Menopause and HRT Flashcards
Facts about ovarian function state the four things that happen when a woman is 40
In 40s prime oocytes declines steeply
Progesterone, oestradiol and testosterone decline
Fertility declines
FSH & LH ↑ to stimulate the failing ovary
Eventually all oocytes are exhausted
Ovarian function 2
no oestrogen production to stimulate the monthly build up of the womb lining (endometrium)
No build up → no shedding or menstruation
The menopause has begun
Oestrogen levels can fall to 7% of normal
Ovarian function 3
Oestrogen does not only drive the reproductive cycle and prepare the body for pregnancy and lactation
It is also a major player in bones, blood vessels, the brain, the gut and the immune system
So when the ovary fails to produce oestrogen
These other systems are affected
Define menopause
Greek menos = month
pausos = ending
Occurs between 40-60yrs
Av. age is 51.4yrs
Facts about menopause
Determined after 12 months amenorrhoea Retrospective diagnosis (FSH levels) Average age is 51 years Over 55 in ≈ 2-3% Under 40 in ≈ 1% Occurs 1-2 years earlier in smokers
Menopause is determined after…..
12 months amenorrhoea
Menopause occurs 1-2 years earlier in smokers. True or false?
True
Age of menopause is unrelated to….
-number of pregnancies
-use of oral contraception
-socio-economic factors
Age of menarche
General symptoms of menopause
Loss of fertility
Early stages - erratic menstrual cycle or perimenopause
End stage - Cessation of periods is the menopause
list the 7 stages of women
see table slide 12
What is perimenopause?
Transition from cyclic menstruation to total cessation of menses About 4 years Menstrual irregularity and amenorrhoea Declining P and O Ends at 12 months ammenorrhoea
What is Post menopause?
Life span AFTER menopause is called post-menopause
early menopause- 40 onwards- between 1 and 4years of amenorrhoea
late meopause- 47-51years- no periods at all
State the Physical Vasomotor Symptoms
Hot flushes Night sweats Vaginal dryness Giddiness Faintness Headaches Insomnia
State the most common side effect of menopause
Hot flush
Facts about menopausal symptoms
All women effected, different experience Hot flush most common side effect Prevalence decreases with age: 60% 50-54yrs 15% 55-59yrs 6% 60-69yrs 3% >70yrs Culture and dietary influences
Pathophysiology in Menopause
Declining oestradiol – urogenital atrophy in 40% post menopausal women
Vaginal epithelial thinning, decreased secretions, reduction in vaginal size.
Painful intercourse, vaginal infections and UTIs
State the psychological symptoms of menopause
Irritability Poor concentration Poor short term memory Depression Tiredness Anxiety Mood swings
State the Medium term consequences of oestrogen deficiency
Genital atrophy (Sexual dysfunction) Vaginal dryness, can lead to dyspareunia Urinary symptoms Stress incontinence Loss of collagen from skin, muscle & bone Myalgia – pain in the muscles Hair loss Brittle nails Dry skin
State the Long term consequences of oestrogen deficiency
Cardiovascular disease
Osteoporosis
State one of the treatments of Menopause?
HRT- Hormonal replacement therapy
What does HRT do?
Offers relief from symptoms of oestrogen deficiency
HRT NOT first-line preventative treatment for osteoporosis
Not used to reduce risk of long term complications (associated with osteoporosis and CVD )
Diet and exercise for peri and post menopause
Use HRT in caution if patient has…..
Migraines
Unexplained vaginal bleeding
Had breast cancer or any lumps in your breast, or if a close family member has had breast cancer.
Has or a close family member have ever had a blood clot in the legs or lungs.
Has diabetes, epilepsy or asthma
Depression
Blood pressure or heart conditions
Treatment options for Menopausal symptoms
If menopausal symptoms interfere with quality of life
Non-pharmacological (lifestyle and alternative)
Pharmacological (hormonal and non-hormonal)
State the nonpharmacological treatment for relieving mild Vasomotor Symptoms of Menopause
Lifestyle changes
esp if opposed to HRT
Weight loss, if appropriate, and exercise
Benefit CV and wellbeing
Avoid spicy food, alcohol, hot drinks & warm environments
Cooling methods
Yoga – psychological symptoms benefit but no impact on VMS and urogenital
State the alternative or herbal therapies for mild VMS
Alternative/herbal therapies
Acupuncture
Dietary soya isoflavones, red clover, black cohosh (CI with aspirin sensitivity, as contains salicylates)
Benefit hot flushes, mood changes, sleep disturbances, fatigue and vaginal dryness
State the moderate to the severe treatment of VMS
- Intact uterus
Must have BOTH Oestrogen and P
Prevents hypertrophy of endothelial lining
Minimises endometriosis
Protects the endometrium
Induces a monthly bleed to reduce the risk of developing abnormal cancerous cells
Can be sequential or continuous combined - No uterus (following hysterectomy)
Only needs Oestrogen
Treatment for intact uterus for moderate to severe VMS
Cyclic (sequential O and P)
O for 21 days, P days 7-21 and 7 days none
Withdrawal bleed days 22-30
O at lowest dose to minimise risks (see slide 29)
Note that P can also be every 3 mths
Eg Elleste duet
Facts about Continuous combines O and P therapy in moderate to severe VMS
Protect endometrial hyperplasia and cancer.
Risks and benefits, history, symptoms and concerns.
Start O at lowest dose 0.3mg/day oral or 0.05mg patch
BC, S and thromboembolic and CV events
P may ↑ risk BC than O alone
O and P daily, easiest to follow, no menstruation and preferred by most (avoid in perimenopause if irreg bleeding)
If breakthrough bleed after first 9 mths switch to cyclic
eg Premique
Treatment options for those without uterus
Transdermal or topical O
P not needed, O alone if tolerated
Transdermal may be preferred to oral if taking other meds, borderline triglyceride levels, gallstone risk or adherence issues
Could have less risk than oral O but no RCT so probably same for (BC, S,T and CV events)
VMS relief in 4-12 weeks
Topical vaginal O
Dryness
other treatment for patients without a uterus
Oral Oestrogen Safe if no CIs for up to 7 years No increase of CVD, S or BC if alone Start low and increase slowly If not tolerated – non-hormonal considered Taper dose every 6 months
State the risk and benefit of HRT
Risks of HRT diminish over time after stopping
Peri – screening tests e.g. mammography, smear, colonoscopy (50yrs), osteoporosis (65yrs), serum lipids (few months post start of O)
Well balanced diet and exercise
Risk and benefits of HRT 2
More than 1 year = higher risk of breast cancer than women who never use HRT (except vaginal oestrogen)
If ages 40s and 50s and HRT for 5 years risk:
1 extra case for every 200 women taking oestrogen-only HR
1 extra case for every 70 women taking cyclical HRT
1 extra case for every 50 women taking continuous HRT
Extra cases double if take HRT for 10 years.
Increased risk of BC falls if stop HRT, but can remain for more than 10 years compared to women who have never used HRT.
If for less than 1 year, no increased risk of BC.
Important to attend breast cancer screening appointments if taking HRT.
State when to stop taking HRT
Sudden chest pain.
Sudden breathlessness, or if you cough up blood.
Swelling or pain in a leg.
An unusually severe headache.
Yellowing of your skin or the whites of your eyes (jaundice).
What to prescribe if HRT not tolerated
- Antidepressants
SSRIs and SNRIs
Escitalopram most effective
Hot flushes with varying degrees - Clonidine
VMS
Caution with high does - ↓ BP - Gabapentine
VMS but SE of drowsiness, dizziness and unsteadiness
Taper dose as VMS subside
State the treatment for Vulvovaginal symtoms
- Vaginal oestrogen
Cream, pessaries or ring for local symptoms not VMS.
Less systemic effect
But long term use – endometrial proliferation
Ring expensive but less messy
Safe in BC sufferers - Vaginal moisturiser
Polycarbophil gel – for vaginal atrophy, dryness and dyspareunia
Urinary stress incontinence only
Pelvic floor rehabilitation
May be useful for urinary stress incontinence
compliance with HRT
Most women take it for:
vasomotor symptoms
Women stop because they dislike side effects, bleeding or have concerns about risks
>50% will stop within a year
Points to note about HRT
HRT is not a contraceptive.
If still having periods, or have only recently stopped, still use contraception for one year after last period if older than 50, or for two years after last period if less than 50.
Regular check-ups to discuss risks and benefits of taking HRT.
Overview of HRT, types, side effects, risks and alternatives to HRT.
SEE SLIDE 40 for more info
State the side effects of HRT
breast tenderness headaches feeling sick indigestion abdominal (tummy) pain vaginal bleeding
OTHER treatment of HRT
- Bioidentical or “natural” hormones
Bioidentical hormones are hormone preparations made from plant sources that are promoted as being similar or identical to human hormones.
Practitioners claim these hormones are a “natural” and safer alternative to standard HRT medicines.
However, bioidentical preparations are not recommended because:
they are not regulated and it’s not clear how safe they are – there’s no good evidence to suggest they’re safer than standard HRT
it’s not known how effective they are in reducing menopausal symptoms
the balance of hormones used in bioidentical preparations is usually based on the hormone levels in your saliva, but there’s no evidence that these levels are related to your symptoms
Bioidentical hormones are not the same as body identical hormones. A body identical hormone, or micronised progesterone, can be prescribed to treat menopausal symptoms.
Many standard HRT hormones are made from natural sources, but unlike bioidentical hormones, they’re closely regulated and have been well researched to ensure they’re as effective and safe as possible.
- Complementary therapies
Several products are sold in health shops for treating menopausal symptoms, including herbal remedies such as evening primrose oil, black cohosh, angelica, ginseng and St John’s wort.
There’s evidence to suggest that some of these remedies, including black cohosh and St John’s wort, may help reduce hot flushes, but many complementary therapies are not supported by scientific evidence.
Even when there is some supporting evidence, there’s uncertainty about the right doses to use and whether the health benefits last. Some of these remedies (especially St John’s wort) may also cause serious side effects if they’re taken with other medicines.
These products are often marketed as “natural”, but this does not necessarily mean they’re safe. The quality, purity and ingredients cannot always be guaranteed, and they may cause unpleasant side effects.
