Menopause Management - family-doctor.org.uk Navani.pdf · Non HRT options ( Alternatives to HRT)...
Transcript of Menopause Management - family-doctor.org.uk Navani.pdf · Non HRT options ( Alternatives to HRT)...
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Menopause Management
Dr Manju Navani
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Definition
• Menopause: 12 months after LMP • Average age of menopause is 51 yrs
• Peri-menopause: start of symptoms to 12 m after LMP
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Menopause – Men…o….Pause
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Signs and Symptoms
Vasomotor SymptomsSleep DisordersMood ChangesJoint pains, aches, tiredForgetfulness
Urogenital AtrophyReduced sex drive
OsteoporosisAtherosclerosisCoronary Heart DiseaseDementia-POI
40 yrs 50 yrs
Menopause
60 yrs
Adapted from Van Keep PA et al. Maturitas 1990;12:163–70. Slide donated by Mylan
Menstrual Disorders
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Assessment in Primary care
• History – symptoms • Exclude other causes of symptoms: thyroid ,
depression, Iron deficiency • Medical history/Family Hx - R/O Contra-indications• Discuss benefits & personalise risks• Discuss Rx options • Info on websiteswww.menopausematters.co.uk, www.womans-health-concern.org.uk
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Role of Blood test(FSH)to diagnose menopause
NOT NEEDED IN OVER 45 yrs (Qualilty Standard 1)
Indication for measuring FSH (<45 yrs)QS21. Under 40 yrs2. Age 40-45 yrs , symptoms • FSH > 30 mIU/L (Repeat in 6-8 weeks), levels
pulsatile DO NOT Measure if • On COCCan check FSH if on on Depo Provera injections –but do around 10 weeks
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Premature Ovarian Insufficiency (POI)
• Menopause < 40 years ( 1%)
• Causes: Idiopathic, F/Hx , chromosomal , Auto-immune, iatrogenic
• Investigations- Baseline BMD, repeat if osteopenia/osteoporosis
• Management – COC/HRT till 51 (QS 3) • Contraception• Consequences- QoL, IHD, Osteoporosis, Dementia,
Parkinsonism
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Support Group for POIwww.daisynetwork.org.uk
www.womens-health-concern.org
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History & Examination HISTORY
SymptomsRx tried
Menstrual HxContraception
Gynae HxSexual History
Medical HxFamily Hx
Mental healthAlcohol, smoking,
ex , diet Occupation
LMP, Periods- ?heavyHave they stopped ?
Gynae Hx: Endometriosis, fibroids, Hysterectomy, BSO, Gynae cancers
CVD /Stroke & Risk Factors,• VTE
• Cancers: Breast , ovarian ,Bowel Osteoporosis
• Migraines+/- aura, epilepsy , Thyroxine, Malabsorption
EXAMN: BMI, BP Investigations: if indicated –TFT, DEXA scan,
lipid profile, FSH (<45)
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of HRT• Symptom relief• POI , early menopause• Prevention & RX of
osteoporosis under 60• In early post menopausal
years: window of opportunity & protects from CVD
• Reduces risk of colorectal cancer
• HRT doubles risk of VTE • Oral HRT has higher risk
>transdermal • Risk with Transdermal
HRT no greater than baseline
• Risk factors: age, BMI>30, smoking ,F/Hx , immobility
• If high risk VTE : refer to Specialist , Heamatologist
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HRT and breast cancer risk
HRT has similar risks to late menopauseWoman’s risk breast cancer with late menopause• 2.8% increase per year • With HRT: 2.3% increase per year
• E only HRT: li le/no ↑ risk• E + P – slight ↑ risk related to
duration, reduces after stopping , and baseline risk varies from one woman to another depending on underlying risk
• 1/1000 per year over 5 yrs
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CVD / Stroke / Ovarian Cancer
• Re-analysis of WHI study: within 10 yrs of menopause HRT is cardio-protective (window of opportunity)
• Risk increases with age, depends on risk factors.
• Increased risk of stroke with Oral HRT, risk is 1:1000 under 60 .
• Over 60: risk of stroke 4.5/1000
IMS recommendation on womens midlife health and MHT- Climacteric 2016:19(2)109-50Danish Osteoporosis Prevention Study (DOPS study) :2012, 17B E2 + NETA in early post menopausal yearsFinnish Study: Hodis HN et al. Vascular effects of Early v late post menopausal Rx with E . New Eng J of Med 2016;374(13)1221-31ELITE study, KEEPS trial
• 2015 meta-analysis of 52 studies• Increased risk with HRT• 1/5000 per year • 1 additional death per 1700 users
Ovarian Cancer
Condition %age Extra/1000.yr
Heart Attack +29% +0.7
Stroke +41% _0,8
All VTE +100% +1,8
PEs +113% +0.8
Breast Cancer +26% _0.8
Endometrial cancer
0 nil
Ovarian cancer
0 nil
Colorectal Cancer
-37% -0.6
Hip fracture -34% -0.5
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• Higher mortality rate from heart disease (53%) vs mortality rate from breast cancer (3%)
Management : Life style advice
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Management
Diet, Lifestyle changesHRT options- Local , Systemic
Non HRT options ( Alternatives to HRT) RCOG leaflet 1. Pharmacological Rx (SSRI, SNRIs) 2. Non - pharmacological Rx• Phytoestrogens• Herbal Psychological – CBTComplementary therapy
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When to Say No…..No to HRT?
• Breast Cancer• Endometrial Cancer beyond Stage 1 • Undiagnosed genital bleeding• Current thromboembolic disease/ IHD• Active liver disease
• CAUTION STARTING OVER 60• Migraine • Hypertension• Past Hx of VTE/Family HX of VTE• Hyperlipidemia• Fibroids• Endometriosis
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Types of HRT
Progestogen
Oestrogen EstrogenOnly(no uterus)
Oestrogen17-28
CyclicalBleed (Sequential)
Oestrogen
No BleedContinuous combined HRT (CCHRT)
Estrogen
Progestogen
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Which HRT?
Systemic HRT Local HRT
HAS UTERUS/ENDOMETRIAL PROTECTION NEEDED
NO YESE+P
E ONLY Periods<1 yr
Sequential HRT E + IUS
Periods>1 yr or age 54CCHRT
TiboloneE+IUS
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Indication for CCHRT
• If LMP>1 yr back
• At age 54-55
• >3-4 yrs on Sequential HRT
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HORMONES
Oestrogens • Oestradiol
• Conjugated equine Oestrogens
• Oestradiol Valerate
• +/- Testosterone
ProgestogensC19 – Nor-ethisterone, levonorgestrel
C21 – MPA, Dydrogesterone
Natural Progesterone: Uterogestan
IUS – LNG x 5 yrs
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Progestogens1. Androgenic : Norethisterone(NET) , Levonorgestrel
PMS , less lipid friendly
2. Non - Androgenic : DydrogesteroneIndication: if has PMS with NET, DM , Raised cholesterol
3. Uterogestan – Complex medical problems , Risk factors of VTE , F/Hx of breast cancer (less androgenic, less thrombogenic, less carcinogenic on breast)
4. IUS- no safety data on breast
5. Drosperinone (Angelique)- anti- mineralocorticoid activity
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Women with a uterus (Seq HRT)1st line HRT (Oral) NET • Elleste Duet 1mg • Elleste Duet 2 mg
2nd line HRT ( Oral) DG• Femoston 1/10• Femoston 2/10
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Women with a uterus ( CCHRT)No periods x 1 yr
• Elleste Duet Conti 2 mg ( E + Norethisterone)
• Femoston Conti - I mg ( E + Dydrogesterone )• Femoston Ultra Low dose ( 0. 5mg) • Tibolone (improves sex drive, endometriosis)• IUS x 5 years
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Oestrogen only – No Uterus
• Oral Estradiol - Elleste Solo ( 1 mg, 2 mg )
• E2 patches ( 25, 37.5 , 40 , 50, 75, 80, 100 mcg )
• Oestrogel (2 measures =1.5 mg)
• Sandrena gel ( 0.5mg , 1 mg sachets)
50 mcg patch= 1mg oral E2 =1- 2 measures of Oestrogel
Implant E2- Hysterectomy , poor response to above
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Indications for transdermal HRT
• Migraines• BMI>30• HT• Diabetes• Hx of VTE• On Thyroxine, anti-
epileptics• Crohn`s disease• Poor relief with oral HRT• Hypertriglyceridemia• Gall Bladder disease
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Oestrogel
• 1-2 measures daily, can increase dose to 3-4
Uterogestan• 100 mg cap daily (CCHRT)• 200mg x12 days • At bedtime , on empty
stomach • Drowsy, somnolence
COMPOUNDED BIO-IDENTICAL HORMONES(unregulated)
BODY-IDENTICAL (Regulated)
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Duration & F/U of systemic HRT
• POI - until age 51 at least• >51 yrs : Informed choices ,
No arbitrary time limit (under 5 yrs – safety data)
• Discontinue gradually-makes no difference
• Individualise Rx: - 50-60 yrs- Benefits
outweigh risk- 60-70 Benefits = risk, - Over 70 Risk outweigh
benefits
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1 At 3/12, followed by Annual review (QS4)2. BP, BMI3. Check Bleeding pattern, symptom control4. Risk Benefit Analysis5.Any changes in Medical History6. Dose reduction with age When to stop??
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Indication to refer to Specialist
• Uncertainty about Rx options• Side Effects on HRT• Multiple Rx failures• Tried 2-3 preparations• Abnormal bleeding on HRT• Premature Ovarian Insufficiency ( POI) <40 yrs• Complex medical problems• Personal /Family Hx of VTE & Breast Cancer • Endometriosis , fibroids, focal migraines• Age over 60 • Safety concerns/CI to HRT
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HRT and contraception
• SEQ HRT is not a contraceptive • CCHRT – post menopausal • POP- Micronor/Norgeston• IUS will be best option
• Implant or Depo Provera• Barrier Method
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Case 1
• Age 52, C/O hot flushes night sweats , for past 6 months and is unable to sleep. Has low sex drive.
• Periods are irregular every 6-8 weeks and lasts for 4-5 days
• Keen to start HRT • BP-120/80, BMI=28, non smoker, Alcohol 2 bottles of
wine/week• Has Googled about HRT and keen to start HRT• What advice, HRT options ?• Contraception?
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Management• History taking, Counsel about HRT , Benefits and Risks of HRT• Examination?• HRT- Oral or Transdermal • Sequential or Combined HRT• Elleste Duet 1 mg or Oral Estrogen and IUS • Follow up – Review when?• Still has some hot flushes , low mood on Elleste Duet 1 mg -
Which HRT will you prescribe?• Elleste Duet 2 mg • Has PMS symptoms in second half of cycle ?• Which HRT?• Femoston 2/10, Now age 55 – which HRT can you change to?
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Case 2
• Age 52, IUS fitted 2 year back • No periods • Gaining weight and wants IUS removed • C/O hot flushes few, foggy head - 6 months• Sex is painful, dryness, recurrent thrush • BMI=31 , BP 120/80
When can contraception be stopped ?Which HRT?What if she was HT ?What blood test if she has poor response to HRT ?
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Vaginal Oestrogens (LOCAL EFFECT ONLY)
Tablets Cream Ring
Small to insert, licensed for long term use
For vulvalirritation , messy , licensed 3-6 months
Remains in vagina x 3 months , licensed for 2 years
Nightlyx2 wks follby twice a wk
Same regime Changed 3 monthly
Vagifem 10 mcg Oestriol 0.1% and 0.01%
Estring 7.5 mcg /day
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Vaginal Moisturisers
• Pjur Med ( silicone based)• Yes, oil based lubricant • ReplensWater based – not so effective• Regelle, Replens, Hyalofemme• With Tamoxifen- can have very low dose local
E but need to liase with Breast cancer surgeons
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Case 3
• Age 42 , No periods for 6 months after stopping COC (x8yrs) • Has 2 children - 5yrs, 7 yrs• Hot flushes, feels tired , low mood, loss of sex drive• Started on Citalopram by GP- slight improvement in
symptoms • FHx – early menopause mother in 40`s• BMI =26, BP 120/80
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Rx options
• COC/HRT till age 50• Zoely/Qlaira- natural hormones(cont/extended regimes) • IUS+ E2 (estradiol) tablets (IUSx5 years)• HRT- Seq HRT- Elleste Duet 1 mg tablets daily and use
condoms• HRT – as above and Micronor pill (POP) • FU in 3/12 and thereafter yearly • When will you change her HRT to CCHRT?• Age 51 – Do you stop her HRT ??
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Case 4
• Age 55, no periods for 3 years• Has hot flushes , night sweats x 2-3 yrs, • BMI=30, BP 120/80• Non smoker , good health, • Alcohol - 18 units/wk• Her mother in law died of breast cancer on HRT • Would like further information on
Alternatives to HRT
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Alternatives to HRT
RCOG – Pt info leaflet www.rcog.org.uk• CBT
Paroxetine /Fluoxetine 10 mg vs 20 mg- less side effects, effective Potent CYP2D6 inhibitor- reduces efficacy of Tamoxifen
Sertraline50 mg daily
Citalopram 10-20 mg daily
Venlaflaxine – 37.5 mg daily, can increase dose to 75 mg
Can be given with Tamoxifen, take in the morning to avoid insomnia Clonidine, Gabapentin
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Herbal Remedies & Diet
• Red Clover : Promensil
• Black Cohosh
• Sage, alfa alfa
• Phytoestrogens in diet
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Case 5
• Age 52, TAH with BSO at 50• Menopausal symptoms , low sex drive , tiredness• She is worried about risk of breast cancer with
HRT .• How can you reassure her?
• NICE Guidance : E only HRT – no increased risk or lower risk compared with Combined HRT , as no progestogen
• Which HRT??
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Why NICE?
40
1.Menopausal symptoms >45- Don’t send FSH2. If low mood- don’t start on anti-depressants, consider CBT, HRT3. Individualise HRT Rx- dose , type, with age lower doses 5. Risk Benefit Analysis 6. HRT within 10 yrs of menopause or under 60 – benefits outweigh risks7. POI, Early menopause – HRT till age 51 8. Vaginal E low dose – licence for indefinite use 9.BMS vision for menopause care
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Training
• http://www.pcwhf.co.uk/(Primary Primary Womans Health Care Forum)
• www.menopauseacademy.co.uk
- Mylan Webinars • BMJ learning• Management of The
Menopause- 6th edition -BMS • Special Skills Module in
Menopause ( British Menopause Society website)
• Patient info leaflet ( NICE)• Menopause & me leaflet • www.menopausematters.co.u
k• www.womens-health-
concern.org.uk• www.bms.org.uk• www.managemymenopause.co.
uk• www.menopausedoctor.co.uk• www.nice.org.uk
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![Page 43: Menopause Management - family-doctor.org.uk Navani.pdf · Non HRT options ( Alternatives to HRT) RCOG leaflet 1. Pharmacological Rx (SSRI, SNRIs) 2. ... • Patient info leaflet (](https://reader035.fdocuments.us/reader035/viewer/2022062317/5cc95a6d88c993e4268c6c4c/html5/thumbnails/43.jpg)
Thank you for your attention
Questions ?