Menopause Management - Dr Manju Navani 1 - The Family Doctor Association
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Menopause Management
Dr Manju Navani
1
Definition
• Menopause: 12 months after LMP
• Average age of menopause is 51 yrs
• Peri-menopause: start of symptoms to 12 m
after LMP
2
Menopause – Men…o….Pause
This image cannot currently be display ed.
3
Signs and Symptoms
Menopause
40 yrs 50 yrs 60 yrs
Vasomotor Symptoms
Sleep Disorders
Mood Changes Urogenital Atrophy
Joint pains, aches, tired Reduced sex drive
Forgetfulness
Osteoporosis
Atherosclerosis
Menstrual Disorders Coronary Heart Disease
Dementia-POI
Adapted from Van Keep PA et al. Maturitas 1990;12:163–70. Slide donated by Mylan
Assessment in Primary care
• History – symptoms
• Exclude other causes of symptoms: thyroid ,
depression, Iron deficiency
• Medical history/Family Hx - R/O Contra-indications
• Discuss benefits & personalise risks
• Discuss Rx options
• Info on websites
www.menopausematters.co.uk,
www.womans-health-concern.org.uk
5
Role of Blood test(FSH)
to diagnose menopause
NOT NEEDED IN OVER 45 yrs (Qualilty Standard 1)
Indication for measuring FSH ( 30 mIU/L (Repeat in 6-8 weeks), levels
pulsatile
DO NOT Measure if
• On COC
Can check FSH if on on Depo Provera injections –
but do around 10 weeks
6
Premature Ovarian Insufficiency (POI)
• Menopause < 40 years ( 1%)
• Causes: Idiopathic, F/Hx , chromosomal , Auto-
immune, iatrogenic
• Investigations- Baseline BMD, repeat if
osteopenia/osteoporosis
• Management – COC/HRT till 51 (QS 3)
• Contraception
• Consequences- QoL, IHD, Osteoporosis, Dementia,
Parkinsonism
7
Support Group for POI www.daisynetwork.org.uk www.womens-health-concern.org
History & Examination
HISTORY LMP, Periods- ?heavy
Symptoms Have they stopped ?
Rx tried
Menstrual Hx
Contraception Gynae Hx: Endometriosis, fibroids,
Gynae Hx Hysterectomy, BSO, Gynae cancers
Sexual History
Medical Hx CVD /Stroke & Risk Factors,
Family Hx • VTE
Mental health • Cancers: Breast , ovarian ,Bowel
Alcohol, smoking, Osteoporosis
ex , diet • Migraines+/- aura, epilepsy ,
Occupation Thyroxine, Malabsorption
EXAMN: BMI, BP
Investigations: if indicated –TFT, DEXA scan,
lipid profile, FSH (
of HRT
• Symptom relief
• POI , early menopause • HRT doubles risk of VTE
• Prevention & RX of • Oral HRT has higher risk
osteoporosis under 60 >transdermal
• In early post menopausal • Risk with Transdermal
years: window of HRT no greater than
opportunity & protects baseline
from CVD • Risk factors: age, BMI>30,
• Reduces risk of colorectal smoking ,F/Hx ,
cancer immobility
• If high risk VTE : refer to
Specialist , HeamatologistHRT and breast cancer risk HRT has similar risks to late menopause Woman’s risk breast cancer with late menopause • 2.8% increase per year • With HRT: 2.3% increase per year • E only HRT: li le/no ↑ risk • E + P – slight ↑ risk related to duration, reduces after stopping , and baseline risk varies from one woman to another depending on underlying risk • 1/1000 per year over 5 yrs
CVD / Stroke / Ovarian Cancer
Condition %age Extra/1000.yr
Heart Attack +29% +0.7
• Re-analysis of WHI study: within 10 Stroke +41% _0,8
yrs of menopause HRT is cardio- All VTE +100% +1,8
protective (window of opportunity) PEs +113% +0.8
• Risk increases with age, depends on Breast Cancer +26% _0.8
risk factors. Endometrial 0 nil
• Increased risk of stroke with Oral cancer
HRT, risk is 1:1000 under 60 . Ovarian 0 nil
cancer
• Over 60: risk of stroke 4.5/1000 Colorectal -37% -0.6
Cancer
IMS recommendation on womens midlife health and
MHT- Climacteric 2016:19(2)109-50 Hip fracture -34% -0.5
Danish Osteoporosis Prevention Study (DOPS study)
:2012, 17B E2 + NETA in early post menopausal years Ovarian Cancer
Finnish Study: Hodis HN et al. Vascular effects of Early v • 2015 meta-analysis of 52 studies
late post menopausal Rx with E . New Eng J of Med
2016;374(13)1221-31 • Increased risk with HRT
ELITE study, KEEPS trial • 1/5000 per year
• 1 additional death per 1700 usersManagement : Life style advice • Higher mortality rate from heart disease (53%) vs mortality rate from breast cancer (3%)
Management Diet, Lifestyle changes HRT options- Local , Systemic Non HRT options ( Alternatives to HRT) RCOG leaflet 1. Pharmacological Rx (SSRI, SNRIs) 2. Non - pharmacological Rx • Phytoestrogens • Herbal Psychological – CBT Complementary therapy
When to Say No…..No to HRT?
• Breast Cancer
• Endometrial Cancer beyond Stage 1
• Undiagnosed genital bleeding
• Current thromboembolic disease/ IHD
• Active liver disease
• CAUTION STARTING OVER 60
• Migraine
• Hypertension
• Past Hx of VTE/Family HX of VTE
• Hyperlipidemia
• Fibroids
• EndometriosisTypes of HRT
Estrogen
Oestrogen Only(no uterus)
Oestrogen Cyclical
Bleed
17-28 (Sequential)
Progestogen No Bleed
Continuous
Oestrogen combined HRT
(CCHRT)
Estrogen ProgestogenWhich HRT?
Systemic HRT Local HRT
HAS UTERUS/ENDOMETRIAL PROTECTION
NEEDED
YES
NO
E+P
Periods>1 yr or age 54
PeriodsIndication for CCHRT • If LMP>1 yr back • At age 54-55 • >3-4 yrs on Sequential HRT
HORMONES
Oestrogens Progestogens
• Oestradiol C19 – Nor-ethisterone,
levonorgestrel
• Conjugated equine
Oestrogens C21 – MPA, Dydrogesterone
Natural Progesterone:
• Oestradiol Valerate
Uterogestan
IUS – LNG x 5 yrs
• +/- TestosteroneProgestogens
1. Androgenic : Norethisterone(NET) , Levonorgestrel
PMS , less lipid friendly
2. Non - Androgenic : Dydrogesterone
Indication: if has PMS with NET, DM , Raised cholesterol
3. Uterogestan – Complex medical problems , Risk
factors of VTE , F/Hx of breast cancer
(less androgenic, less thrombogenic, less carcinogenic on
breast)
4. IUS- no safety data on breast
5. Drosperinone (Angelique)- anti- mineralocorticoid
activityWomen with a uterus (Seq HRT) 1st line HRT (Oral) NET • Elleste Duet 1mg • Elleste Duet 2 mg 2nd line HRT ( Oral) DG • Femoston 1/10 • Femoston 2/10
Women with a uterus ( CCHRT)
No periods x 1 yr
• Elleste Duet Conti 2 mg ( E + Norethisterone)
• Femoston Conti - I mg ( E + Dydrogesterone )
• Femoston Ultra Low dose ( 0. 5mg)
• Tibolone (improves sex drive, endometriosis)
• IUS x 5 yearsOestrogen only – No Uterus • Oral Estradiol - Elleste Solo ( 1 mg, 2 mg ) • E2 patches ( 25, 37.5 , 40 , 50, 75, 80, 100 mcg ) • Oestrogel (2 measures =1.5 mg) • Sandrena gel ( 0.5mg , 1 mg sachets) 50 mcg patch= 1mg oral E2 =1- 2 measures of Oestrogel Implant E2- Hysterectomy , poor response to above
Indications for transdermal HRT
• Migraines
• BMI>30
• HT
• Diabetes
• Hx of VTE
• On Thyroxine, anti-
epileptics
• Crohn`s disease
• Poor relief with oral HRT
• Hypertriglyceridemia
• Gall Bladder diseaseCOMPOUNDED BIO-IDENTICAL
HORMONES(unregulated)
BODY-IDENTICAL (Regulated)
Oestrogel Uterogestan
• 1-2 measures daily, can • 100 mg cap daily (CCHRT)
increase dose to 3-4 • 200mg x12 days
• At bedtime , on empty
stomach
• Drowsy, somnolenceDuration & F/U of systemic HRT
• POI - until age 51 at least 1 At 3/12, followed by
• >51 yrs : Informed choices , Annual review (QS4)
No arbitrary time limit 2. BP, BMI
(under 5 yrs – safety data) 3. Check Bleeding pattern,
• Discontinue gradually- symptom control
makes no difference 4. Risk Benefit Analysis
• Individualise Rx: 5.Any changes in Medical
- 50-60 yrs- Benefits History
outweigh risk 6. Dose reduction with age
- 60-70 Benefits = risk, When to stop??
- Over 70 Risk outweigh
benefits
26Indication to refer to Specialist • Uncertainty about Rx options • Side Effects on HRT • Multiple Rx failures • Tried 2-3 preparations • Abnormal bleeding on HRT • Premature Ovarian Insufficiency ( POI)
HRT and contraception • SEQ HRT is not a contraceptive • CCHRT – post menopausal • POP- Micronor/Norgeston • IUS will be best option • Implant or Depo Provera • Barrier Method
Case 1 • Age 52, C/O hot flushes night sweats , for past 6 months and is unable to sleep. Has low sex drive. • Periods are irregular every 6-8 weeks and lasts for 4-5 days • Keen to start HRT • BP-120/80, BMI=28, non smoker, Alcohol 2 bottles of wine/week • Has Googled about HRT and keen to start HRT • What advice, HRT options ? • Contraception?
Management
• History taking, Counsel about HRT , Benefits and Risks of HRT
• Examination?
• HRT- Oral or Transdermal
• Sequential or Combined HRT
• Elleste Duet 1 mg or Oral Estrogen and IUS
• Follow up – Review when?
• Still has some hot flushes , low mood on Elleste Duet 1 mg -
Which HRT will you prescribe?
• Elleste Duet 2 mg
• Has PMS symptoms in second half of cycle ?
• Which HRT?
• Femoston 2/10, Now age 55 – which HRT can you change to?Case 2 • Age 52, IUS fitted 2 year back • No periods • Gaining weight and wants IUS removed • C/O hot flushes few, foggy head - 6 months • Sex is painful, dryness, recurrent thrush • BMI=31 , BP 120/80 When can contraception be stopped ? Which HRT? What if she was HT ? What blood test if she has poor response to HRT ?
Vaginal Oestrogens
(LOCAL EFFECT ONLY)
Tablets Cream Ring
Small to insert, For vulval Remains in vagina
licensed for long irritation , messy , x 3 months ,
term use licensed 3-6 licensed for 2
months years
Nightlyx2 wks foll Same regime Changed 3
by twice a wk monthly
Vagifem 10 mcg Oestriol 0.1% and Estring 7.5 mcg
0.01% /day
32Vaginal Moisturisers • Pjur Med ( silicone based) • Yes, oil based lubricant • Replens Water based – not so effective • Regelle, Replens, Hyalofemme • With Tamoxifen- can have very low dose local E but need to liase with Breast cancer surgeons 33
Case 3 • Age 42 , No periods for 6 months after stopping COC (x8yrs) • Has 2 children - 5yrs, 7 yrs • Hot flushes, feels tired , low mood, loss of sex drive • Started on Citalopram by GP- slight improvement in symptoms • FHx – early menopause mother in 40`s • BMI =26, BP 120/80
Rx options
• COC/HRT till age 50
• Zoely/Qlaira- natural hormones(cont/extended regimes)
• IUS+ E2 (estradiol) tablets (IUSx5 years)
• HRT- Seq HRT- Elleste Duet 1 mg tablets daily and use
condoms
• HRT – as above and Micronor pill (POP)
• FU in 3/12 and thereafter yearly
• When will you change her HRT to CCHRT?
• Age 51 – Do you stop her HRT ??Case 4
• Age 55, no periods for 3 years
• Has hot flushes , night sweats x 2-3 yrs,
• BMI=30, BP 120/80
• Non smoker , good health,
• Alcohol - 18 units/wk
• Her mother in law died of breast cancer on HRT
• Would like further information on
Alternatives to HRTAlternatives to HRT
Paroxetine /Fluoxetine
10 mg vs 20 mg- less side effects, effective RCOG – Pt info leaflet
Potent CYP2D6 inhibitor- reduces efficacy of www.rcog.org.uk
Tamoxifen • CBT
Sertraline
50 mg daily
Citalopram 10-20 mg daily
Venlaflaxine – 37.5 mg daily, can increase
dose to 75 mg
Can be given with Tamoxifen, take in the
morning to avoid insomnia
Clonidine,
37
GabapentinHerbal Remedies & Diet • Red Clover : Promensil • Black Cohosh • Sage, alfa alfa • Phytoestrogens in diet
Case 5 • Age 52, TAH with BSO at 50 • Menopausal symptoms , low sex drive , tiredness • She is worried about risk of breast cancer with HRT . • How can you reassure her? • NICE Guidance : E only HRT – no increased risk or lower risk compared with Combined HRT , as no progestogen • Which HRT??
Why NICE? 1.Menopausal symptoms >45- Don’t send FSH 2. If low mood- don’t start on anti-depressants, consider CBT, HRT 3. Individualise HRT Rx- dose , type, with age lower doses 5. Risk Benefit Analysis 6. HRT within 10 yrs of menopause or under 60 – benefits outweigh risks 7. POI, Early menopause – HRT till age 51 8. Vaginal E low dose – licence for indefinite use 9.BMS vision for menopause care 40
Training
• http://www.pcwhf.co.uk/(Pri • Patient info leaflet ( NICE)
mary Primary Womans Health • Menopause & me leaflet
Care Forum)
• www.menopauseacademy.co. • www.menopausematters.co.u
uk k
- Mylan Webinars • www.womens-health-
• BMJ learning concern.org.uk
• Management of The • www.bms.org.uk
Menopause- 6th edition -BMS • www.managemymenopause.co.
• Special Skills Module in uk
Menopause ( British • www.menopausedoctor.co.uk
Menopause Society website)
• www.nice.org.ukThank you for your
attention
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