The Menopause and HRT Dr Joanne Thompson November 2014

How Many…. Deal with women directly concerning the Menopause and HRT? (HRT checks/well women clinics etc.) Deal with women indirectly concerning Menopause and HRT? (queries at other appointments, e.g. minor illness, smears etc)

How Many….. • Have had specific training around the Menopause and HRT? • Initiate or prescribe HRT? • Feel confident to give advice about the Menopause, and where to go for help and advice?

Write down as many Symptoms of the Menopause that you can think of!

What is the Menopause?

Definition ‘The Cessation of Menstruation’ Practically speaking 12 months without a period in a woman in the appropriate age group. May be better to say Ovarian failure as this would cover other groups of women e.g. those who have had hysterectomy

• Chambers Dictionary Definition of ‘menopausal’ – • ‘…suffering from strange moods or behaviour in middle age’ !

• Normal age range considered to be 45-55

• Occurring 40-45 = early menopause

• Occurring < 40 = Premature Ovarian Failure (1/100 incidence)

Causes of Menopause • Natural/Genetic • Surgical • Drug induced

•Emma, 50, comes for a routine smear test. She obviously finds the procedure very uncomfortable, and when you mention this she bursts into tears, and tells you that she is getting a lot of symptoms that she thinks are to do with the menopause. She wonders if she should have ‘some tests’. •Her periods are all over the place – she had one last week but that was the first one that she had had for 6 months. It was very light. Sex is very uncomfortable as she feels very dry, and in any case she doesn’t often feel like it anyway. •She is very tired as her sleep is disrupted by bouts of sweating when she has to throw all the covers off, and during the day at work she regularly comes over all hot, and feels embarrassed as her colleagues notice this.

•Has Emma had her Menopause? •Does she need any tests? •What would you do next? •If Emma was having heavy prolonged bleeding would you consider anything else?

Options • Reliable information • Bring back to suitable appt., e.g. ‘Well Woman’ Clinic

• Refer to interested GP/menopause clinic • Consider local treatment for smear test • Advice re vaginal lubricants

Testing for Menopause • Raised FSH levels • Not indicated routinely • If still having periods, even irregularly, hormone levels will fluctuate • Raised FSH levels will not be detected in those taking oestrogen (COC,HRT) However can be found in those using progestogens only e.g. POP, Mirena

Endometrial Cancer • 25% Endometrial cancers are diagnosed premenopausally. • Increasingly heavy prolonged periods or bleeding between periods for example may need investigation.

• U/S and endometrial biopsy may be needed.

Where to go for Information • British Menopause Society – www.theBMS.org.uk • Women’s Health Concern – www.womens-health-concern.org • Menopause Matters – www.menopausematters.co.uk • The Daisy Network – www.daisynetwork.org.uk

Ctd…

• There are also sections on menopause on NHS website and Patient.co.uk

•You run a ‘Well Woman’ Clinic at your surgery and ask Emma to make an appointment to come back to discuss things further. •Emma has had a look at the Websites you have recommended, but is still undecided about whether HRT is a good idea, or if she should stick to ‘Natural’ treatments. •What are the ‘over the counter’ alternatives to HRT, and do they work? •What can you tell her about the risks and benefits of HRT?

‘Over the Counter’Alternatives to HRT

Ctd… • Oil of Evening Primrose

• St. John’s Wort

• Black Cohosh

• Sage

• Agnus Castus

• Valerian

• Gingko Biloba

• Red Clover

Prescribable Alternatives to HRT • Clonidine 50mcg bd rising to 75mcg bd after 2 weeks. • Venlafaxine 37.5mg bd (+ other SSRI) • Gabapentin start 100mg tds, can gradually increase.

Benefits of HRT • Eradication of flushes and sweats

• Possibly reduced colon cancer

• Improves vaginal dryness

• Possibly reduction in dementia

• Improves Overactive Bladder

•

Bone Health

• Possible benefits to cardiovascular system when started in the 10 yrs following the menopause

Risks associated with HRT

Ctd… • Blood Clots • Risk of VTE low in women > 50 (1.7:1000) • Doubled in women taking HRT, but still low overall

• Women 50-59 using HRT had same risk as those NOT using HRT in WHI data • Risks greater in first year of use

• Risks probably less with transdermal HRT and lower dose oral HRT

Ctd… • Stroke • Incidence 3: 1000 over 5 yrs in women aged 50-59 NOT on HRT

• 5 yrs HRT associated with 1 extra case • HOWEVER some studies appear to show reduction in incidence

• Cardiovascular Disease • Women within 10 yrs of menopause showed NO increased risk; in fact there may well be a benefit to cardiovascular system. • Increased cardiovascular events shown in women starting HRT 20yrs + after menopause

Four Bs and Two Cs! • Bones

• Clots

• Breast

• Cardiac

• Brain

• Bowel

Emma decides that she would like to try HRT, and asks you to tell her more about it. •What exactly is HRT? •What are the contraindications to HRT? •How would you decide what sort of HRT might suit Emma? •Are there any checks you would carry out before Emma starts HRT?

What is HRT? • Oestrogen in replaced by using oestradiol valerate, or less comonly conjugated oestrogens or ethinyl oestradiol.

• Progestogen protection is needed for the endometrium in those who have not had a hysterectomy. Various different progestogens are used, for example norethisterone or levenorgestrel.

Ways of Taking HRT • Oral • Transdermal • Combinations

• Vaginal

History and Examination •

Periods, Symptoms and Contraception

•

Personal or Family Medical Problems

LMP (? pregnancy?)

Breast/ovarian/bowel cancer

Frequency/duration/ heaviness of periods

DVT or PE Risk factors CVD/Stroke

Hot flushes/sweats Risk factors osteoporosis Vaginal dryness Migraines Other symptoms

Medication Contraception

‘The Initial Menopause Consultation’ – Sally Hope, Margaret Rees 2008

Ctd… • Examination BMI BP Encourage smear (national screening programme) Mammography (national screening programme) Committee on Safety of Medicines 2001 – ‘Clinical examination of the breasts and pelvic examination are not routinely necessary in all women taking HRT but should be performed if clinically indicated’

Flow Chart for HRT HRT History Taken

No Hysterectomy

< 1 year since last period

Sequential HRT Mirena + Oestrogen Local HRT

Hysterectomy

> 1 year since last period

Oestrogen only HRT

Continuous Combined HRT Mirena + Oestrogen Tibolone Local HRT

Combined HRT PROGESTOGEN TYPE

ORAL

TRANSDERMAL

Norethisterone

Climagest Elleste Duet/Conti Kliofem/Kliovance Trisequens

Evorel Sequi/Conti

Levenorgestrel

Cyclo-Progynova

Femseven Sequi/Conti

Drospirenone

Indivina

Dydrogesterone

Femoston/Conti

Medroxyprogesterone Acetate

Tridestra

Oestrogen Only Conjugated Oestrogens

Oestradiol Valerate - oral

Oestradiol Valerate – Transdermal Patches

Oestradiol Valerate – Transdermal Gel

Premarin

Climaval Elleste-Solo Progynova Zumenon

Evorel Elleste-SoloMX ProgynovaTS Estraderm MX Femseven Estradot

Oestrogel Sandrena

Also… • Progestogens – Micronised Progesterone (Utrogestan) – Mirena Intrauterine System – (progestogens already mentioned can in many cases be used on their own to add to separate oestrogen preparation to create tailored regimes)

• Tibolone • Livial

Emma is prescribed a sequential patch preparation containing 50 mcg estradiol valerate and norethisterone. When you see her 3 months later her sweats and flushes have resolved and there has been some improvement in her vaginal dryness. Her libido is still quite low. Are there any other options that might help Emma’s libido and vaginal dryness?

How long should Emma continue taking HRT?

Does Emma need contraception?

Testosterone • NO licensed preparations for female use • Specialist clinics may use preparations licensed for men in smaller quantities.(Testim, Testogel)

Contraception • If a woman has her menopause under the age of 50, contraception should be continued for TWO years. • If a woman has her menopause at 50 or over, contraception should be continued for ONE year.

How long should HRT be used? • Most women will use HRT for a limited number of years around the time of the menopause.

• For some, the benefits of taking HRT outweigh the risks of HRT, and as long as the woman has enough information to make an informed choice, there is no age at which HRT must be stopped.

Ctd… • Stopping HRT, then restarting at a later date, is associated with increased risk of some side effects. • PLEASE NOTE – DURATION OF USE/ INCIDENCE OF SIDE EFFECTS APPLIES TO THE YEARS AFTER AGE 50 – IT IS VERY IMPORTANT FOR THE HEALTH OF WOMEN WHO SUFFER PREMATURE OVARIAN FAILURE TO HAVE HRT UNTIL AT LEAST THE AGE OF 50.

•Jean is 72 and you see her in your minor illness session complaining of ‘itching down below for a long time’. She thinks she might have thrush. She is otherwise in generally good health and has no chronic illnesses. •Her history shows that she has had a couple of urine infections over the past year, and has to go to the toilet quite often to pass urine during the day, as well as getting up 2 or 3 times each night. You do a dipstick of her urine which is NAD.

•Is Jean likely to have thrush? •How would you manage her?

Local HRT

Local HRT ctd… • Vagifem licensed for indefinite use • Can usually be used even if systemic HRT contraindicated, e.g. blood clots, breast cancer • Can be used in addition to systemic HRT for vaginal symptoms • Ideal to use prior to smear test/ring pessary fitting • Can help bladder symptoms • 10mcg twice weekly may not be enough for some. • Advice re information leaflet!

Summary • Recognise symptoms of menopause • Understand what the menopause is • Know where to go to for reliable advice • Have an understanding of the principles of prescribing HRT, both systemically and locally • Understand the main benefits and risks of HRT • Have some knowledge re alternatives to HRT

Comments or Queries?

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