Menopause & HRT

Question 1

Definition of:

• Menopause
• Perimenopause
• Premature menopause

Answer 1

Menopause

• Permanent cessation of menstruation due to the loss of ovarian follicular activity
• Diagnosed with certainty after 12 months of sponataneous amenorrhoea

Perimenopause

• Time period during which symptoms of decreasing oestrogen levels present
• Ends 12 months after the last menstrual cycle

Premature menopause

• Menopause occurring at < 40 years old

Question 2

Aetiology/pathophysiology of the menopause

Answer 2

• Each ovary has a finite number of oocytes. This number decreases with age until depleted at ~50 years old
• During the perimenopause:
  
  • Ovarian follicular activity begins to fail
  • ↓ oestrogen → ↓ -ve feedback (pituitary) → ↑ FSH + LH
• ↓ Oestrogen levels →
  
  • Irregular → anovulatory menstrual cycle
  • Hot flushes
  • Night sweats

Question 3

Risks after the menopause

Answer 3

*Risk is ↑↑ with premature menopause*

• ↑ risk of:
  
  • Osteoporosis
  • Urogenital atrophy
  • Cardiovascular disease
  • Stroke
• ↓ risk of breast cancer

Question 4

Clinical features of the menopause

Answer 4

• Change in menstrual pattern (often heavier)
• Vasomotor symptoms
  
  • Hot flushes
  • Night sweats
• Urogenital symptoms
  
  • Vaginal dryness
  • Dyspareunia
  • Recurrent LUTIs
• Sleep disturbance

Question 5

Investigations for the menopause

Answer 5

*Clinical diagnosis*

• If premature menopause suspected:
  
  • 2 FSH levels >30 IU/L
    
    • Suggestive of menopause (unreliable if on oestrogens)

Question 6

Management for the menopause

Answer 6

*Raloxifene (SERM, selective oestrogen receptor modulator) - Protects against menopause-induced osteoporosis*

• HRT
• Non-HRT (contraindicated)
  
  • Lifestyle advice
  • Vasomotor symptoms
    
    • Clonidine (α2 agonist)
      
      • ↓ vascular resistance
  • Vaginal dryness
    
    • Lubricant or moisturiser
  • Psychological symptoms
    
    • Counselling
    • Antidepressants

Question 7

Contraindications for HRT

Answer 7

• Pregnancy and breastfeeding
• Undiagnosed PV bleeding
• VTE disease
• Active or recent CV disease
  
  • Angina/MI
• Uncontrolled HTN
• Oestrogen-dependent cancer (breast/endometrial)
• Active liver disease with abnormal LFTs

Question 8

Benefits of HRT

Answer 8

• HRT is effective for:
  
  • Treating vasomotor symptoms
    
    • Hot flushes
    • Night sweats
  • Treating urogenital symptoms
    
    • Vaginal dryness
    • Dsypareunia
    • Recurrent LUTIs
  • Managing sleep
  • Preventing osteoporosis

Question 9

Possible risks/side effects of HRT

Answer 9

• ↑ risk of:
  
  • Breast cancer
  • MI
  • VTE
  • Stroke
• Side effects:
  
  • Oestrogen
    
    • Breast tenderness
    • Nausea
    • Bloating
    • Leg cramps
    • Headaches
  • Progesterone
    
    • Pelvic pain
    • Backache
  • Bleeding upon starting and cessation

Question 10

Management with HRT

Answer 10

*Contraception should be used for 1 year after LMP*

• Offer lifestyle advice
  
  • Exercise & weight loss may improve hot flushes
  • Wear lighter clothing, sleep in a cool room, reduce stress etc.
• Preparation
  
  • Cyclical (LMP <1 year ago)
  • Continuous (LMP >1 year ago)
  • Local (urogenital symptoms)
• Delivery route
  
  • Oral
  • Transdermal
    
    • Avoids first-pass metabolism
    • ↓ risk of thrombosis and other side effects
    • Solves malabsorption
  • Creams or gels
  • Mirena coil
  • Oestrogen-eluting vaginal ring
• Drugs
  
  • Combined (uterus intact)
    
    • Combination with progesterone is protective against endometrial cancer
  • Oestrogen only (hysterectomy/poor progesterone tolerance)

*In premature/early menopause, HRT is recommended up to 51 years. Not recommended starting HRT after 60 years*

Question 11

Follow up assessment for HRT

Answer 11

• Check for side-effects
• BP and weight
• Encourage breast awareness and report breast change

Question 12

Menopause and HRT explanation

Answer 12

• What is the menopause?
  
  • By definition, the menopause is your last period. However, most women tend to think of the menopause as the time of life leading up to, and after their last period.
  • Women are said to be postmenopausal when they have not had any periods for a year
• What happens during the menopause?
  
  • As you get older, your ovaries stop producing eggs and male less of the hormone oestrogen.
  • Low levels of oestrogen contribute to certain symptoms that are associated with the menopause, namely:
    
    • Hot flushes
    • Night sweats
    • Changes to your period (eventually stopping)
    • Changes to your vagina (dry)
• Complications of the menopause?
  
  • Osteoporosis
  • Cardiovascular disease (stroke)
• Do I need treatment?
  
  • Short-term symptoms 2-5 years
  • Treatment can help ease these symptoms, but there are benefits and risks
• What is HRT?
  
  • Replacing the oestrogen that your ovaries no longer make
  • Tablets, skin patches, gels, creams or vaginal rings
• How do I take HRT?
  
  • LMP < 12 months
    
    • 1 or 3 months cyclical
  • LMP > 12 months
    
    • Continuous
• Mainly vaginal dryness?
  
  • Oestrogen cream/pessary

Question 13

Risk assessment for HRT

Answer 13

• VTE
  
  • Risk increases with:
    
    • Age
    • Previous VTE
    • Obesity
    • Smoking
    • Immobility
  • (Risk reduced with transdermal delivery)
• Stroke
• Breast cancer
  
  • Risk increases with:
    
    • Late menopause
    • Early menarche
    • Nulliparity
    • Obesity
    • Tamoxifen
  • Risk returns to normal 5 years after cessation of HRT
• Endometrial cancer
  
  • Progestrone is protective
  • Oestrogen only if hysterectomy