Symptoms

  • Vasomotor
    • Hot flushes
    • Night sweats
    • Formication (insects under skin)
  • Urogenital symptoms
    • Vaginal dryness
    • Dyspareunia
    • Urinary frequency
    • Incontinence
    • Recurrent UTI’s
  • Changes in libido – usually lowering
  • Changes in mood
  • Also lots of other symptoms…

Symptom Management

  • No symptoms in 20%
  • Severe symptoms 20%
  • Mild to moderate symptoms 60%
  • MHT is the most effective treatment for vasomotor symptoms and urogenital symptoms
  • The impact of symptoms on quality of life is an important decision

Diagnosing

  • DO NOT
    • Check FSH, LH, oestradiol or testosterone levels in a woman with symptoms at the normal age of menopause (over 45 years) because these results are unlikely to change your management
  • The indications for intervention are clinical

Management

  • Great website for patient information is Jean Hailes
  • Lifestyle modification
  • Dietary supplementation
  • Hormone Replacement Therapy
  • “Alternative Therapies”

Initiation of HRT

  • Does the patient have an intact uterus?
    • Yes
      • How long has it been since their last period?
        • Less than 12-18 months
          • Peri-menopausal patient with an intact uterus
          • Cyclical MHT, switch to continuous therapy at around 12 months
          • Requiring contraception
            • Low dose COCP
            • Vaginal Contraceptive ring
            • LNG IUD + oral or topical oestrogen
            • Cyclic HRT + barrier method
            • Not requiring contraception
          • Not requiring contraception
            • Combined OCP
            • Cyclic MRT
            • LNG IUD + oral
      • More than 12-18 months
        • Continuous combined hormone treatment
        • Tibolone
    • No
      • Oestrogen therapy alone
      • Endometriosis is a different matter – may do better with some pregesterone as well

Benefits

  • Decreased risk of
    • OP / fractures
    • Heart disease
    • Endometrial cancer
    • Colorectal cancer
    • T2DM
    • Cataracts
  • Symptoms relief / improved quality of life

Risks

  • Thrombosis
  • Stroke
  • Gall stones (oral oestrogen)
  • Endometrial cancer (if given oestrogen alone with intact uterus)
  • Breast cancer – 1 extra case per 1,000 women treated using MHT per year

Breast cancer and MHT

  • Not taking HRT = 3 in 1,000 risk/yr
  • Taking MHT for >5 years = 4 in 1,000 risk/yr
  • After 5 years of stopping MHT the increased risk is lost
  • Bigger risk factors than MHT include
    • 2+ Standard Drinks of alcohol/day
    • Being overweight or obese
    • Having first child when >35 years of age
    • Menopause in your late 50’s

Contraindications

  • Breast cancer
  • Osterogen dependent cancers
  • Undiagnosed vaginal bleeding
  • Current thrombosis
  • Thrombophilia
  • Untreated hypertension
  • Acute liver disease
  • CVD

When to stop

  • There is no set time
  • Mean duration of menopause is 8 years
  • 20-25% of women may still experience symptoms into 60’s and 70’s
  • 10% will still experience symptoms for 10yrs+
  • Ongoing use should be reviewed yearly
  • If premature menopause – continue until 50yrs

Additional non hormonal options?

  • Black Cohosh
  • Phytoestrogens
  • Low dose SSRI
  • Clonidine
  • High dose progestogens
  • Pregabalin, Gabapentin

Alternative therapies

  • Hypnosis
    • Limited number of studies may be of benefit in sleep and hot flushes
  • Acupuncture
    • Small numbers of studies with mixed results
  • Vitamin E
    • No benefit in women with breast cancer
  • Evening Primrose Oil
    • Small numbers of studies with results showing no benefit
  • Black Cohosh
    • Recent review concluded insufficient evidence to support use for hot flushes
  • Phytoestrogens
    • Possible small effect on hot flushes, varied evidence and no good long term studies – but good for cardiovascular health!
  • Wild Yam cream
    • Limited data, probably not beneficial on current evidence
  • Bio-identical hormones – these are NOT Body Identical HRT
    • Combinations of hormones in a troch (lozenge)
    • Manufactured in compounding pharmacies
    • Not approved for use in Australia by TGA
    • Medico-legal indemnity questionable
    • Minimal data on safety or efficacy
    • Some concerns regarding endometrial carcinoma
    • Expensive, marketing is misleading
  • Testosterone
    • No clear definition of female androgen deficiency, no single blood test to make diagnosis
    • Several studies have demonstrated improved sexual satisfaction and wellbeing with premonopausal and postmenopausal treatment with testosterone.
    • Not approved for use in women in Australia
    • Need to monitor rigorously
    • Ask for advice and look at the research before prescribing