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

2. WHAT DO YOU KNOW?
OR NOT KNOW?!

3. 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

4. ‘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

5. ‘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

6. The all important counselling
Symptoms
Management:
Symptoms: hot flushes and night sweats, sleep disturbance, menstrual irregularities, vaginal dryness, urinary problems

7. HRT

8. 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.

9. 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.

10. 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
↑/↔

11. 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

12. 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.

13. 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

14. ‘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)

15. 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

16. ‘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

17. 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.

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

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

20. 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

21. 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

22. 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.

23. 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.

24. 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

25. 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

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