‘Dr….I get really bad hot sweats and always feel irritable’ Dr Monica Chitkara GPST3

WHAT DO YOU KNOW? OR NOT KNOW?!

Aims for the next 30 mins Knowing when to consider the menopause in your differential How to go about diagnosis HRT! Other treatment options Vulgovaginal atrophy

‘Is this the menopause?’ Average age 52 yrs old 1 year amenorrhoea >50yrs 2 years amenorrhoea >45yrs Symptoms usually around 45yr Symptoms: hot flushes and night sweats (80%), sleep disturbance, menstrual irregularities, vaginal dryness, urinary problems Symptoms due to oestrogen deficiency

‘Can I have a blood test?’ NO! (if over 45yrs old) If menopausal, no negative feedback loop…↑↑ FSH Do FSH Diagnosis of premature ovarian failure (<45yrs) Hysterectomy with ovaries preserved To decide whether woman should stop contraception FSH fluctuates in perimenopause so unhelpful in diagnosis in >45yrs. FSH stimulates ovarian folliculogenesis, Ovaries do not respond FSH fluctuates in perimenopause so unhelpful in diagnosis in >45yrs old. Do FSH – diagnosis of premature ovarian failire, 2 measurements 4-8wks apart >30-40IU/L - contraception: measure on 2 occasions 6w apart. >30IU/L suggestive of menopause but guidance to continue contraception for 1 yr

The all important counselling Symptoms http://www.menopausematters.co.uk Management: Symptoms: hot flushes and night sweats, sleep disturbance, menstrual irregularities, vaginal dryness, urinary problems

HRT

HRT Unopposed oestrogen  endometrial proliferation. Progesterone given if uterus intact. Oestrogen only – hysterectomy or IUS Sequential combined – oestrogen with progesterone sequentially to trigger bleed. Minimises irregular bleeding in perimenopausal women. Switch to continuous after 1yr min. Continuous combined – daily dose of oestrogen and progestogen. Only after 1 yr of last period. Move from sequential by 54yrs old.

HRT Vasomotor symptoms, vaginal dryness, low mood and libido ↓ ↑ ↔ Decreased risk Increased risk Small increased risk Equivocal risk HRT Vasomotor symptoms, vaginal dryness, low mood and libido E&P E ORAL TRANSDERMAL FRAGILITY # ↓ CHD ↔ VTE ↑ STROKE BREAST CA ↑/↔ When HRT started when women <60yrs old Increased risk of CVA and VTE – use transdermal No increased risk of CHD Oestrogen only HRT – little/no change in breast cancer risk. Combined HRT increases breast cancer risk but related to tx duration. Risk reduces after stopping. Fragility fracture risk decreased if taking HRT, reduction decreases once stopped. Slight increase in ovarian cancer.

HRT Vasomotor symptoms, vaginal dryness, low mood and libido ↓ ↑ ↔ Decreased risk Increased risk Small increased risk Equivocal risk HRT Vasomotor symptoms, vaginal dryness, low mood and libido E&P E ORAL TRANSDERMAL FRAGILITY # ↓ CHD ↔ VTE ↑ STROKE BREAST CA ↑/↔

HRT – the bad bits Oestrogen-related: fluid retention, bloating, breast tenderness, nausea, headaches, leg cramps, and dyspepsia. Progestogen-related: fluid retention, breast tenderness, headaches or migraine, mood swings, depression, acne, and lower abdominal pain. Bleeding

Monitoring 3m initial review and annual review BMI and BP Lifestyle advice Cervical and breast cancer screening Bleeding pattern – unscheduled bleeding in first 3m but if after 3m, needs further ix.

Stopping HRT If risks>benefits Risk of breast Ca increases with duration of use >60  Lowest dose, transdermal route (VTE risk) Taper off Stay off for 2-3 months before deciding whether to recommence Tapering off 2w – 6m reduced short term recurrence of symptoms but no long term difference

‘Dr, I like HRT but….’ Breakthrough bleeding Progestogenic S/E If after switching to continuous combined and does not settle in 3-6m, switch back to sequential for 1 yr. If heavy/erratic on sequential, double progestogen or increase duration to 21d. If persistent >6m, USS endometrial biopsy Progestogenic S/E Androgenic (acne, hirsutism), switch to non-testosterone derived progestogen (medroxyprogesterone acetate) Mood swings – halve dose and duration of progestogen (7-10d)

Genitourinary syndrome of menopause (vulvovaginal atrophy) Changes of vulva, vagina, lower urinary tract due to oestrogen deficiency. Symptoms: vaginal dryness/lack of lubrication, dyspareunia, PCB, Itching, soreness, burning, urinary frequency, urgency, nocturia, stress incontinence. Topical oestrogens No systemic risks Pessaries and cream can improve sexual dysfunction Overactive bladder – topical oestrogens with antimuscarinincs (plus bldadder training and lifestyle measures) Be aware of unexpected bleeding YES products Top oestrogens can be given with PO/TOP HRT Lubrication can help sexual dysfunction Topical lubricants/moisturisers if want to avoid hormones – YES products

‘It’s natural doc – it must be safe’ Vasomotor symptoms — a trial of fluoxetine, citalopram, or venlafaxine (37.5mg bd). Vaginal dryness — a vaginal lubricant or moisturizer. Psychological symptoms — self-help groups, psychotherapy, counselling, or antidepressants. Black cohosh (Menoherb has THR number) – liver toxicity Isoflavones/red clover (phytoestrogens) Dong quai Evening primrose Ginseng THR number Traditional herbal medicine registration – 30y of use, specified strength and composition, provides patient info) Black cohosh – equivocal Isoflav – no Others insufficient evidence

TAKE HOME POINTS Diagnosis is based on clinical symptoms and time from last period Risks and benefits of HRT should be discussed with all women. Use transdermal where possible (and explain why!) For vaginal problems, lubricants are useful. Herbal remedies are not proven to be safe.

QUESTION 1 SAM, 48 yrs old, irregular periods for the last 6, still has a uterus. Wants to try HRT. Progynova Elleste Duet Angelique

QUESTION 1 SAM, 48 yrs old, irregular periods for the last 6, still has a uterus. Wants to try HRT. Progynova Elleste Duet Angelique

QUESTION 2 Sam attends for annual review. Elleste Duet has helped her hot flushes, night sweats and sleep quality. Has bloating, headache and feels irritable when she takes green (E&P) tablets in pack. She is adamant she does not want to stop HRT. Switch to Tridestra Switch to Fomoston Switch her to IUS and start Progynova Decrease days of progestogen, change to diff progestogen, low dose progestogen

QUESTION 2 Sam attends for annual review. Elleste Duet has helped her hot flushes, night sweats and sleep quality. Has bloating, headache and feels irritable when she takes green (E&P) tablets in pack. She is adamant she does not want to stop HRT. Switch to Tridestra Switch to Fomoston Switch her to IUS and start Progynova Decrease days of progestogen, change to diff progestogen, low dose progestogen

QUESTION 3 Sam is now 52 yrs old. More bleeding problems! She settled into a regular, light pattern but now she is having irregular and heavy bleeding. Switch to Prempak C. Advise to stop HRT and refer under 2WW to post-menopausal bleeding clinic. Advise to stop HRT and review in 4 weeks.

QUESTION 3 Sam is now 52 yrs old. More bleeding problems! She settled into a regular, light pattern but now she is having irregular and heavy bleeding. Switch to Prempak C. Advise to stop HRT and refer under 2WW to post-menopausal bleeding clinic. Advise to stop HRT and review in 4 weeks.

QUESTION 4 Sam returns 6 weeks later. Her bleeding stopped after stopping the HRT but menopausal symptoms are back. Her BMI is 33 as she continues to work in a stressful job at the bakers. She is adamant she can’t cope without HRT but she can’t cope with the bleeding either. Start Indiva Fit IUS and start Elleste Solo Start Feseven Conti

QUESTION 4 Sam returns 6 weeks later. Her bleeding stopped after stopping the HRT but menopausal symptoms are back. Her BMI is 33 as she continues to work in a stressful job at the bakers. She is adamant she can’t cope without HRT but she can’t cope with the bleeding either. Start Indiva Fit IUS and start Elleste Solo Start Feseven Conti BMI and VTE risk. Feseven Conti is transdermal

(Not sure I am qualified enough to answer any) Questions? (Not sure I am qualified enough to answer any)