-term Vasomotor (85%) -Headache
Problems -Hot flushes
(0-5 years) -Night Sweats
-Palpitations
-Insomnia
Psychological -Irritability, mood changes
-Poor concentration
-Poor short-term memory
-Depression
-Lethargy
Intermediate Urogenital -Urethral Symptoms (urgency,dysuria,etc)
Problems - Recurrent UTI
(3-10 years) -pelvic floor dysfunction
-Atrophic vaginitis/vulvitis
-reduced libido
Cutaneous/ -Vaginal Dryness
Connective - Dry skin
Tissue -Dry Hair
-Brittle Nails
Long-term Skeletal -Osteoporosis
Problems Cardiovascular -Coronary Heart Disease
(>50% of women) -Thrombosis
(>10 years)
◦HAVOC
◦ History should concentrate on ascertaining the frequency and severity of menopausal
symptoms and their impact on day to day activities
◦ Enquiry into any sexual problems particularly vaginal dryness, soreness
◦ Bladder symptoms
◦ Any previous treatments and side effects
◦ Family and personal history
◦ Risk factors for CVS, osteoporosis, breast ca, thrombosis, ovarian ca
2)What are the other main
consequences of lack of oestrogen in
the medium and long term?
Symptoms
Intermediate Urogenital -Urethral Symptoms (urgency,dysuria,etc)
Problems - Recurrent UTI
-pelvic floor dysfunction
-Atrophic vaginitis/vulvitis
-reduced libido
Cutaneous/ -Vaginal Dryness
Connective - Dry skin
Tissue -Dry Hair
-Brittle Nails
Long-term Skeletal -Osteoporosis
Problems Cardiovascular -Coronary Heart Disease
(>50% of women) -Thrombosis
3) What treatment is available to
control this woman’s symptoms?

Hormonal
Prescription
Treatment
Non hormonal
available
Alternative
Non Prescription Description
Lifestyle changes Diet and exercise
Complementary therapies Acupuntuncture,
reflexology, magnestism
Herbal remedies Black cohosh, Dong Quai,
evening primrose oil,
gingko, ginseng, kava
kava, st John’s wort
Bio identical hormone Natural progesterone gel,
DHEA, phytoestrogen
Prescription Description
a- adrenegic agonist Clonidine
Beta-blockers Propanolol
Selective serotonin Venlaflaxine, fluoxetine,
reuptake inhibitor (SSRI) paroxetine, citalopram,
gabapentin
Hormone replacement Oestrogen alone
therapy (HRT ) Oestrogen and
progestogen combined
Progestogen alone
(ii) What would you suggest would
be most appropriate?

◦ Holistic approach

◦Hormonal therapy + ( lifestyle modification,

proper diet, regular exercise, cessation of
smoking and avoidance of alcohol abuse )
Hormonal therapy
◦ Indication and contraindication
◦ Counselling and decision making
◦ Pre treatment evaluation
◦ Timing of initiation
◦ Dosages and routes of administration
◦ Addition of progestogen
◦ Duration of use
◦ Risk of HRT
◦ Follow up assessment and frequency
 Indications
Type Description

Presence of symptoms Relief of :

i) Vasomotor symptoms
ii) Joint and muscle aches and pains
iii) Sleeplessness
iv) Depressed mood
v) Urogenital symptoms, vaginal dryness
vi) Sexual dysfunction
vii) Improve quality of life

Osteoporosis prevention First line choice postmenopausal

Prevention of fracture in postmenopausal
Contraindication
◦ History of breast cancer
◦ History of VTE or stroke
◦ Undiagnosed uterine bleeding
◦ Significant CVS disease
◦ Hypersentivity to oestrogen
Counselling
◦ Risks of menopause vs benefit of HRT
◦ Risk and side effect of HRT
◦ Type of HRT and how to take it
◦ Preferences and expectations
◦ Compliance and follow up
◦ Informed consent
Pretreatment Evaluation
Evaluation Description

History Medical, hysterectomy

and family
Examination Weight, height, BMI, BP,
Breast, Vaginal, Cervix

Investigation Mammography,
Cardiovascular ( Lipid
profile, diabetes, FBC )
Timing
Algorithm
for HT
Dosage
◦ Lowest effective dose of oestrogen and progesterone
◦ Same effective as standard dose
◦ Progestogen is added to systemic oestrogen
◦ Protect endometrial from unopposed oestrogen
◦ 12-14 days for every 28 days of estrogen ( cyclical ) or together (continuous )
◦ Not required in patient who had hysterectomy
 Dose Regimes
Estrogen (ET) Standard Dose Low dose
Conjugated equine 0.625mg 0.3mg
estrogen
17B estradiol valerate 2.0mg 0.5mg- 1.0mg
Micronised estradiol 1.0-2.0mg 0.25 – 0.5mg
Transdermal estradiol 50-100mg 25mcg
Progestogens (EPT) Standard Dose Low dose
Medroxyprogesterone 2.5-5.0mg 1.5mg
acetate
Norethindrone acetate 1.0-2.0mg 0.1-0.5mg
Drosperinone 2mg 0.5mg
Micronised progesterone 100mg 50mg
 Hormone therapy preparation in
Malaysia
Name Type Dose
Angelic Estradiol hemihydrate + 1.0mg
Drosperinone 2.0mg
Climen 16 pills Estradiol valerate 2.0mg
12 pills Estradiol valerate + 2.0mg
Cyproterone acetate 1.0mg
Divigel gel 28sachet Estradiol 1mg/g
Femoston Estradiol 1.0mg
Estradiol + 1.0mg
dydrogesterone 10.0mg
Femoston Contii Estradiol + 1.0mg
dydrogesterone 5.0mg
Oestrogel Gel 17B Estradiol 1.5 / 2.5g
Name Type Dose (mg)
Premarin Conjugated equine estrogen 0.3mg /0.625mg

Premarin vaginal cream Conjugated equine estrogen 0.3mg/0.625/42.5g

Premelle 2.5 Conjugated equine estrogen + 0.625mg

medroxyprogesterone acetate
2.5mg

Premelle 5.0 Conjugated equine estrogen + 1.0mg

medroxyprogesterone acetate
2.0mg

Progynova Estradiol valerate 1.0mg

Estradiol valerate 2.0mg
Progyluton 11 pills Estradiol valerate 2.0mg
10 pills Estradiol valerate + norgestrel 2.0mg
500mcg
Hormone therapy in HPP
a.Patient with uterus (EPT)
◦ Bleeding:
1.Progyluton, Premelle 2.5 OD

◦ Non bleeding:
1. T. Premarin 0.625mg with Provera 5mg OD
2. T. Kilogest (estradiol + norethisterone acetate ) OD
3. T. Tibolone (livial ) OD

Cyclical ( Regular period – monthly )

( irregular period – 3monthly )
Continuous (Post Menopause)
b. Patient without uterus (ET)
1. T. Premarin 0.625mg OD
2. T. Progynova OD
 Route
◦ Oral
◦ Transdermal
◦ Cream ( atrophic vaginitis )

• Depends on the woman’s preference

• No mandatory limitation as long no contraindication ( usually stop when 5 years of use )
Follow-up at Gynaecology Clinic
◦ Annual ( 6 or 12 monthly )
◦ Counselling
◦ Pretreatment evaluation
◦ Mammography ( if initial normal, 2-3 yearly )
◦ Genital tract cancer (pap smear 3 yearly )
iii) What are the potential benefits of
combined oestrogen/ progestogen (
E/P ) hormone replacement therapy
( HRT ) if it was given?
Potential Benefit Of HRT
◦ Relieving menopausal symptoms
◦ Reduce incidence of osteoporotic fractures
◦ Reduce rate of tooth loss
◦ Protect endometrial from unopposed oestrogen ! ( COCP only )
4)What are the adverse effects
taking this treatment Dr?
Common side effects with HRT
•Progestogen related
◦ Oestrogen related •(more troublesome, often
◦ (usually dose related, settle resemble premenstrual
within afew weeks) symptoms)
•Fluid retention
◦ Fluid retention
•Breast tenderness
◦ Nausea
•Headaches
◦ Headaches •Acne
◦ Breast enlargement •Mood swings
◦ Leg cramps •Depression
◦ dyspepsia •Irritability
•Boating
•Constipation
•Increased appetite
◦ Increase risk of :
◦ Breast carcinoma
◦ Endometrial carcinoma
◦ Thromboembolic disease X2-4
◦ Cardiovascular disease – MI and CVA (stroke)
5a) If the patient has experienced
the same symptoms at the age of 38
years, and her serum FSH and LH
levels were shown markedly
elevated, would the treatment
advice be any different?
NO
◦ Premature menopause = menopause before 45 years old.
◦ Need to rule out other causes of premature ovarian failure
◦ Confirm diagnosis, start HRT treatment as soon as possible primarily to prevent
osteoporosis
◦ Usually continue until the average menopausal age
◦ Advice about healthy lifestyle
Primary Secondary

Chromosome Anomalies Surgical Menopause after bilateral

e.g. Turner’s, Fragile X syndrome oophorectomy

Autoimmune Disease Chemotherapy or Radiotherapy

e.g hypothyroidism, myasthenia gravis,
Addison’s

Enzyme Deficiencies Infections

e.g. Galactosaemia e.g. mumps, tuberculosis, malaria
5b) Are the adverse effect will be
different if E/P is given for 10 years
from the age of 38 years as
compared to the same length of
time from the age of 52 years old?
◦The minor symptoms are similar
◦Minor side effects – headache, nausea, breast
tenderness, fluid retention, weight gain

◦The increased risk of 1.35 for breast ca in women

taking 5 years HRT is not seen in women who start
early for premature menopause.
◦ Suggesting that it may be the lifetime sex hormone exposure that is relevant
6) Are the benefit and adverse
effect are different if the women is
only given oestrogen HRT?
Benefit
◦ Relief menopausal symptoms such as hot flushes
◦ Reduce risk of progestogenic effect :
◦ Breast tenderness
◦ Acne
◦ Mood swings
◦ Bloating
◦ Constipation
◦ Increase appetite
◦ Improve urogenital function and sexual function
◦ No increase in risk of breast cancer, VTE and CHD compared to combined therapy
Adverse Effect
◦Increase risk of endometrial
hyperplasia further progress to
carcinoma in non-hysterectomized
women.