1. Menopause and HRT- made easy Anita Juliana MBBS, MD, FRCOG Consultant Obstetrician and Gynaecologist Menopause Lead for NUH

2. ‘I didn’t feel like a ‘real woman’. I felt inferior’
Setting the scene
‘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’………………

3. Objectives Refresh and strengthen the basics Clarify myths NICE Update
Case discussions

4. Menopause- Basics What is Menopause? Symptoms Treatment – Yes or No
Myths around HRT

5. What is Menopause? Meno - pause ( Cessation of periods)
12 months after last Menstrual period
Average age in UK is 51 years
Peri Menopause – Irregular periods +Symptoms (45-55 age range)
Premature Menopause – Below 40 years (1% of women)
Early Menopause is below 45 years (Around 5%-20%)

7. Menopause – Why ? Fixed number of eggs when a girl baby is born.
2,000,000 oocytes at birth
25000 at 37 years
1000 oocytes at the age of 50
Rate of decline is variable

8. Menopause - Process
Climacteric
Perimenopause
Post menopause

9. Menopause

10. Premature menopause Aetiology - Various
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

11. Primary care challenges
One third of women's life is post menopause
Post cancer survivors
Quality is priority
Risks versus Benefits
Role of Media
Time limit
Too many visits....

12. Yes You Can Prescribe HRT in 45+ year old women Symptoms obvious
No contraindications
Initial investigations
Premature Menopause

13. Primary care Dilemmas Premature / Early menopause
Not so obvious peri -menopause
Post cancer, post surgical menopause
Older women
Unsettled with HRT
Contraindication for HRT
Increased risks
Media wise customers ( Bio- identicals, Natural hormones)

14. Menopause-How does it affect?
Not everybody suffers with symptoms
70% - Vasomotor symptoms (Hot flushes, sweats)
Varies – familial , Ethnicity
Duration – 6 months – 20 years (Average 7.4 years)
Crucial time ( years)
After 60, requirement for estrogen reduced

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

16. Diet, Exercise, Lifestyle
Diet – Healthy eating ( Fruit, Veg, Dairy, Fish, Low fat, high fibre)
Managing Optimal weight and BMI
( Reduces risk of CHD, Type 2 diabetes, Osteoporotic Fracture)
Exercise (Weight bearing, Fast walking, Tai chi, Pilates )
Helps to reduce risk of heart disease, osteoporotic fractures by increasing bone mineral density
Stop smoking
Limited alcohol

17. Hormone Replacement Therapy - HRT
Estrogen (Main), Progestogens (Endometrial protection) and Testosterone (Rarely used)
Truly effective to reduce symptoms and long term benefits for bones
Variable preparations
More than 50 different types, doses, routes)

18. HRT - Continued Cyclical/Sequential Women with uterus
Estrogen and Progesterone
Still having periods or within 1 year of LMP
Cyclical/Sequential
More than one year of LMP or after 54 years
Continuous Combined
After 1 year of Cyclical
Change to Continuous Combined
Women without uterus Estrogen only

19. HRT - Continued
Progestogen preparations Norethisterone Levonorgesterol Dydrogestrone MPA Mirena IUS Micronised Progesterone – Utrogesterone ( Natural)
Estrogen preparations Ethinyl estradiol Conjugated estrogen Estradiol Estriol Estrone

20. 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

21. HRT – Side effects Headaches Breast tenderness Fluid retention
Bloating
Nausea
Mood swings

22. HRT – Contraindications
Very few category of women
Estrogen dependant malignant tumor
( Breast, Endometrial)
Undiagnosed vaginal bleeding
Current DVT/PE
Pregnancy

23. HRT - Concerns
Myths Increases Breast cancer risk Increases Coronary heart disease Published by Media widely in 2003 Is this true?

25. HRT – Risks Two studies in early 2000 Women's Health Initiative (WHI)
Million Women study (MWS)

26. HRT – Risks Million Women study (MWS) Women's Health Initiative (WHI)
UK ( )
One million women attending NHS Breast screening clinic over 50 years old
Questionnaire sent out
Large number of drop outs
Screening women are already high risk
Study methodology has been criticised
Oestrogen only increases risk of breast, womb and ovarian cancer
Combined more risk than estrogen only
Women's Health Initiative (WHI)
USA ( )
16600 women (50-79)
Average age 63.2, BMI 28.5
Randomised HRT Vs Placebo
Increase in Breast cancer and coronary events, stroke, DVT in HRT group
Study stopped early in 2002
HRT in under 60 – Protective
In over 70, not beneficial could be increased risk
Risk is duration dependant, more risk with combined than for estrogen only.

27. HRT – Risks ( Latest analysis)
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)
Ovarian cancer – No increased risk
Endometrial cancer – Adding progestogen decreases risk

28. HRT – Risks ( Latest analysis)
Risk of heart disease not increased if started between 50 and 59
Stroke – not increased if started under 60. More risk with Smoke 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.

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, homeotherap
Insufficient data for safety & effectiveness
Non –Pharmacological - CBT

30. Bio-identical Hormones
Identical to those produced by body
17 – beta estradiol or Micronized progesterone
Claimed to be safe than traditional hormones
Same risk and benefit as traditional
Not regulated
Not enough evidence for safety
Salivary hormones – not representative of serum levels

31. NICE
Menopause – Diagnosis and Management
Nov 2015

32. Diagnosis of perimenopause and menopause
Challenge is to reduce the use of FSH in diagnosing perimenopause and menopause
No periods for at least 12 months & not using hormonal contraception = menopause
Women without uterus but has menopausal symptoms = menopause
DO NOT use FSH test to diagnose menopause if on COCP or high dose progestogen
Consider using FSH test as a diagnostic test for menopause:
Age years with menopausal symptoms including irregular periods
< age 40 with a suspicion of early onset of menopause

33. Diagnosis of perimenopause and menopause
DO NOT use the following test to diagnose menopause
> 45 years old
Inhibin A and inhibin B
Estradiol
Anti-Mullerian hormone
Antral follicle
Ovarian volume

34. Vaginal oestrogens
Can be used in HRT contraindicated women after expert advice
Increase dose if needed after expert advice (Up to 5 times a week)
Used along with vaginal lubricants and moisturisers

35. Altered sexual function
HRT
If HRT alone not effective, consider testosterone supplementation
In younger women where ovaries are absent, testosterone is considered.

36. HRT and Contraception Age 40
Women using HRT should not rely on this as contraception
POP can be used with HRT to provide effective contraception (must be combine HRT)
Can use oestrogen replacement therapy + MIRENA to provide endometrial protection

37. Women with, or at high risk of breast cancer
Give information on all treatment options
Paroxetine and Fluoxetine should not be offered to patients with breast cancer on tamoxifen
Refer for expert advice

38. Stopping HRT Advice regarding stopping HRT
2 choices – gradually reducing or immediate cessation
Gradually reducing HRT may reduce the recurrence of symptoms in the short term
No difference of symptoms in long term

39. Case discussion

40. 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

41. 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 then sweats
No interest in sex, often it hurts

42. What to do next? Explanation Information www.menopausematters.co.uk

43. What do we choose now? Sequential combined HRT Elleste duet 1mg
Estradiol 1mg plus NET 1mg from day
NHS cost £9.72 for 3 months

44. 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

45. 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
2- 3 days in to the new pack
Would like to improve things

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

47. HRT- Dilemmas
More Case Discussions

48. Case 1
33 year old, Aplastic anemia ( when she was 25), had chemo, No periods for many years. Now, random periods, terrible menopausal symptoms

49. Case 1 - Discussion Possible Premature Ovarian Insufficiency
Confirm with FSH
Combined, sequential HRT until 51.

50. Case 2 52 years old, post Lap BSO for BRAC2.
On Tamoxifen for Chemo prevention of breast Cancer
Low mood, tiredness, night sweats, Vaginal dryness, No sex drive
Type 1 diabetic, high BMI, High BP

51. Case 2 - Discussion
Clarify Tamoxifen
HRT?
If so what type?

52. Case 3
59 year old, police officer, been on HRT for 7 years. Trying to come off it. GP advised to stop. Severe symptoms. Back on it. Better now. Advised to come off it gradually. How?

53. Case 3 - Discussion
How to stop HRT?
Doses
Choices

54. Case 4 For patients with endometriosis who had a TAH BSO Choice of HRT
36 year old, Had TAH+BSO, 2 years ago, HRT stopped after caution from pelvic pain.
Want are the options?

55. Menopause clinic at NUH
Service offered by
Anita Juliana MBBS,MD, FRCOG
Special interest in Menopause
RCOG Accredited
Started service at NUH from June 2015
Weekly clinic with Senior nurse support

56. What's on offer? Individually tailored advice, care and support
30 minutes minimum, sometimes longer
Careful risk assessment
Necessary investigations ( DEXA Scan, blood tests and scans when needed )
Life style advice, information leaflets/web info
Clear plan of management and communication

57. Referrals Choose and Book Oncologists Gynaecologists
Breast cancer service
Family history clinics

58. Outside Menopause clinic
NUH - Staff awareness sessions on Menopause Run quarterly, alternates both sites
Tea party talks for BRCA positive patients
Both are very well received and popular with high demand

59. We are partners in Women's health
Think of Menopause service at NUH
Safe, Reliable, Gold standard care

60. Feedback from our patients
Finally, somebody listened to me
Got my life back
Excellent service
All questions answered
Put my mind at rest
Very happy....
Took a long time to reach here....

61. Questions?

62. Thank you