1. DR FULVA DAVE 29th November 2016
Menopause & HRT
DR FULVA DAVE
29th November 2016

2. ‘Aging’ an unavoidable property of all living tissue..
- Charles Darwin

3. ‘They thought I was a hypochondriac
‘They thought I was a hypochondriac. It’s taken me years to convince them that there was something else besides neurosis’
‘I didn’t feel like a ‘real woman’. I felt inferior’
‘I felt like a new person. I was reborn, even though they were brought on by tablets’
‘Most people say; ‘At my age’, ‘I’m at the age’ and I think, ‘well, I’m not, not at all, I’m half the age’………………

4. Women’s one third of life in menopause
Women make up almost half (47%) the workforce in the UK – occupational health issue
3.5 million women age 50 or over
Research at University of Nottingham in 2011
- majority felt they were little preparted for this ‘change of life’
- need for further advice & support
- some considered working part-time/alternatives
- Issue about temperature control at workplace, poor toilet facilities, lack of access to
cold drinking water, uniform etc

5. Objectives Refresh and strengthen the basics NICE update
Clarify myths related to HRT

6. What is menopause? Meno-pause (cessation of periods)
12 months after last menstrual period
Average age in UK - 51 years
Perimenopause - symptoms + irregular periods (45-55 years)
Early menopause < 45 years (around 5%)
Premature menopause < 40 years (1%)

7. Menopause contd.
DO NOT use FSH test to diagnose menopause if on women using hormones
Consider using FSH test as a diagnostic test for menopause ONLY if:
Age years with menopausal symptoms including a change in menstrual cycle
Age < 40 with a suspicion of early onset of menopause

8. Premature menopause Aetiology
Elevated FSH levels > 30 IU/L (two samples 4-6 weeks apart)
Fertility issues
Osteoporosis - Increased risk
Need HRT until 51 years
Refer for expert opinion

9. Symptoms & effects Hot flushes Osteoporosis
Night sweats Cardiovascular disease
Sleep disturbances Dementia
Joint pains, aches Degenerative/debilitating disease
Headaches Incontinence
Memory loss
Anxiety, depression
Vaginal dryness, low libido Oestrogen deficiency
Bloating
Increased urinary frequency

11. How does it affect? Not everyone suffers with symptoms
70% - vasomotor symptoms
Varies - familial, ethnicity
Duration : 6 months - 20 years
After 60, requirement for oestrogen reduced

12. What to do? Awareness Coping mechanisms (Diet, lifestyle, Exercises)
If severe, consider HRT

13. Diet, Exercise, Lifestyle
Greatest impact on women’s life
Balanced diet & optimum BMI
Weight bearing exercise, brisk walking
Smoking, alcohol, caffeine, excess salt & sugar

14. Hormone replacement therapy (HRT)
Oestrogen (Main), Progestogens (Endometrial protection) and Testosterone (Rarely used)
Truly effective to reduce symptoms and long term benefits for bones
Women without uterus Women with uterus
- Oestrogen only Oestrogen & Progesterone
Still having periods or within 1 year of LMP
Cyclical/Sequential
More than one year of LMP or after 54 years
Continuous combined

15. HRT contd. Oestrogen preparations Progesterone preparations
Ethinyl estradiol (synthetic) Norethisterone
Estradiol Levonorgesterol
Estriol Medroxyprogesterone acetate
Estrone Mirena IUS
Micronised Progesterone –
Utrogesterone (natural)

16. Doses & routes Oral 0.5mg, 1mg, 2mg (once a day)
Patches 25, 37.5, 50, 75, 100 mcg (twice weekly) – below waist
Gel/Pessary/Cream
Progestogens - variable
Mirena (20mcg LNG/day)
Natural progestogen (utrogestan) 100 or 200mcg
Testosterone (gel, cream)
Implants no longer available in UK

17. Side effects Fluid retention Headaches Breast tenderness Bloating
Nausea
Mood swings
PMS like symptoms

18. Contraindications
Oestrogen dependent malignant tumours - breast, endometrium
Undiagnosed vaginal bleeding
Current DVT/PE
Pregnancy

19. Controversies…..

21. Women’s Health Initiative (WHI) Million Women Study (MWS)
- USA ( ) UK (1996 – 2003)
(50-79) One million women attending NHS
- Randomised HRT Vs placebo breast screening clinic over 50 years old
- Increase in breast cancer, coronary Screening women already high risk
events, stroke, DVT in HRT group Study methodology criticised
- Study stopped early in Oestrogen only increases risk of breast,
- HRT in under 60 - Protective uterine and ovarian cancer
- Risk is duration dependent, more risk Combined more risk than oestrogen only
with combined than oestrogen only

22. HRT - risks
Breast cancer risk - 4 extra cases /1000 women after 5 years
(This is less risk than smoking 10 cigs/day)
45/1000 – population risk
49/1000 – HRT (5 years)
51/1000 – HRT (10 years)
Combined HRT more risk than with Oestrogen only
Safe for receptor negative cancers
SSRIs should not be offered to patients with breast cancer on tamoxifen
Risk reduces after stopping HRT

23. HRT risks contd. Ovarian cancer - No increased risk
Endometrial cancer - Adding progestogen decreases risk

24. HRT risks contd. Venous thromboembolism
Risk of VTE is increased with oral HRT compared to baseline population risk
Risk of VTE associated with transdermal preparations given at the standard
therapeutic dose is no greater than the baseline population risk
Risk of VTE is greater in oral HRT compared with transdermal preparations
Patients with high risk of VTE (strong FH of VTE or hereditary thrombophilia)
refer to menopause specialist or haematologist for assessment before
considering HRT

25. HRT risks contd.
Risk of heart disease not increased if started between 50 and 59
Stroke - not increased if started under 60. More risk with smoking and over weight
Weight gain - RCT no evidence
Osteoporosis - Useful more in Premature menopause, but not a first line for prevention
in older
Do not use HRT
In Breast or Endometrial cancer, Stroke or DVT, Severe liver disease.

26. Review At 3 months to assess efficacy and tolerability
Annually thereafter unless treatment becomes ineffective or side
effects from HRT

27. Referral Ongoing troublesome side effects
Treatment does not improve their menopausal symptoms
Ongoing troublesome side effects
Menopausal symptoms & contraindication to HRT
Uncertainty about the most suitable treatment options

28. Criteria for ultrasound
Any bleeding after 6 months of continuous combined HRT even in low risk women
Bleeding after amenorrhoea has been established
Any bleeding in the first 6 months if any risk factors present

29. Alternative options
Tibolone (Livial) – oestrogenic, progestogenic & androgenic properties
SERM - Raloxifene
SSRI/SNRI - Venlafaxine/Fluoxetine/Paroxetine
Clonidine - not very effective
Complementary - soya, red clover, black cohosh, evening primrose, acupuncture, homeotherapy
Insufficient data for safety & effectiveness

30. Alternative options contd.
Bio-identical hormones - not enough evidence for safety
- same risk and benefit as traditional
- unregulated
Cognitive behavioural therapy

31. To summarise…. Premature menopause Peri menopause and Post menopause
Totally safe until 51 years, then review
Peri menopause and Post menopause
Benefits Vs Risk (Individualised)
Symptom control & long term benefits (Bones, Heart)
Lowest effective dose
Sooner the better
Not advisable to start after 60 years

32. Do not use FSH test routinely to diagnose menopause
Contraception after last menstrual period – 2 years if < 50 years
1 year if > 50 years
Consider referral to appropriate health professional expert for
complex cases

33. Where to refer?

34. Menopause clinic at QMC, NUH (every Thursday am)
Miss Anita Juliana – RCOG & BMS accredited Menopause specialist
Staff awareness session quarterly - NUH workers
10500 women
4000 > 45 years old

35. Case discussion

36. Case study 52 year old secondary school teacher
No relevant medical history
Always calm and organised
Recently irritable and struggling to cope with minor challenges
Exploited by school children of her weakness
Unable to sleep, asking GP for more sleeping tablets

37. How to approach? Relevant history LMP 6/12 ago, before that 3/12 ago
Night sweats with severe chills sometimes, occasional day time flushes
Often wakes up then sweats
No interest in sex, often it hurts

38. She would like to try some HRT
Where in menopause transition is she?
What are the symptoms?
What is her main concern?
What is her risk profile?

39. What do we choose now? Elleste duet 1mg
Estradiol 1mg plus NET 1mg from day 17-28
NHS cost £9.72 for 3 months

40. Review in 3 months Persistence of symptoms
Any new symptoms/side effects?
When do they occur in the cycle?
Bleeding pattern BP
Review of risk analysis

41. 3 months later
Symptoms and sleep better in the first 2 weeks of the pack
Not so good and tearful when pill colour changes
Bleeding is fine
Would like to improve things

42. Modify treatment Increase estrogen Change progestogen preparation
Femoston 2:10
( 17B estradiol 2mg plus 10mg dydrogesterone)
Cost £13.47 for 3 months

43. Additional resources NICE guideline 2015 British menopause society
TOG article by Dr Dave et al…!

44. Thank you