MENOPAUSE MENOPAUSE

WHAT ? Menopause is a deviation of the ancient Greek words menos ( month) and pauses (ending). menopause is sometimes known as the 'change of life' and is marked by the ending of menstruation. The menopause is sometimes known as the 'change of life' and is marked by the ending of menstruation.

WHAT?WHAT? It be defined with certainty after twelve months' spontaneous amenorrhoea. It be defined with certainty after twelve months' spontaneous amenorrhoea. End of reproductive life. End of reproductive life.

Age (years) Pre-menopause Post-menopause MENOPAUSE 1 YEAR Peri-menopause “ Climacteric” RELATED TERMINOLOGY

WHEN?WHEN? Menopausal age: years Menopausal age: years (mean : 50.7 years) (mean : 50.7 years) If the menopause occurs in a woman who is under 45 years of age, it is known as premature menopause. If the menopause occurs in a woman who is under 45 years of age, it is known as premature menopause. Late menopause: >55 years old Late menopause: >55 years old

WHEN?WHEN? Other factors that can affect the age at which women have their final period include age at menarche, parity, previous oral contraceptive history ethnicity and family history. Other factors that can affect the age at which women have their final period include age at menarche, parity, previous oral contraceptive history ethnicity and family history.

WHY?WHY? RELATIVE ACTIVITY OF ESTROGEN

WHY?WHY? The menopause is the end of egg production (ovulation). This occurs as a result of falling levels of the female sex hormone oestrogen, which regulates a woman's periods. The menopause is the end of egg production (ovulation). This occurs as a result of falling levels of the female sex hormone oestrogen, which regulates a woman's periods.

WHY?WHY? The menopause results from a fall in the level of the female hormone oestrogen in the blood. The menopause results from a fall in the level of the female hormone oestrogen in the blood.

WHY?WHY? At a hormonal level - as ovarian follicular activity begins to fail, oestrogen and progesterone levels fall and the reduced negative feedback to the pituitary causes a rise in luteinising hormone (LH) and follicle stimulating hormone (FSH). At a hormonal level - as ovarian follicular activity begins to fail, oestrogen and progesterone levels fall and the reduced negative feedback to the pituitary causes a rise in luteinising hormone (LH) and follicle stimulating hormone (FSH).

HOW?HOW? Oestrogen reduction eventually results in menstrual cycle disruption and other menopausal symptoms. Oestrogen reduction eventually results in menstrual cycle disruption and other menopausal symptoms.

HOW?HOW? * * FSHhigh (30 – 170 mU/ml) * LHhigh (20 – 80 mU/ml) * Estradiollow (< 110 pmol/L)

Vasomotor Symptoms Sleep Disorders Menstrual Disorders Mood Changes Vaginal Atrophy Dyspareunia Skin Atrophy OsteoporosisAtherosclerosis Coronary Heart Disease Cerebrovascular Disease 40 yrs 50 yrs Menopause 60 yrs SYMPTOMS!SYMPTOMS! ONSET OF SYMPTOMS IN RELATION TO AGE OF MENOPAUSE

SYMPTOMS!SYMPTOMS! Changes in your period—time between periods or flow may be different. Changes in your period—time between periods or flow may be different. Hot flashes (“hot flushes”)—getting warm in the face, neck and chest. Hot flashes (“hot flushes”)—getting warm in the face, neck and chest. Night sweats and sleeping problems that may lead to feeling tired, stressed or tense. Night sweats and sleeping problems that may lead to feeling tired, stressed or tense. Vaginal changes—the vagina may become dry and thin, and sex may be painful. Vaginal changes—the vagina may become dry and thin, and sex may be painful. Thinning of your bones, which may lead to loss of height and bone breaks (osteoporosis). Thinning of your bones, which may lead to loss of height and bone breaks (osteoporosis).

SYMPTOMS!SYMPTOMS! It is estimated that 8 out of 10 women in the UK experience symptoms leading up to the menopause. It is estimated that 8 out of 10 women in the UK experience symptoms leading up to the menopause. Of these, 45% find their symptoms difficult to deal with. Of these, 45% find their symptoms difficult to deal with.

SYMPTOMS!SYMPTOMS! Without treatment, most menopausal symptoms gradually stop naturally. This usually happens two to five years after the symptoms start. Without treatment, most menopausal symptoms gradually stop naturally. This usually happens two to five years after the symptoms start. Although some women experience symptoms for many more years. Although some women experience symptoms for many more years.

SYMPTOMS!SYMPTOMS!

SYMPTOMS!SYMPTOMS! NORMAL TRABECULAR BONE OSTEROPEROTIC BONE

TREATMENTTREATMENT Only 1 in 10 women seek medical advice when they go through the menopause and many do not need any treatment. Only 1 in 10 women seek medical advice when they go through the menopause and many do not need any treatment. If menopausal symptoms are severe enough to interfere with daily life, there are treatments that can help. If menopausal symptoms are severe enough to interfere with daily life, there are treatments that can help.

TREATMENTTREATMENT The kind of treatment you can take depends on the severity of the symptoms, medical history and patient’s own preferences. The kind of treatment you can take depends on the severity of the symptoms, medical history and patient’s own preferences.

TREATMENTTREATMENT HRT HRT NON- HRT NON- HRT

HOMONE REPLACEMENT THERAPY (HRT) As the name suggests, HRT works by replacing oestrogen. As the name suggests, HRT works by replacing oestrogen. Hormone replacement therapy (HRT) can be an effective treatment for the typical menopause-related symptoms. Hormone replacement therapy (HRT) can be an effective treatment for the typical menopause-related symptoms.

HOMONE REPLACEMENT THERAPY (HRT) HRT may also have an influence on the long term health problems(osteoporosis, cardiovascular disease and stroke), though it should be noted that it does not necessarily reduce their risk for all women. HRT may also have an influence on the long term health problems(osteoporosis, cardiovascular disease and stroke), though it should be noted that it does not necessarily reduce their risk for all women.osteoporosis cardiovascular diseasestrokeosteoporosis cardiovascular diseasestroke

HOMONE REPLACEMENT THERAPY (HRT) BENEFITSRISKS

For the treatment of menopausal symptoms where the risk-benefit ratio* is favorable, in fully informed women, in the lowest possible dose to control symptoms and for the shortest duration possible. For the treatment of menopausal symptoms where the risk-benefit ratio* is favorable, in fully informed women, in the lowest possible dose to control symptoms and for the shortest duration possible.

HOMONE REPLACEMENT THERAPY (HRT) BENEFITS BENEFITS Relieve menopausal symptoms Maintenance of quality of life Prevention of osteoporosis Note: HRT should not be used as a first-line treatment in osteoparosis except in women who have premature menopause Note: HRT should not be used as a first-line treatment in osteoparosis except in women who have premature menopausepremature menopausepremature menopause

HOMONE REPLACEMENT THERAPY (HRT) RISKS OF VTE RISKS OF VTE HRT (combined or oestrogen-alone) increases the risk of a deep vein thrombosis or pulmonary embolism, especially in the first year of treatment. The risk is more pronounced in women with pre-existing risk factors. A recent meta-analysis suggests that transdermal oestrogens may be a safer option than oral oestrogens for HRT.

HOMONE REPLACEMENT THERAPY (HRT) RISKS OF BREAST CANCER RISKS OF BREAST CANCER The increased breast cancer risk is proportional to the duration of HRT. HRT increases this risk by about 1.6 times after 5 years of use and 2.3 times after 10 years of use. Risk decreases within a few years of stopping HRT. The increased breast cancer risk is proportional to the duration of HRT. HRT increases this risk by about 1.6 times after 5 years of use and 2.3 times after 10 years of use. Risk decreases within a few years of stopping HRT. Her actual risk increases 0.08% (ACOG) Women considering HRT should be counselled that the absolute risk for breast cancer for any individual remains relatively low* Her actual risk increases 0.08% (ACOG)

HOMONE REPLACEMENT THERAPY (HRT) RISKS OF ENDOMETRIAL CANCER RISKS OF ENDOMETRIAL CANCER Endometrial cancer: increased risk only with unopposed oestrogen. There is no increased risk with combined (oestrogen and progestogen) HRT. RISKS OF OVARIAN CANCER long-term use of oestrogen-only HRT and combined HRT may slightly increase the risk. Risk decreases after stopping HRT.

HOMONE REPLACEMENT THERAPY (HRT) RISKS OF CARDIOVASCULAR DISEASE RISKS OF CARDIOVASCULAR DISEASE There is not the same evidence of cardioprotection from HRT as was originally thought. There is not the same evidence of cardioprotection from HRT as was originally thought. Assess all women's risk of CHD prior to starting HRT. Assess all women's risk of CHD prior to starting HRT.

HRT E+PE HOMONE REPLACEMENT THERAPY (HRT)

E+P E For hysterectomized pts HOMONE REPLACEMENT THERAPY (HRT) s Sequentially combined HRT  E(continuously D1-D21)  P(sequentially D11-D21) Continuous combined HRT  E &P (continuous: D1- D28)

HOMONE REPLACEMENT THERAPY (HRT) Women with an intact uterus Women with an intact uterus Vasomotor symptoms Perimenopausal: systemic cyclical combined HRT. Perimenopausal: systemic cyclical combined HRT. Postmenopausal: systemic continuous combined HRT or tibolone. Postmenopausal: systemic continuous combined HRT or tibolone. Urogenital symptoms Perimenopausal: low-dose vaginal oestrogen or systemic cyclical combined HRT. Perimenopausal: low-dose vaginal oestrogen or systemic cyclical combined HRT. Postmenopausal: low-dose vaginal oestrogen or systemic continuous combined HRT. Postmenopausal: low-dose vaginal oestrogen or systemic continuous combined HRT.

HOMONE REPLACEMENT THERAPY (HRT) Women who have had a hysterectomy Women who have had a hysterectomy Vasomotor symptoms: systemic oestrogen-only HRT. Urogenital symptoms: low-dose vaginal oestrogen or systemic oestrogen-only HRT.

HOMONE REPLACEMENT THERAPY (HRT)

CONTRAINDICATIONS OF HRT! Pregnancy and breast-feeding Pregnancy and breast-feeding Undiagnosed abnormal vaginal bleeding Undiagnosed abnormal vaginal bleeding Venous thromboembolic disease Venous thromboembolic disease Active or recent angina or myocardial infarction Active or recent angina or myocardial infarctionanginamyocardial infarctionanginamyocardial infarction Suspected, current or past breast cancer Suspected, current or past breast cancer Endometrial cancer or other oestrogen-dependent cancer Endometrial cancer or other oestrogen-dependent cancer Active liver disease with abnormal liver function tests Active liver disease with abnormal liver function testsliver function testsliver function tests

START-UP SYMPTOMS OF HRT! Breast tenderness Breast tenderness Nipple sensitivity Nipple sensitivity Bloating Bloating Nausea, headaches Nausea, headaches Appetite Appetite Weight gain Weight gain Leg cramps Leg cramps

INVESTIGATIONS BEFORE HRT! Investigations are not usually necessary before starting HRT unless there is : Investigations are not usually necessary before starting HRT unless there is : sudden change in menstrual pattern (IMB/PCB) sudden change in menstrual pattern (IMB/PCB) High risk of breast cancer High risk of breast cancer Personal /family history of VTE Personal /family history of VTE Woman has arterial risk factors Woman has arterial risk factors

ALTERNATIVE TO HRT! “ Tibolone” is a synthetic hormone that acts in the same way as HRT (SERM) “ Tibolone” is a synthetic hormone that acts in the same way as HRT (SERM) Useful for post-menopausal women who want to end their periods. Useful for post-menopausal women who want to end their periods. Which has oestrogenic, progestogenic and androgenic properties. (estrogenic activity in bone, CNS vasomotor suppression of hot flushes and helpful in improving sexual function. Which has oestrogenic, progestogenic and androgenic properties. (estrogenic activity in bone, CNS vasomotor suppression of hot flushes and helpful in improving sexual function.

STARTING HRT! “A full physical examination is mandatory” “A full physical examination is mandatory” Full blood count Full blood count Renal Profile- Baseline Renal Profile- Baseline Liver Function Test Liver Function Test Lipid profile Lipid profile

FOLLOW UP OF TAKING HRT! Review the woman 3 months after starting HRT and once each year thereafter. Review the woman 3 months after starting HRT and once each year thereafter. At 3-months: At 3-months: –Enquire about bleeding patterns, check blood pressure, and body weight. –Assess the effectiveness of treatment and adjust to achieve symptom control. –Enquire about adverse effects and manage appropriately.

FOLLOW UP OF TAKING HRT! Once each year: Once each year: –Check blood pressure, effectiveness of treatment and adjust to achieve symptom control. –Enquire about adverse effects and manage appropriately. –Consider switching from cyclical HRT to continuous combined HRT, if appropriate. continuous combined HRT, if appropriate.

FOLLOW UP OF TAKING HRT! –Discuss the risks and benefits of HRT. –Perform a breast examination if indicated by personal or family history. –Encourage breast awareness and participation in the national breast screening programme as appropriate for their age. –Pelvic examination is required only if clinically indicated

NON- HRT Lifestyle modification Stop smoking Healthy diet Weight control Regular moderate-intensity exercise Control blood pressure and cholesterol

NON- HRT For vasomotor symptoms For vasomotor symptoms –A trial (2 weeks) of paroxetine,fluoxetine citalopram or venlafaxine (SSRI) –A trial (2–4 weeks) of clonidine –A progestogen such as norethisterone or megestrol

NON- HRT For vaginal dryness For vaginal dryness Vaginal lubricant or moisturizer, such as Replens ®. Vaginal lubricant or moisturizer, such as Replens ®.

NON- HRT For osteoporosis For osteoporosis –Alendronate (Fosamax ) –Rocaltriol –Alpha-calcidol –Raloxifene (Evista)

NON- HRT For psychological symptoms For psychological symptoms - Self-help groups - Psychotherapy - Other forms of counselling - Antidepressants.

NON- HRT Complementary therapies Remifemin (Cimicifuga rhizome extract) Remifemin (Cimicifuga rhizome extract) Red clover plant Red clover plant Soy products Soy products Evening primrose Evening primrose Black cohosh Black cohosh Phytoestrogens Phytoestrogens Ginseng Ginseng

NON- HRT Complementary interventions Acupuncture Acupuncture Reflexology Reflexology Diet and supplements Vitamins and minerals Vitamins and minerals Vitamin E Vitamin EHomeopathy

Premature menopause? Menopausal symptoms in women who are younger than 40 years (1%) Menopausal symptoms in women who are younger than 40 years (1%) Offer lifestyle advice. Offer lifestyle advice. Offer systemic hormone replacement therapy (HRT) or the combined oral contraceptive pill (COC) Offer systemic hormone replacement therapy (HRT) or the combined oral contraceptive pill (COC) Decreased libido: testosterone implants and patches may be considered Decreased libido: testosterone implants and patches may be considered

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