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Living with the Menopause Dr Henrietta Antscherl

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Presentation on theme: "Living with the Menopause Dr Henrietta Antscherl"— Presentation transcript:

1 Living with the Menopause Dr Henrietta Antscherl

2 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

3 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

4 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)

5

6 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

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

8 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

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

10 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

11 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

12 Hormonal Therapy

13 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

14 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

15 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

16 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

17 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)

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

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

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

21 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

22 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

23 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

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

25 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

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

27 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

28 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

29 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

30 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

31 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

32 And finally………


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