Menopause Flashcards
Metabolic pathway of oral estrogen
First pass liver metabolism
Therefore prothrombotic on coagulation cascade and adverse effect on proinflammatory markers
Percentage of women with premature menopause
1%
Age cut-off and premature menopause
<40yrs
Biochemical changes of menopause
Increased LH and FSH
Decrease inhibin
Decrease oestradiol
Symptoms of menopause
Hot flushes night sweats dry skin and hair arthralgia headaches Urinary frequency dysuria Vaginal atrophy Decreased libido Dyspareunia Mood disturbance Memory loss Insomnia
What factors reduce the age of menopause
Smoking Hysterectomy with ovarian conservation Uterine artery embolization Intrauterine growth restriction low birht weight poor weight gain in infancy childhood starvation early puberty childlessness living at high altitude Downs syndrome Congenital differences e.g, Turners or fragile X social deprivation
What factors may contribute to a later age of menopause
being breastfed
higher childhood cognitive ability
increased parity
later onset of puberty
what proportion of women in western cultures experience vasomotor symptoms
70%
Factors associated with menopausal psychological symtoms
aging parents parental dependence death of parent or close relative death of spouse divorce or separation lack of social support difficulties affecting children poor personal health work stress / redundancy financial difficulties sleep problems
what percentage of women continue to experience vasomotor symptoms at age 60-65
42%
what psychological symptoms may be associated with the menopause
depressed mood anxiety irritability mood swings lethargy lack of energy reduced concentration and memory
Vaginal symptoms of the menopause
dryness burning pruritus dysparunia prolapse
urinary tract symptoms of the menopause
urgency frequency dysuria UTIs incontinence voiding difficulties
sexual problems associated with the menopause
decreased libido
vaginal dryness
dysparunia
what is believed to be the cause of the increase in cardiovascular disease in women after the menopause
Related to decline in estrogen levels
Estrogen is known to be beneficial to cardiovascular health
When is starting HRT considered to be cardio-protective
If started in the peri-menopause or in the early menopausal years
When is starting HRT considered to increase cardiovascular risk?
If started 10+ years after menopause onset or if stopped for a prolonged period then re-started
risk factors for cardiovascular disease
Smoking hypertension abnormal lipid profile abdominal obesity diabetes psychosocial factors low intake of fruit + veg Alcohol >14 units per wk lack of activity BMI >25
What do the 2014 guidelines state as cut off for initiating pharmacological treatment of hypertension?
Men and Women under 60yrs treat if BP >140/90
Men and Women 60+yrs treat if BP >150/90
A 1mmol/L reduction in LDL cholesterol shows what % decrease in CHD mortality
20% reduction per 1mmol/L reduction in LDL cholesterol
raised LDL cholesterol increases risk of what?
increased risk of CHD incl MI and Stroke
what impact does estrogen containing HRT have on lipid profiles
estrogen replacement lowers LDL cholesterol
(but not as much as statins)
and lowers lipoprotein (a)
HRT also increases HDL cholesterol
what percentage of women have osteoporosis at age 50 and age 80
osteoporosis 2% at 50
25% at 80
what proportion of women will suffer with an osteoporotic fracture in their lifetime?
1 in 3
what factors affect bone mass
age - peaks at ~30 and declines from ~40
gender
ethnicity - higher in white europeans
genetic factors
HRT effect on fibrinogen and fibrinolysis
HRT increases fibrinolysis
And decreases fibrinogen
risk factors for osteoporosis
age - >50
Family hx of # - esp 1st degree hip #
prev hx fagility #
Premature ovarian insufficiency
early menopause
hypogonadism
BMI <18.5
alcohol >2 units / day
smoking - any amount
low calcium or vitamin D intake
lack of physical activity
Medication - corticosteroids, chemotherapy, some AEDs, some ARVs, heparin
Pmhx - RA, neuromuscular disease, chronic liver disease, malabsorption, hyperparathyroidism, hyperthyroidism, cushings
management options for preventing / treating osteoporosis
estrogen replacement - HRT 1st line for <60yo F esp if syx bisphosphonates selective estrogen receptor modulators parathyroid hormone calcitonin
factors to consider in menopausal F reporting memory problems
imapired memory common during menopause transition - related to estrogen deficiency consider stress Sleep disturbance depression alcohol or substance abuse SE of prescription medication
Is HRT beneficial for treating menopausal women with clinical depression
no - no evidence
but may help if low mood and memory affected by menopause transition - but not clinical depression.
What is the evidence re HRT and memory / dementia
HRT is not advised to improve memory or prevent dementia
But HRT does appear to decrease risk of Alzheumers in F with early menopause or POI
what impact may the menopause have on migraines
Peri-menopause may aggravate menopause due to hormonal fluctuations and associated neuro-endocrine responses
Other menopausal symptoms - VM, insomnia etc may exacerbate or provoke migraines
Some F report improvement in migraine
What impact may HRT have on migraines?
Cyclical progestogen used in HRT may induce migraine in some women
Micronised progestogens may reduce this
consider IUS or continuous combined as alternative
what proportion of women suffer with urinary incontinence at the time of the menopause
(either stress, urge or mixed)
1/3
What is the role of vaginal estrogens for women with urinary incontinence
vaginal estrogens should be used for menopausal women with vaginal atrophy and reduce the risk of recurrent UTIs
May decrease symptoms of urinary urgency
risk factors for urogenital prolpase
age parity obesity smoking chronic raised intra-abdominal pressure (constipation, chronic cough) connective tissue disorder estrogen deficiency previous hysterectomy
what proportion of women experience joint pain and stiffness around the menopause
50%
more frequent and severe if - obese, unemployed, low mood
symptoms of the menopause
daytime sweats and flushes night time sweats and flushes insomnia headaches tiredness reduced energy arthralgia and myalgia generalised itching tearfulness low mood irritability anger panic attacks palpitations day time urinary frequency / urgency nocturia urge incontinence stress incontinence vaginal dryness / soreness / itching dysparunia PCB decreased libido / difficulty achieving orgasm decreased memory / concentration menstrual irregularity / HMB / lighter bleeding
Components of a menopause consultation
symptoms menstrual hx pmhx, surgical, gynae, obs, medications family hx social hx - stress, alcohol, drugs, OTC discuss attitude to menopause / address misconceptions / concerns Contraceptive and sexual health needs HRT benefits and risks non HRT management options Baseline BP, height, weight, BMI, examination and investigation as indicated
areas to ask about regarding personal or family history with regard to a menopause consultation
Breast / bowel / ovarian cancer - 1st degree relative, what age, BRCA testing?
VTE - 1st degree relatative, when, was it provoked, what treatment
risk for heart disease / stroke - exercise, past hx, 1st degree relative + what age, smoking, HTN, DM, lipid profile, obesity
Risk for osteorporosis - menopause <45yo, corticosteroids for 6m+, anorexia, family hx, calcium / vit D deficiency, prev # + details
other - migraine, current medication, OTC / supplements / alternative remedies, risk of pregnancy, sexual health needs, discomfort with sex, bladder symptoms, diet, alcohol.
when should an FSH level be taken to diagnose menopause
< 40 and suspicion of POI
Consider if 40-45 and change in cycle
Needs to be repeated on at least 2 occasions.
Day 1-5 of cycle
At what point of the cycle should an FSH level be taken
day 1-5 of cycle
random if amenorrhoic
what contraceptives will make FSH levels unreliable
CHCs
HRT
(not depo provera - inhibits LH surge only)
when may serum estradiol levels be useful in management of a menopause patient?
for F using transdermal HRT to check absorption of estradiol
What is the major circiulating estrogen when HRT is given transdermally
estradiol
What is the major circiulating estrogen when HRT is given orally
estrone
are serum levels of LH / estradiol / progesterone / testosterone useful in assessing a suspected menopausal F
no value in making the diagnosis
estadiol used to assess absorption of transdermal HRT
Testosterone not helpful - check free androgen index when considering testosterone prescription for low libido
why are testosterone levels not helpful in assessing menopausal women?
2/3 of testosterone is bound to SHBG
1/3 is bound to albumin
~2% is free
free androgen index may be more useful = 100 x (total testosterone / SHBG)
what are the issues around measuring free androgen index for menopausal women with libido symptoms?
And why do we do it?
no universally accepted normal range
Free androgen index is not accurate
levels dont necessarily correlate with symptoms
Sometimes used for monitoring when prescribing testosterone therapy.
what secondary health investigations may be considered when assessing menopausal patients?
Consider investigation to exclude other causes of symptoms
FBC
TFT
fasting glucose
autoautibody screen
catecholamines (for phaeochromocytoma)
24 hour urinary 5-hydroxyindoleacetic acid (carcinoid syndrome)
when is a thrombophilia screen advised in managing menopausal patients?
NOT routinely <40yo with prev unprovoked VTE recurrent unprovoked VTE VTE at unusual sites family hx of unexplained VTE in 2x 1st degree relatives family hx of specific thrombophilia warfarin induced skin necrosis
what are the limitations of thrombophila screening
cannot completely exclude an underlying increased risk of thrombosis
can only test for currently known thrombophilias
investigation for bleeding outside of expected patterns whilst on HRT
speculum, bimanual + visualise cervix cervical cytology up to date TV USS - cut off 4mm for continuous combined HRT, no cut off for cyclical HRT but do USS at end of withdrawal bleed Endometrial biopsy hysteroscopy
what 9 factors account for 94% of all population attributable risk of MI in women
smoking dyslipidaemia hypertension diabetes abdominal obesity dietary daily fruit and veg regular exercise alcohol consumption psychosocial factors
What diet is recommended for post-menopausal women
High protein
include fish and lean meat, eggs, beans, peas, soy.
Avoid excessive red / processed meat - breast ca risk and increased mortality
increased fibre - decreases CVD, colon cancer and mortality
5 servings fruit / veg per day
wholegrain carbs
limit salt
calcium and vitamin D
what proportion of our vitamin D comes from food
10%
what foods contain vitamin D
egg yolks
oily fish
risk factors for bowel cancer
age family history inflammatory bowel disease obesity diet high in red meat
factors associated with a reduced risk of bowel cancer
exercise
high fibre diet
regular use of aspirin / NSAIDs
HRT
what is the NHS bowel cancer screening programme
60 to 75 yr olds
Home kit for faecal occult blood testing
2 yearly
any positive test is called for colonoscopy
Advice re IUD in peri-menopausal women
IUD fitted at age 40+ can be retained until menopause (2yr after LMP if <50, 12m after LMP if 50+)
No hormones - can diagnose menopause
Can add in HRT
Advice re IUS in peri-menopausal women
If fitted age 45+ can retain until menopause confirmed or age 55
Licensed as progestogen component of HRT FOR 4 yr (FSRH support 5 yr)
Advice re SDI in peri-menopausal women
No upper age limit
Not licensed for endometrial protection
Can be used alongside combined HRT
Advice re POIC in peri-menopausal women
Consider BMD - risk assess for osteoporosis
Re-assess suitability every 2 years
switch to alternative age 50
Advice re CHC in peri-menopausal women
Can be used up to age 50 if not CI
levonorgestrel or norethisterone should be considered 1st line CHC for >40yo - potentially lower VTE risk
And COC ≤30 μg ethinylestradiol considered first-line preparation for >40yo
Consider extended or continuous use for symptom control
May help maintain BMD
Advice re POP in peri-menopausal women
No upper age limit
No increase in VTE risk
Do not mask menopause symptoms
Can be used alongside combined HRT
Advice re condoms in peri-menopausal women
Condoms advised for STI protection
Avoid spermicide - increases HIV transmission
Avoid oil based lubricants / products
Estrogen creams can damage condoms
Risk of condom rupture is increased with vaginal atrophic changes
Advice re diaphragms in peri-menopausal women
Use with spermicide
Mucosal atrophy and / or prolapse can cause problems with fitting or retention
Estrogen creams may damage them
Advice re natural family planning in peri-menopausal women
Not recommended - too unreliable
Unpredictable cycles
Inconsistent temperature changes
Atypical mucus changes
Advice re coitus interruptus as a contraceptive method in peri-menopausal women
Unreliable
But still used by many people
Failure rate similar to that of condoms
Duration of use of local estrogen for vulvo -vaginal atrophy
As long as needed
Indefinite
Symptoms often recur once topical estrogen stopped
Difference between vaginal moisturisers and lubricants
Lubricants applied before SI - to relieve vaginal dryness
Moisturisers are water based - line vagi always walls and deliver continuous moisture - longer symptom relief - applied every few days - not just for SI
What is Ospemifene?
Selective estrogen receptor modulator
What is Ospemifene used for
Oral treatment for treating vulvo-vaginal atrophy
60mg OD
What is tibolone
Synthetic steroid
Estrogen is, progestogenic and androgenic properties
What are the 2 broad categories of estrogen available
synthetic - e.g. ethinylestradiol
natural - estradiol, estrone, estriol
Why are synthetic estrogens such as ethinylestradiol usually unsuitable for HRT
greater metabolic impact - lipoprotein changes, insulin response to glucose and coagulation factors
what is the risk of unopposed estrogen HRT and who does this apply to
Endometrial cancer
in women who still have a uterus
what is the rationale for switching from cyclical HRT to continuous combined after 5 years max
The protective effect on the endometrium of cyclical progesterone decreases after 5 years of use.
Continuous combined HRT lowers the endometrial cancer risk to below that of a post menopausal woman not on HRT
in what time frame is irregular bleeding permitted when starting continuous combined HRT
irregular bleeding / spotting may occur for 4-6m after starting continuous combined HRT
Investigate if beyond 6m or becoming heavier not better
transdermal estrogen for HRT is associated with a lower risk of what consequnces
VTE
stroke
gallbladder disease
is breast cancer risk related to HRT greater with combined or estrogen only HRT?
combined
Do women who have had endometrial ablation require combined or estrogen only HRT?
Combined - cannot guarantee endometrium fully ablated
Estrogen related SE from HRT
fluid retention bloating breast tenderness headaches leg cramps dyspepsia
progestogen related SE from HRT
fluid retention breast tenderness headaches migraine mood swings low mood acne low abdominal pain backache
What are progestogenic SE related to
dose
type
duration
can try changing type, changing route or changing dose
Why do different routes of HRT administration have different risks?
They follow different metabolic pathways
Oral estrogen follows first pass metabolism and has a pro-thrombotic effect on the coagulation cascade and adversely affects pro-inflammatory markers
What is the risk of stroke / VTE with transdermal combined HRT
Not increased with transdermal therapy - therefore consider transdermal 1st line
What is the risk of stroke / VTE with transdermal estrogen only HRT
Not increased with transdermal therapy - therefore consider transdermal 1st line
What form of HRT increases the risk of Stroke / VTE
Oral combined or oral estrogen only HRT
But not significant if started <60yo / within 10 yrs of menopause
How is micronised progesterone different to synthetic progestogens
micronised progesterone selectively binds to the progesterone receptors.
Fewer adverse effects via the androgenic, mineral corticoid and glucocorticoid receptiors than synthetic progestogens.
May have a better safety profile - less risk of VTE, CVD and breast cancer
With HRT what is the ‘cardiovascular timing hypothesis’?
Concept of a window of opportunity for reducing CVD risk when HRT started before age 60.
Starting HRT within 10 years of menopause decreases CVD by 50%, reduced atherosclerosis progression + decreased mortality.
most common indication for HRT
Treatment of vasomotor symptoms
median duration of vasomotor symptoms at menopause
7.4 years
Most effective treatment for menopasual vasomotor symtoms
Estrogen replacement
Treatments for urogenital symptoms of the menopause
estrogen replacement - vaginal or systemic
Follow up recommended for women on systemic HRT
Annual review
No arbitrary limit of used based on age or duration of use
Follow up recommended for women using vaginal estrogens
None required
can continue long term for as long as symptoms are an issue.
Very low systemic absorption,
No need for endometrial monitoring
Treatments for sexual dysfunction symptoms of the menopause
Estrogen replacement - sytemic or vaginal
+/- systemic testosterone if HRT alone not effective
Systemic treatment can act additionally on the arousal centres of the brain.
Estrogen has a proliferative effect on the vulva and vaginal epithelium and improve atrophy and dysparunia
Tibolone may also have an effect - has weak androgenic effect
when should testosterone treatment be considered as part of menopause management
For sexual dysfunction and reduced sexual desire or anorgasmia related to the menopause which has not been resolved by HRT alone.
Tibolone may also have an effect - has weak androgenic effect
Impact of HRT on mood
HRT improves mood, anxiety and dressive symptoms during the menopause transition / early menopause
Not beneficial for clinical depression.
NOT an alternative to anti-depressant treatment
Impact of HRT on cognition
HRT imroves cognition.
Possible reduction in Alzheimers if used for women with POI or in early menopause
May increase risk of dementia if started >10 yrs after menopause
impact of HRT on the musculo-skeletal system
may have a protective effect on connective tissue.
May reduce myalgia and arthralgia symptoms
impact of HRT on colorectal cancer risk
possible reduced risk with oral combined HRT - mechanism unknown
more evidence needed re PO estrogen only or transdermal methods
Impact of HRT on breast cancer risk
combined HRT increases the risk by 4 in 1000 over 5 years
oestrogen only HRT reduces the risk by 4 in 1000 over 5 years
Risk returns to baseline 5 years after stopping HRT
Number of increased cases of breast cancer per 1000 women using combined HRT for 5 years
3 in 1000 more
Baseline breast cancer incidence per 1,000 women aged 50-59
23 in 1000
Is it the estrogen or progestogen component of comined HRT that carries the breast cancer risk?
Progestogen
Are there any progestogens with a lower breast cancer risk?
Insufficient evidence
Possibly micronised progestogen or dydrogesterone
Impact of drinking 2+ units of alcohol on breast cancer risk per 1000 in F aged 50-59 over 5 years
Increases risk by additional 5 per 1000
compared to 4 per 1000 increase risk from combined HRT
Impact of being a current smoker on breast cancer risk per 1000 in F aged 50-59 over 5 years
Increases risk by additional 3 per 1000
compared to 4 per 1000 increase risk from combined HRT
Impact of having a BMI >30 on breast cancer risk per 1000 in F aged 50-59 over 5 years
Increases risk by additional 24 per 1000 (double)
compared to 4 per 1000 increase risk from combined HRT
Impact of doing 2.5 hours of moderate exercise per week on breast cancer risk per 1000 in F aged 50-59 over 5 years
Reduces risk by 7 per 1000 (double)
compared to 4 per 1000 increase risk from combined HRT
management options for low mood related to the menopause
Exclude +/- treat clinical depression
For menopause related low mood consider
- CBT
- HRT
Advice for women stopping HRT re best way to stop
Choice of reducing dose and stopping gradually
or stopping immediately
No evidence to support either way
No arbitrary time limit on duration of use
does the peri-menopausal or menopausal levels of FSH correlate with symptom severity of menopause?
No
diet and lifestyle advice for menopause
Smoking cessation Alcohol reduction weight loss increasing exercise stress management / reduction techniques
BMS guidance for GPs on follow up for women commencing HRT
review at 3 months after starting HRT
Once settled on treatment review annually
Impact of HRT on diabetes risk of glucose control
Unlikely to have any impact
Combined HRT increases the cases of breast cancer by 3 in 1000.
What is the associated impact on mortality rate from breast cancer
HRT does not increase the risk of death from breast cancer.
HRT may promote growth of breast cancer cells already present and therefore make them more likely to be detected.
HRT does not appear to cause breast cancer cells to develop where they were not already present.
Impact of HRT on risk of osteoporotic fracture
Decreased risk of osteoporosis and osteoporotic fracture whilst taking HRT.
Benefit appears to continue for some time after stopping HRT.
Commonly reported difficulties relating to menopause at work
reduced concentration fatigue poor memory low mood lower confidence problematic hot flushes
Considerations for women with HIV and the menopause
Conflicting evidence - HIV may cause earlier age of menopause
HIV increases risk of osteoporosis and CVD
Women with HIV experience anxiety that symptoms of the menopause are actually HIV related
Menopausal symptoms often decrease adherence to ART
Women with HIV report higher prevalence of flushes, urogenital and psychological symptoms
Recommended route for HRT for women living with HIV
transdermal
lower risk of GI SE and VTE / stroke
Types of estrogen used in HRT
Estradiol
- oral dose 0.5 - 2mg
- patches 25mcg - 100mcg
- Oestrogel 0.06% = 0.75mg
- Sandrena gel 500mcg - 1mg
- PV tablet 10mcg
- PV ring 7.5mcg
Estriol cream 0.1% / 0.01%
Conjugated estrogens - 0.3 / 0.625 / 1.25mcgTypes of progestogens used in HRT
Norethisterone Dydrogesterone (Combined only) Levonorgestrel (IUS or combined prep) Norgestrel (Combined only) Drospirenone (Combined only) Micronised progesterone Medroxyprogesterone acetate
what forms of testosterone are available for prescription for menopausal women
testosterone gel - off licence
Implants and patches are no longer available
what is considered to be an ‘ultra low’ starting dose of estradiol (equivalent across routes)
0.5mg PO
1/2 a 25mcg patch
1/2 pump of gel
1/2 a 0.5mg gel sachet
what is considered to be an ‘low’ oral starting dose of estradiol
And what is the equivalent for other routes
Low oral starting dose of estradiol = 1mg
equivalent to 25mcg patch
= 1 pump gel
= 0.5mg sachet of gel
Which women should have the estrogen only HRT regimen
Hysterectomised patients
Which women should have the sequential / cyclical HRT preparations
Uterus present and peri-menopausal
Which women should have the continuous combined HRT preparations
Uterus present and post-menopausal
Which women can consider using HRT with a 3 monthly bleed
Uterus present and peri-menopausal
Common side effects of estrogen
Fluid retention breast tenderness bloating nausea dyspepsia headaches
How can we deal with estrogen side effects from HRT
reduce dose
change route
change type
If on combined HRT consider if progesterone is the cause of the SE
Common side effects of progestogen
Fluid retention breast tenderness headaches mood swings PMT- like symptoms
How can we deal with progestogen side effects from HRT
Change type
Change route
Reduce dose - if available
alter duration
why may the menopause cause and increase in anxiety and stress
Direct effect of hormonal and biochemical changes Anxiety due to unpredictable hot flushes Social embarrassment Avoidance of social / other activities due to symptoms and anxiety of symtoms occuring Associated palpitations Lower self esteem Stigma disrupted sleep
What is the main predictor of depressed mood related to menopause
Past history of depression
Indications for vaginal estrogen alone
Predominance of urogenital symptoms Vaginal dryness / atrophy dysparunia bladder symptoms (Can be given in addition to systemic HRT)
what is Estring
a vaginal estradiol ring for local estrogen
changed 3 monthly
What are Ovestin and Gynest
Vaginal estrogen creams = estriol
what is vagifem
Vaginal estrogen tablet or pessary
How often should the vaginal estrogen tablet / pessary or cream be used
ON for 2 weeks
then 2x per week can be continued long term
Duration of systemic HRT for women with POI
Advised until at least age 51
Then for as long as it is beneficial regarding symptom control and improved QOL
What are the proven benefits of HRT
Control of menopausal symtoms
Maintaining BMD
Reduced risk of osteoporotic fractures
What are some potential benefits of HRT
In addition to the proven benefits of HRT (symptom control and bone protection)
Reduced risk of CHD - when started <60yo
Reduced risk of alzheimers - when started <60yo
Reduced risk of colorectal cancer
Reduced risk of T2 DM
Possible protection against Parkinsons disease
Known risks of HRT
Endometrial cancer - from unopposed estrogen with uterus present. Reduced with progestogen. Continuous is better than cyclical
DVT / PE - 2-3x increase - greatest in 1st 12m - Less / not increased with patch or gel
CHD - increased if combined HRT started >60yo
Stroke - increased if combined HRT started >60yo
Breast cancer - probably increased after 5 years combined HRT (risk of estrogen alone is less / not increased) Mortality is NOT increased
Indications for transdermal HRT
Patient preference Previous VTE Family hx of VTE BMI >30 Variable BP control Migraine Current use of hepatic enzyme inducers Gall bladder disease GI disorder affecting oral absorption Poor symptom control with oral treatment
How to decide starting dose of HRT
For symptoms control in women >45 start with low dose and titrate upwards until symptoms controlled
For patients with POI start with a medium dose - may require increase to higher dose + consider adding in testosterone after BSO
What should be assessed at each annual HRT review
Effectiveness in controlling symptoms Any side effects Any bleeding pattern Review the type and dose used Help assess the ongoing risk / benefit balance
When should bleeding problems on HRT be referred for investigation
> On sequential HRT — if increase in heaviness
or duration of bleeding, or irregular bleeding
On continuous combined — if bleeding
beyond six months from starting therapy, or occurs
after a time of amenorrhoea.
Impact of menopause on migraine
Fluctuating hormone levels can increase migraine prevalence during perimenopause
Effective management of VM symptoms with HRT can improve migraine symptoms
Managing peri-menopausal women with migraine
Women with migraine without aura and no other CI may benefit from CHC until age 50
Migraine with aura is NOT a CI to HRT
Transdermal estrogen is recommended
Continuous delivery of progestogen is recommended
If women cannot use / dont want HRT consider SSRI / SNRI which may improve VM symptoms and migraine
Non-pharmacological suggestions for management of migraine and vasomotor symptoms in peri-menopause / menopause
Regular exercise
Weight loss
Alternatives to HRT
Gabapentin Pregabalin Clonidine SSRIs - paroxetine, fluoxetine, citalopram, estitalopram, sertraline SNRI - Venlafaxine
Benefits of Gabapentin for menopause management
Improves quality of sleep
Reduces pain
SE of gabapentin
Dry mouth
Dizziness
Drowsiness
Weight gain
Benefits of pregabalin for menopause management
Improves quality of sleep
Antidepressant
improved QOL
SE of pregabalin
Same as gabapentin but less severe + better tollerated Dry mouth Dizziness Drowsiness Weight gain
Benefits of clonidine for menopause management
Complements Anti-hypertensive treatment
Licenced
SE of Clonidine
Not suitable for patients with baseline Low BP
Reduce gradually or causes rebound hypertension
sleep distrubance
dry mouth
nausea
fatigue
Benefits of SSRI paroxetine / fluoextine / citalopram / estitalopram for menopause management
Antidepressant
Improved QOL
Benefits of SSRI sertraline for menopause management
Anti-anxiety
Antidepressant
Improved QOL
caution for use of SSRIs in menopause management
Avoid paroxetine / fluoxetine / sertraline with tamoxifen
Interacts with cytochrome P450
= makes tamoxifen less effective
Side effects of SSRIs
Initial SE = nausea, dizziness, short term increased anxiety
Sexual dysfunction
Benefits of SNRI venlafaxine for menopause management
Antidepressant
Improved QOL
Side effects of SNRI venlafaxine
Poorly tollerated initially - dizziness, nausea
Sexual dysfunction
Slow titration improves SE profile
NO interaction with tamoxifen - no interaction with cytochrome p450
Average production of testosterone in a healthy young F
100 - 400mcg per day
1/2 from ovaries - androstenedione
1/2 from adrenal glands - dehydroepiandrosterone
Levels naturally decline with age
Role of testosterone in women
Contribute to libido, sexual arousal, orgasm
increasing dopamine levels in CNS
Maintains metabolic function, muscle and bone strength, urogenital health, mood and cognitive function
impact of testosterone deficiency in women
Low sexual desire
reduced arousal
difficulty achieving orgasm
(fatigue, low mood, headaches, osteoporosis, sarcopenia = loss of muscle mass)
Possible contributory factors to consider in peri-menopausal women presenting with sexual dysfucntion
Vaginal atrophy + related estrogen deficiency symptoms Testosterone levels psychosexual factors physical causes iatrogenic causes environmental contributors
what is hyposexual sexual desire disorder
female androgen deficiency syndrome
or female sexual interest and arousal disorder
Low sexual desire with distress
why is measuring testosterone levels problematic
Majority of testosterone is protein bound.
Free testosterone assays not commonly available.
Measure total testosterone and Sex hormone binding globulin
Calculate free androgen index = total testosterone x 100 / SHBG
What would be considered a low free androgen index in a female?>
<1%
Supports the use of testosterone to manage low sexual desire.
Can repeat at 2-3m after starting testosterone
When providing testosterone replacement what is the maximum testosterone level which is considered physiological for women?
Free androgen index <5%
Above this makes androgenic side effects more likely
female dose of tostran
and testogel
Tostran = 2% testosterone gel in a 60mg cannister - use 1 metered pump per day Testogel = 1% testosterone in 5g sachet - use 1/10 sachet per day
Advice re application of testosterone gel
Apply to clean dry skn
Lower abdomen or upper thigh
allow to dry before dressing
Avoid skin contact with partners / children until dry
wash hands after application
do not wash applied area for 2-3 after application
Clinical trials suggest the benefit of testosterone gel for female hyposexual desire may take how long to show benefit?
8 - 12 weeks
Therefore trial treatment for a minimum of 3 months.
side effects of testosterone treatment
Often related to dose.
- increased body hair at application site (spread thinner and vary site or lower dose)
- Generalised hirsuitism
- Alopecia / male pattern hair loss
- acne / greasy skin
- deepening voice
- enlarged clitoris
When should female testosterone treatment be avoided or used with caution?
Pregnancy breastfeeding active liver disease hormone senstive breast cancer competitive athletes women with normal / high baseline testosterone levels / Free androgen index
cardiovascular benefits of estrogen
Reduces atherosclerosis Increases HDL cholesterol Lowers LDL cholesterol promotes coronary artery vasodilation prevents platelet aggregation decreases lipoprotein-a Inhibits LDL cholesterol oxidation
What impact does HRT have for a women diagnosed with breast caner whilst taking HRT?
No impact on survival
Recommended HRT regimen for women with a subtotal hysterectomy?
Estrogen only if no endometrium was identified in the lower resection margin at histology
Otherwise use continuous combined
Recommended HRT regimen for women who have had an endometrial ablation?
Combined
Either cyclical or continuous combined
Recommended combined HRT regimen for women who are progestogen sensitive
Use a MIrena
or micronised progesterone
What HRT treatment can be considered for non-responders to standard treatment
Consider SC estrogen implants
and serum monitoring
Evidence re HRT and weightgain
Non causal
Relative contraindications to HRT which need assessing in a specialist menopause clinic
Pre-existing cardiac disease Acute liver diease SLE Previous / current breast cancer Previous / current endometrial / ovarian cancer Undiagnosed vaginal bleeding Personal / family history of VTE
management of a POI patient who hopes for pregnancy
Referal for fertility assessment and treatment
Use sequential HRT as this is non-contraceptive
Reccomended maximum duration of using sequential HRT and rationale for this?
Recommend not more than 5 years on sequential HRT.
After this switch to continuous combined.
Sequential HRT has a higher risk of endometrial hyperplasia and cancer than continuous combined with long term use.
In a peri-menopausal woman at what point in the cycle should HRT be started?
If cycle relatively regular - start HRT with next bleed.
If cycle irregular / infrequent then commence without period but warn the first withdrawal bleed may be heacy but subsequent ones should be normal for her.
Advice for timing of switching from sequential HRT to continuous combined in relation to withdrawal bleed
Complete month of squential HRT
Have withdrawal bleed
Then start continuous combined
Risk of endometrial cancer in CC HRT users compared to non-HRT users
Using CC HRT = lower risk of endometrial cancer than non users
Management of bleeding occuring after a time of amenorrhoea in CC HRT user in whom there is a causative factor identified
e.g. missed pills / addition of new medication or OTC preparation
Investigate
PMB pathway
Refer for TV USS +/- endometrial biopsy
Self help tips and coping strategies for managing vasomotor symptoms
Avoid sudden temperature changes (hot drinks)
Decrease caffeine
Decrease alcohol
Avoid spicy foods
Increase exercise
Reduce weight
Wear layers of clothing to take off an put on as required
Practice relaxation techniques
Use cooling devices - facial sprays / fans / cold pillows or pads in bed
Wear absorptive nightwear
Advice for HRT in a BRCA1 or BRCA 2 carrier who has undergone risk reducing surgeries - bilateral mastectomies + TAH BSO
HRT recommended - esp if young - for CVD and bone protection
If hysterectomised use estrogen only
Evidence HRT is safe after risk reducing surgeries - esp if estrogen only as this does not increase breast cancer risk
Recommended treatment for a patient with a history of breast cancer on tamoxifen who experiences PV dryness and dysparunia
Systemic HRT contraindicated - may promote breast cancer recurrence
Can have PV estrogen (NICE)
Which SSRI is safe to use in a patient taking tamoxifen
Citalopram / escitalopram (But venlafaxine SNRI is safer)
Avoid paroxetine / fluoxetine / sertraline with tamoxifen
Interacts with cytochrome P450
= makes tamoxifen less effective = increased breast ca recurrence
Are pre-existing cardiovascular risk factors a contraindication to HRT?
No (NICE)
as long as adequately controlled and patient is <65yrs
Recommended to be assessed in specialist menopause clinic
What is the risk of stroke with tibolone use?
similar to those for oral HRT - slightly increased but not significant if <60 / within 10 yrs of menopause
Oral estrogens increase the risk of VTE by how much?
2 - 4x - highest risk is 1st yr of use
VTE risk also icreased by raised BMI, older age, reduced mobility and prev / family history
Transdermal does not increase risk above baseline for that patient
In combined HRT does the type of progesterone influence the VTE risk?
Yes
- greater risk with Medroxy-progesterone acetate and norpregnane derivatives
= Nomegestrol acetate, nesterone, Demegestone, promegestone, trimegestone
Lower risk with micronised progestogens and pregnane derivatives
= Dydrogesterone, megestrol acetate, chlormadinone acetate, cyproterone acetate, medrogestone
Synthetic progestogens - Structurally related to progesterone include:
Pregnane derivatives
= Dydrogesterone, megestrol acetate, chlormadinone acetate, cyproterone acetate, medrogestone
AND 19-Norpregnane derivatives
= Nomegestrol acetate, nesterone, Demegestone, promegestone, trimegestone
NOT Norethisterone, ethynodiol diacetate, norethynodrel, lynestrenol, tibolone, Levonorgestrel, desogestrel, norgestimate, gestodene, Dienogest, drospirenone
= testosterone related in structure
Synthetic progestogens - Structurally related to testosterone include:
Norethisterone, Desogestrel Levonorgestrel Gestodene Dienogest Drospirenone Tibolone Ethynodiol diacetate, Norethynodrel, Lynestrenol, Norgestimate,
does HRT impact ovarian cancer risk
Combined or estrogen only HRT increases serous and endometrioid ovarian cancer risk by 1 in 1000
when used for 5 years+
extra death of 1 per 1700 users
does HRT impact endometrial cancer risk
avoid unopposed estrogens - high risk
long term use of sequential combined HRT for >5yrs may increase endometrial cancer risk
Switch to continuous combined at age 54
For sequential HRT what is the minimum recommended days of progesterone
minimum 10 - little evidence re safety below this
ideally 12 - 14 days
does HRT impact lung cancer risk
no clear association
what is clonidine
centrally acting alpha-adrenoceptor agonist
what is the evidence for using clonidine as non-hormonal treatment for vasomotor symptoms
limited evidence
conflicting from RCTs
used since 1980s
May help some women with tamoxifen induced flushes
Daily dose of clonidine for menopausal flushing
50-75 mcg BD
what is the evidence for using SSRI / SNRIs as non-hormonal treatment for menopausal symptoms
Found to be effective in several studies
best data for venlafaxine (SNRI) 37.5 - 75mg BD
Few studies look at long term effectiveness (>12wk)
what is the evidence for using gabapentin as non-hormonal treatment for menopausal symptoms
gabapentin 900mg OD reduces hot flushes by 50%
what is the evidence for using progestogens only as non-estrogen based treatment for menopausal symptoms
can be effective in controlling night sweats and hot-flushes - but requires large doses therefore may have a VTE risk. Breast safety unknown norethisterone 5mg/day megestrol acetate 40mg /day medroxyprogesterone acetate 20mg/day
what is the evidence for using beta-blockers as non-hormonal treatment for menopause related anxiety / panic attack / palpitations
useful for autonomic symptoms
do not affect psychological symptoms
Propranolol MR 80mg OD
what is the evidence for using CBT as non-hormonal treatment for menopause related anxiety / panic attack / palpitations
Moderate quality evidence
Can be effective
what is the evidence for using mindfulness as non-hormonal treatment for menopause related anxiety / panic attack / palpitations
Recommended by NICE
Can improve focus and concentration, decrease stress, improve self-awareness
what is the evidence for exercise for management of menopause symptoms
Limited evidence from RCTs
Aerobic exercise improves psychological health and mood. Improves sleep and QOL.
Low intensity exercises such as yoga may improve hot flushes
Why may some women want to avoid HRT
- Believe symptoms are not severe enough to warrant HRT
- Want menopause to occur naturally
- Want to remain in control of the menopause transition
- Do not understand HRT
- Fear / anxiety of potential adverse effects of HRT
- medical contraindications
What are phytoestrogens
Plant substances
Have effects similar to conventional estrogens
Preparations vary from enriched foods to capsules / supplements
Includes isoflavones and lignans
What foods contain isoflavones
isoflavones = type of phytoestrogen
found in soybeans, chickpeas, red clover, legumes
What foods contain lignans
lignans = type of phytoestrogen
oilseeds, cereal bran, whole cereals, vegetables, legumes, fruit
What is the safety profile of phytoestrogens
good
Few SE - GI discomfort
Products are not standardised for dose or quality
What is black cohosh
Actaea Racemosa
many studies show it is effective for improving menopausal symptoms.
Cochrane review = insufficient evidence to recommend
May be beneficial
Dose and quality of product varies
What is the safety profile of black cohosh
Most studies are <6m Long term safety unknown unknown safety in previous breast cancer May cause liver toxicity May interfere with cancer therapy drugs and radiotherapy
what is the evidence for ginseng for management of menopause symptoms
Not effective
lack of evidence
what is the evidence for evening primrose oil for management of menopause symptoms
Rich in gamma-linolenic acid
Better than placebo for hot flushes
what is the evidence for dong duai for management of menopause symptoms
Not effective
Perennial plant in China
Interacts with warfarin
what is the evidence for gingko biloba for management of menopause symptoms
Short term studies show benefit to memory and cognition around menopause
Little long term data
what is the evidence for sage for management of menopause symptoms
popular
no robust data
what is the evidence for wild yam (natural progesterone) for management of menopause symptoms
Diosgenin is extracted from wild yam
does not bind to the human progesterone or estrogen receptor.
Cannot be converted by the human body to progesterone.
Not effective
what is the evidence for St Johns Wort for management of menopause symptoms
Popular
No good evidence for menopause symptoms
Good evidence for mood
Enzyme inducer
what is the evidence for chasteberry (agnus castus) for management of menopause symptoms
Popular
No good evidence
what is the evidence for liquorice root for management of menopause symptoms
Popular
No good evidence
what is the evidence for Valerian for management of menopause symptoms
Popular
No good evidence
what does the term ‘bio-identical’ hormone mean?
Has the same structure as those produced by the body
Estradiol and progesterone produced by the pharmaceutical companies are therefore ‘bio-identical’
term ‘bio-identical’ used to promote alternative HRT = compounded HRT = Unregulated.
Claim to individualize to the patient requirements.
No evidence.
Some do not provide sufficient endometrial protection
what is the evidence for acupuncture for management of menopause symptoms
Some favourable evidence
what is the evidence for yoga / reflexology / homeopathy for management of menopause symptoms
no evidence
may offer women a holistic sense of well-being
what is the evidence for magnetism for management of menopause symptoms
No evidence
what is the evidence for stellate ganglion blocking for management of menopause symptoms
Stellate gangilion block with LA
may reduce hot flushes and night awakening
Mechanism unclear
what is the evidence for DHEA (dehydroepiandrosterone) for management of menopause symptoms
Steroid secreted from adrenal cortex
Blood levels decrease with age
Suggested the effects of aging may be reduced with DHEA replacement
Unlicenced
MAY be beneficial for bones, cognition, libido and vaginal tissues
Some UK fertility centres use if to promote ovarian function before IVF
Diagnosis of osteoporosis
presence of a fragility fracure
or
DXA T-score of -2.5 or less
What does a DXA T-score of -1 to -2.4
Osteopenia
Strategies for prevention of osteoporosis
Maximize peak bone mass
- diet - calcium and vitamin D
- sunlight - vitamin D
- BMI of 19-25
- weight bearing exercise
Minimize rate of bone loss
- BMI of 19-25
- weight bearing exercise
- avoid smoking
- avoid excess alcoholSecondary causes of osteoporosis
rheumatoid arthritis untreated hypogonadism prolonged immobility organ transplantation T1 DM Hyperthyroidism GI disease Chronic liver disease COPD
risk factors for osteoporosis
increasing age hx of parental hip fracture BMI <18.5 Prev fagility # smoking alcohol of 3+ units / day current / past steroid use for 3m+ drugs which decrease BMD
Management of a menopausal woman with previous fragility # or x-ray evidence of osteoporosis
lifestyle measures - diet, weight bearing exercise, smoking cessation, counselling on falls prevention, avoid excess alcohol
Calcium + vitamin D supplements
HRT
or bisphosphonates (alendronate / risedronate)
or raloxifene (SERM)
How does HRT preserve BMD
Reduces osteoclast numbers and function = anti-resoprtive effect
What duration of HRT use will reduce fracture risk?
2 years+
The benefit may persist for several years after stopping HRT
what dose of estrogen is considered bone preserving in HRT
minumum of
0.5mg orally
or 25mcg patch
first line agent for prevention and treatment of osteoporosis is women with POI
HRT
first line agent for prevention and treatment of osteoporosis is women with symtomatic menopause who are <60yo
HRT
Advice re initiating HRT after the age of 60 for bone protection
Not recommended - Risks outweigh benefits Advise bisphosphonates (alendronate / risedronate) or raloxifene (SERM)
advice re taking bisphosphonates
Take on an empty stomach - due to drug being poorly absorbed via GIT
remain upright after taking dose for 30 mins
Discontinue if oesophagitis develops
Do not use in patients on PPIs as these inhibit the absorption of bisphosphonates without reducing oesohageal irritation
why are bisphosphonates usually avoided in <60yo
Long term safety of bisphosphonates is unknown
If <60yo HRT is usually more suitable if menopause symptoms - otherwise Raloxifene
Why do bisphosphonates need a ‘drug holiday’ after 5 years of use
supression of bone remodelling increases the risk of atypical transverse femoral fractures in 5 in 10,000 patient years
Drug holiday allows bone remodelling and skeletal repair - no set duration of drug holiday - resume once T-score falls to -2.5
In what post-menopausal patients is strontium ranelate recommended
Severe osteoporosis
no cardiac problems - increases risk of MI
no uncontrolled hypertension
CV risk assessment pre-treatment and every 6-12m
What is duavive
Tissue selective estrogen complex = combines SERM bazedoxifene with conjugated estrogens
which patients is duavive licensed for?
Treatment of estrogen deficiency in post menopausal women with an intact uterus
who cannot have progestin treatment
What proportion of women have POI earlier than age 30
0.1%
Causes of POI
Chromosomal / gene abnormalities Enzyme deficiencies Automimmune disease Chemotherapy Radiotherapy BSO Hysterectomy without BSO UAE infection
what are the most common genetic causes of POI
X-chromosome abnormalities - defects, deletions, X-autosome translocations, isochromosomes
(Turners, Downs, Fragile X, and BPES (blepharophimosis ptosis and epicanthus inversus syndrome)
what are the enzyme deficiencies which cause POI
Cholesterol desmolase deficiency
17-alpha-hydroxylase deficiency
17-20 desmolase deficiency
what are the most common autoimmune causes of POI
antibodies to thyroid or adrenal gland lupus related antibodies Myasthenia gravis - infrequent Rheumatoid arthritis - infrequent SLE - infrequent
what infections may cause of POI
Pelvic TB mumps malaria - infrequent varicella - infrequent shigella - infrequent
Long term health effects of POI
decreased risk of breast cancer lower BMD increased risk of fracure increased CVD reduced cognition decreased life expectancy
Investigations for POI
- FSH 2x measurements at least 6wk apart
- Karyotyping if onset before 30 - or any age if turners mosaic suspected
- Fragile-X premutation testing (CGG trinucleotide repeats)
- Thyroid (TPO-Ab) and adrenal autoantibody screen (21-hydroxylase autoantibodies) - if an immune disorder suspected
- baseline DXA
- Investigation of secondary diseases if suspected - diabetes, Vit D deficiency
Advice re fibroids and the menopause
Fibroids are likely to shrink during and after the menopause - upto 40%
Commencing HRT may cause increase in volume of fibroids but not development of new fibroids
fibroids are not a CI to HRT
If perimenopausal can offer an IUS with fibroids and HMB
perimenopausal women with symptomatic fibroids can be offered GnRH agonists and addback HRT
Advice re endometrial polyps and the menopause
Postmenopausal HRT may be associated with an increase in benign endometrial polyps
This can lead to PMB
Advice re endometriosis and the menopause / HRT
estrogen treatment could theoretically re-activate endometriosis and potential symptom recurrence
If hysterectomy has been completed the use of estrogen only HRT theoretically may increase the risk of malignant transformation of any reactivated deposits - if this is a concern (e.g severe disease) use combined HRT
No clear evidence
Advice re PCOS and the menopause / HRT
Anovulation secondary to PCOS = chronic estrogen stimulation of the endometrium
increased risk of endometrial hyperplasia and carcinoma
PCOS = increased risk of CVD, diabetes, obesity
Take comorbidities and risk in to account when starting HRT
Advice re hypertension and the menopause / HRT
HRT does not increase BP
Transdermal HRT is safer
HRT can be used alongside antihypertensives
Manage as per NICE HTN guidelines aim <140/90
Advice re valvular disease and the menopause / HRT
HRT is not CI
Women on anticoagulants may have more issues with irregular or heavy bleeding - may require adjustment of progestogen dose
Advice re hyperlipidaemia and the menopause / HRT
High LDL = risk of CVD
Consider statins if indicated
Statins / raised cholesterol is not a CI to HRT but consider overall CVD risk
Transdermal HRT is safer + also improves lipid profiles
Advice re VTE and the menopause / HRT
If VTE risk - offer transdermal HRT
Can have transdermal HRT even with a pro-thrombotic mutation
or start anticoagulation to enable HRT to be given - rare - DW haematology
Advice re HRT use and undergoing surgery
No need to stop HRT before surgery
Small increased risk of VTE if on PO HRT but no rationale for stopping - esp if receiving routine thromboprophylaxis
No increased risk from transdermal HRT
Advice re raised BMI and using HRT
BMI is not a CI to HRT
As obestity increases VTE risk increases = transdermal HRT is preferable
Advice re DM and using HRT
HRT may reduce the incidence of T2 DM and improve glycaemic control
Transdermal HRT also improves lipid profiles
DM = Increased risk of CVD - consider risk in deciding on HRT
Transdermal HRT likely to be preferable
Advice re thyroid disease and using HRT
No clear relationship with thyroid disease and menopause
Not a CI to HRT
dose of thyroxine may need to be increased if PO HRT used - transdermal may be preferable.
Hyperthyroidism = higher risk for osteoporosis therefore offer DXA
Advice re migraine and using HRT
Not a CI to HRT - even with aura
Estrogen may trigger migraine
transdermal route is less triggering due to more stable plasma hormone levels
Advice re epilepsy and menopause / using HRT
Severe epilepsy reduces age of menopause by ~4 yrs
Seizure frequency may increase peri-menopause due to fluctuating hormones and sleep deprivation
Consider medication interactions
Transdermal route may avoid issues with enzyme inducers
Advice re parkinsons risk and menopause
early menopause / POI / BSO increases risk of parkinsons
Risk is negated by the use of HRT
Advice re gallbladder disease and using HRT
oral HRT increases gallbladder disease
Less risk with transdermal
Advice re liver disease and using HRT
HRT is CI in severe liver disease
Seek liver specialist approval before starting if LFTs are abnormal - would advise transdermal
Advice re IBD and using HRT
incrreased risk of osteoporosis
transdermal HRT to ensure absorption
Advice re Rheum. Arthritis and using HRT
increaed risk of osteoporosis
HRT doesnt affect flares and is not CI
HRT may improve joint health and lower need for hip/knee replacements
Advice re SLE and using HRT
Increased risk fo CVD and osteoporosis May experience POI estrogen increases susceptibility to SLE AVOID oral HRT or raloxifene If HRT indicated use transdermal Consider haematology advice
Advice re end stage renal disease and menopause / using HRT
Risk of early menopause and osteoporosis and CVD
No CI to HRT - risk benefit analysis
transdermal may be preferable due to risk proflie
Does the peri-menopausal period increase the risk of depressive symptoms and depression Disorder?
Some evidence of increased risk in peri-menopause and around menopausal transition
The risk is increased if associated with vasomotor symptoms or simultaneous adverse life events or previous history of major depressive disorder.
Possibly the risk is lower after the final menstrual period occurs then it is in the late peri-menopause
Risk factors for depressive symptoms or depressive disorder during peri-menopause
Age <50yo Black / Hispanic / Japanese ethnicity Low education Financial difficulties Unemployment Vasomotor symptoms Sleep difficulties Previous depression / postnatal depression / postpartum blues Use of psychotropic medications / drugs Previous anxiety Raised BMI Current use of antidepressants Nulliparity Chronic medical condition Physical disability / low role functioning Death of partner / major stressful life events Negative attitude to aging and menopause Low social support / few close friends or relatives Smoking POI
Is HRT effective in improving menopause related depressive symptoms or depressive disorder
HRT improves depressive symptoms at the peri-menopause
BUT does not improve or treat depressive disorders at the menopause / peri-menopause
What are the consequences of POI for life expectancy?
Untreated POI is associated with reduced life expectancy
Due to CVD
Advise on lifestyle factors to reduce CV risk - not smoking, regular exercise, healthy weight
What are the consequences of POI for fertility?
small chance of spontaneous pregnancy as ovarian function may fluctuate
Advise to use contraception if they wish to avoid pregnancy
What fertility interventions are effective for POI?
No interventions to increase ovarian activity or natural conception rates.
Oocyte donation is an option
If a patient with POI becomes pregnant what are the associated obstetric risks
- Reassure - spontaneous pregnancies after idiopathic POI or most forms of chemotherapy do not show higher obstetric or neonatal risk
- Oocyte donation pregnancies are high risk
- Pregnancies after pelvic radiation are high risk
- Pregnancies in women with Turner Syndrome are very high risk - cardiologist involvement
