Living with the Menopause Dr Henrietta Antscherl

What is the Menopause Occurs between 45-55 years; average is 51 years Periods become less frequent before they stop; may be light or heavy 1:100 women before 40 years; premature menopause or premature ovarian insufficiency 8:10 women have symptoms before periods stop

What is the menopause Diagnosed after no periods for 1 year Ovaries stop producing eggs each month High FSH level on blood test indicates ovarian failure FSH Levels vary in perimenopause Symptoms due to lack of oestrogen

Common menopausal symptoms Hot flushes, night sweats and difficulty sleeping and day time tiredness Reduced sex drive, vaginal dryness and pain, itching or discomfort during sex Problems with memory/concentration, headaches Low mood/anxiety Palpitations Joint stiffness/aches and pains, reduced muscle strength Recurrent UTIs (cystitis) Weak bones (osteoporosis)

Self-help options Loose natural fabric layers Fans Avoid spicy foods Avoid caffeinated drink, increase soy based foods Reduce alcohol, stop smoking Increase exercise Lose weight

Herbal treatments Black Cohosh ,Sage, Evening primrose oil, vitamin E and Agnus Castus These are all food supplements Poor quality evidence Possibly harmful?

Phytoestrogens Naturally occurring compounds from plants Convert to weak estrogens in gut Reduce hot flushes in some studies Found in - soy bean, whole grain cereals, oil seeds, lentils, rice,fennel anise, bourbon, beer Red clover

Red Clover Concentrated isoflavones/ phytoestrogens in red clover Tablet form eg Promensil, Menopace

Non- hormonal drug options Clonidine Selective Serotonin ( and noradrenaline) reuptake inhibitors e.g. Citalopram Reduction in flushes e.g. venlafaxine Gabapentin Most effective but limited by side effects

Treatment of vaginal symptoms-Non hormonal Lubricants Used for sex, water based, don't last long E.g. YES-organic, Sylk- kiwi based, KY Jelly, astroglyde Moisturisers dryness and irritation Oil based last longer Replens, YES

Hormonal Therapy

Why did HRT go out of fashion? 2 studies published in early 2000s (WHI and MWS) Both showed increase risk breast cancer Both studies shown to be flawed as used older women over 60,some of whom already on HRT Biased studies NICE guidance on Menopause 2015

Risks of HRT Endometrial cancer (unopposed oestrogen), continuous combined protective Blood clots– 2-3 x background risk (1.7/1000 women > 50 years) Risk greatest in first 12 months. Patches little or no risk Heart attacks – small increased when HRT started >60yrs oral Stroke – small increased when HRT started > 60yrs oral Breast Cancer- 1/1000 extra cases per yr over 5 years in combined HRT

Benefits of HRT Treatment of flushes and mood symptoms Treatment of vaginal dryness and urinary symptoms Osteoporosis prevention HRT reduces fracture risk whilst being taken May last longer if long term use Collagen effects- muscle ,skin, hair

Summary of NICE Guidelines Benefits of HRT usually outweigh the risks Lowest effective dose, short term treatment ( 5 years) HRT prescribed before age 60 has favourable benefit/risk profile If used in women >60 lower dose at initiation and preferably transdermal preparations Premature menopause should use HRT until at least 51

Indications for taking HRT ( from NICE ) Control of menopausal symptoms in the peri or post menopause Women who have a premature menopause ( <40 ) until age of 50 Osteoporosis prevention ( not indicated first line without menopausal symptoms)

Types of HRT Sequential Continuous combined Tibolone Oestrogen alone; tablet, patch, gel or implant Local vaginal estrogen Bio-identicals

If hysterectomy or Mirena Estrogenonly Transdermal Patch Gel Oral Estradiolor conjugated equine estrogens

Uterus and no Mirena Estrogenand Progestogen 1 year post menopause Continuous Combined Perimenopasusal Sequential combined

Sequential therapy Used in peri-menopause before periods ceased Combined patch eg Evorel sequi (oestradiol + norethisterone), Oral- Femoston ( estradiol 1mg/2mg + dydrogesterone 10mg/20mg) Monthly period

Continuous combined > I year from last period Or 1 yr-18/12 on sequential therapy Patch Evorel conti Patch/Gel/oral plus mirena Patch/gel plus oral (or vaginal ) progesterone daily Oral eg Femoston Conti 2 strengths No periods

Local (Vaginal ) oestrogen Exerts local effect on vagina, urethra and bladder relieving symptoms No or minimal systemic absorption, no side-effects No/minimal thickening of womb lining Maybe acceptable when systemic estrogens are contraindicated eg treated breast cancer Can use as well as standard HRT Other uses smear taking/colposcopy

Types of vaginal estrogens Vagifem 10(tablet with applicator) Ovestin(cream) Gynest(cream)

Bio-identical Hormone Replacement Therapy natural hormones' hormones that are identical in molecular structure to endogenous hormones ( which also available as some licensed HRT) Customised compounded hormones (sometimes based on blood/salivary tests) No standardisation, no package inserts warning of potential s/e, Unknown effect of compounding the products Likely to have the same risk/ benefits associated with prescribed HRT Mostly USA and private,not NHS

Follow-up 3/12 review of symptoms and side effects altering prescription as necessary Annual review with risk-benefit assessment Bone scans Mammogram

Menopause and when to stop contraception 2y after menopause if age < 50 1y after menopause age > 50 At age 55 ( unless still menstruating ) Stop combined pill and injectable age 50 and switch to a different method

Use of IUD/IUS in older women IUD – If >40 years can keep until no longer need contraception IUS- If >45 years and no periods can keep until no longer need contraception (if bleeding can be kept for 7 years in total) If IUS only used for heavy periods can keep until no longer need For HRT 5 years

HRT and contraception HRT cannot be depended upon to stop ovulation Measurement of FSH unreliable IUS also effective as progestogen component of HRT Can use POP as contraception but not as part of HRT

Key points Optimisation of diet and lifestyle Alternative therapies- red clover for flushes Consider non- hormonal drug therapy eg Venlafaxine Vaginal estrogens effective and safe for long term use Vaginal moisturisers more effective for vaginal lubrication than water based products

Lowest effective dose, short term treatment ( 5 years) Benefits of HRT usually outweigh the risks HRT prescribed before age 60 has favourable benefit/risk profile If used in women >60 lower dose at initiation and preferably transdermal preparations Premature menopause should use until at least 51

And finally………