Menopause and hormone therapy

what is menopause? what causes it?

• permanent cessation of menstrual cycles

• occurs when ovaries run out of egg cells and produce less oestrogen and progesterone

• lining of womb stays thin

• periods stop

when can you tell menopause has officially started

• 12 months after woman’s last period

CNS symptoms of menopause

• vasomotor symptoms

• sleep disruption

• depression and anxiety

• cognitive changes

• migraine

skin, mucosal and hair changes symptoms

• reduced skin thickness

• reduced elasticity

• reduced hydration

• increased wrinkling

• hair loss

weight/metabolic changes during menopause

• weight gain

• increased visceral adiposity

• increased waist circumference

MSK symptoms of menopause

• joint pain

• sarcopenia

Urogenital symptoms of menopause

• vaginal dryness

• vulvar itching and burning

• dysuria

• urinary frequency

• urinary urgency

• recurrent lower UTIs

impacts of menopause on sexual function

• decreased libido

• dyspareunia→ pain after/during sex

what does a hot flush feel like

• creeping feeling of intense warmth that quickly spreads across whole body and face

• lasts several minutes

proportion of post-menopausal women affected by hot flushes (60-65yrs)

• 42%

what to do to prevent hot flushes in diet

• keep hydrated

• add protein, fibre, fruits, vegetables and grains

what to avoid to prevent hot flushes in diet

• caffeine

• smoking

• alcohol

• spicy food

what is premature ovarian insufficiency

• when woman experiences menopause before 40 years old

how to diagnose menopause

• perimenopause based on vasomotor symptoms and irregular periods

• menopause= no period for 12 months with no contraception

• FSH testing

when would you carry out an FSH test

• women ages 40-45 with menopausal symptoms e.g. change to menstrual cycle

• women under 40 with suspected menopause

risks of HRT use

breast cancer

how to use HRT

smallest effective dose for shortest possible period of time

what symptom of menopause does HRT deal with

• vasomotor symptoms→ hot flushes and night sweats

how long does it take to return to same level of risk of breast cancer as before using HRT

5 years

risk of venous thromboembolism (VTE) when using oral HRT

• 10/1000 more (22.5/1000)

is VTE associated with transdermal HRT? why?

no- as bypasses liver

what cardiovascular risk is present when using HRT with oestrogen

no or reduced risk of CHD

what cardiovascular risk is associated with use of HRT, progesterone and oestrogen

• little or no increase in CHD

what % of bone mass to postmenopausal women lose by age of 60

25%

what can be used to prevent osteoporosis in postmenopausal women

• systemic HRT

• 23 fewer women per 1000 at risk

side effects of HRT

• breast tenderness

• headaches

• vaginal bleeding

when is vaginal bleeding normal when using HRT and when should a doctor be contacted

• first 3 months

• after 3 months contact doctor

types of HRT

• oestrogen-only

• sequential combined HRT

• continuous combined daily dose of oestrogen/progesterone

when would you use oestrogen only HRT

• women who have (had):

  • hysterectomy

  • ICS

when would you use sequential combined HRT

• women who are still menstruating

• have menopausal symptoms

• women within 12 months of LMP

how do you use sequential combined HRT

• progesterone daily for 14 days to trigger bleed

• after 1 year sequential combined move to continuous combined

when would you use continuous combined HRT

if 12 months after last period

what are transdermal HRT patches

• popular route of administration of HRT

• available as combined or oestrogen-only

what is benefit of transdermal HRT patches

reduced VTE risk over oral HRt

what should you avoid regarding placement of transdermal HRT patches

avoid placing near or on breasts

how to use oestrogen gel as HRT

• applied to skin once a day absorbed by body

benefit of oestrogen gel

no increased risk of VTE

if taking oestrogen gel what do women with uterus need to take

• form of progesterone to reduce risk of endometrial cancer

how are oestrogen creams and pessaries used

• placed inside of vagina for localised action

reason to use oestrogen creams and pessaries

vaginal dryness

what psychological effects does HRT have

• alleviate low mood due to menopause

other option to treat low mood/anxiety associated with menopause

CBT

options for stopping HRT

• gradually reducing HRT→ may limit recurrence of symptoms in short term

• gradually reducing or immediately stopping HRT makes no difference to symptoms in long term

for how much longer after last menstrual cycle are women under 50 potentially fertile

2 years

for how much longer after last menstrual cycle are women over 50 considered potentially fertile

1 year

what is Tibolone

• synthetic steroid with oestrogenic, progestogenic and androgenic properties

benefits vs risks of Tibolone

• less unscheduled bleeding than combined HRT

• doesn’t increase risk of breast cancer→ increases risk in women with history of breast cancer

• less effective at reducing symptoms

in premature ovarian insufficiency how much do testosterone levels fall

over 50%

what does lack of testosterone lead to

low sexual desire and arousal