1. Menopause scenarios

2. Anita 44yrs, 1 daughter age 6, trying to conceive for 2 years. Periods now irregular, every 6-10/52 Says she’s is under ‘pressure’ from her husband who wants a son

3. Does she want another child? Symptoms of menopause, flushes, libido? Mood? How is her relationship with her husband, think about abuse. What does she know about the menopause? FH, menopause/VTE/breast cancer PMH, breast disease, VTE, liver disease What questions are you going to ask her?

4. What investigations will you do? FSH Consider FBC, TFT, HbA1c, Vit D, Lipids, LFT Check smear, consider swabs bp, BMI, Smoking Breast exam

5. If she is perimenopausal what treatment would you offer? Sequential combined HRT, will have regular bleeds Can be monthly or 3 monthly Oral first line as cheap eg Prempak C Patch avoids first pass effect and does not effect clotting/VTE risk eg Evoral sequi If she needs contraception Mirena plus oestrogen tablet, gel or patch is an option

6. What advice will you give about contraception? Needed for 2 yrs after last period if <50y 1 yr after period if >50y POP licensed can use coc up to 50y if fit non smoker, consider low dose www.fsrh.org has section on contraception over 40 www.fsrh.org

7. Belinda, 49yrs single 2 teenage kids. Works as HCA, 12hr shifts, money tight and worries re kids. Sleep poor. Recently started a relationship with a man, no sex yet, she is anxious about it. Lmp 13/12 ago.

8. What do you need to explore further? What does she know about menopause? Mood? Sleep disturbance, night sweats? Libido, what are worries re new relationship?Think about atrophic vaginitis FH re menopause/breast cancer PMH re breast disease, VTE, liver disease

9. What investigations will you do? NOT FSH Consider FBC, TFT, HbA1c, vit D, lipids, LFT Check smear, bp, BMI, smoking, advice re breast exam Advice re STI screening

10. What advice will you give her? Contraception… Continuous combined HRT, no period 2yrs 50y Again oral or transdermal available, no bleed Refer if still bleeding after 6/12 treatment or after period of amenorrhea Can consider tibolone, better for libido, more likely to bleed. Vaginal oestrogen, eg Vagifem no inc risk VTE or cancer can use long term

11. Cathy 58 yrs, head teacher lives with husband Struggling at work due to hot flushes, poor sleep, worries she is being ratty with her husband who recently retired. Fell on ice in Jan and had Colles left wrist. Hysterectomy 3 yrs ago. Declined HRT last year as worried about SE.

12. What do you need to explore? What are her worries about HRT? Libido? Mood? Self medication eg herbal remedies, alcohol Has fragility fracture been followed up? See NICE osteoporosis guidelines

13. What advice will you give her? Oestrogen only HRT Remember transdermal has NO increased VTE risk Will reduce fracture risk while she is taking it. HRT started < 60yr no increased IHD risk, ? benefit Breast cancer risk negligible with oestrogen only HRT

14. Alternatives to HRT www.menopausematters.co.uk www.menopausematters.co.uk SSRI for flushes, topical testosterone for libido, both off license St Johns Wort Vaginal lubricant Replens, Yes, Sylk CBT, antidepressants Vaginal oestrogen, eg Vagifem no inc risk VTE or cancer can use long term

15. Key Messages about risk Oestrogen increases VTE risk but not if transdermal. Also increases risk of endometrial cancer if not given with progesterone. Progesterone increases risk of breast cancer but only slightly with long term use. Combined HRT may protect against IHD if started under 60yr, increases risk slightly over 60yr.

16. Combined HRT, 3/1,000 extra cases in women 50-59 with 5 yrs use. Risk comparison, alcohol, obesity, HRT > 2-3 units alcohol/day 1.5x Postmenopausal obesity 1.6x > 5yrs HRT 1.35x Breast cancer risk

17. The future Bio identical progesterones may not have increased breast cancer risk Are anxiolytic/hypnotic steroids E.g. Utrogestan licensed for use with oestrogen as combined preparation

18. Useful resources www.fsrh.org has section on contraception over 40 www.fsrh.org http://www.gwh.nhs.uk/media/163808/wiltsh ire_hrt_guidance_2014.pdf very useful summary http://www.gwh.nhs.uk/media/163808/wiltsh ire_hrt_guidance_2014.pdf www.menopausematters.co.uk patient info leaflets www.menopausematters.co.uk www.nice.org.uk latest menopause guidelines www.nice.org.uk