Please enable JavaScript.
Coggle requires JavaScript to display documents.
Menopause and HRT - Coggle Diagram
Menopause and HRT
HRT
Indications
Vasomotor symptoms with menopause
Low mood with menopause
Sexual fx with menopause
Urogenital atrophy with menopause
MSK symptoms / bone mineral density
Special Circumstances
Almost always indicated
Premature ovarian failure / POI
Refer to specilist clinic
Gonadal dysgensis
eg Turner's Syndrmoe
Ostrogen alone from 11yr
Progesterone 2 yrs after commencing Oestrogen
Contraindications
Hx breast cancer
Untreated endometrial hyperplasia
Undiagnosed vaginal bleeding
Uncontrolled HTN
Arterial thromboembolic disease (MI / CVA)
Current VTE (unless anticoagulated)
Thrombophilia
Liver disease with abnormal LFTs
If contraindicated → Refer to specialist clinic
Benefits
Relieves symptoms of menopause
Fragility fracture risk reduction
Decreases once tx is stopped
Cardioprotection
If initiated before 60 y/o or within 10 yrs of menopause
Risks
Breast Cancer
Higher risk with combined HRT than Oestrogen only
Micronised progesterone (Utrogestan) likely safest prep
Lifestyle factors have greater impact on risk than HRT
Does not affect risk of dying from breast cancer
VTE
Increased risk with
oral
preparations
- generally low in early postmenopausal years
Transdermal avoids 1st pass metabolism - doesn't activate clotting fcators
CVD
CVD is Most common cause of death in postmenopausal women
Dose not increase risk of women <65
May be cardioprotective in women <10yrs since LMP
Councelling Risks
CVA (Stroke)
Oral HRT can increase risk of stroke
Transdermal preps are dafer and do not appear to increase risk of CVA
Ovarian cancer
Appears to be slight increased risk
Dementia
Risk is unknown
Tips
Younger often need higher dose
Transdermal OE safest method - no increased risk of VTE
Micronised progesterone is body identical progesterone which is given PO - safer than older types of progestogens
BTB - consider increasing dose of Utrogestan from 200 to 300 or change regimen from 2 weeks on 2 wweksn off to 3 weeks on 1 week off
Apply patch / gel to buttocks / lower abdomen - most consistent absorption
Clinical Presentation of Menopause / Oestrogen Deficiency
Vasomotor symptoms
Hot flushes
Night sweats
Urogenital Symtoms
Vaginal atrophy
Dyspareunia
Itching / dryness
Urinary frequency
Increased risk of UTI
Reduced bone density
Fractures
CVS
Risk Profile becomes similar to males
Increased risk of CVA + CAD
Psychological Symptoms
Brain fog
Mood disorders
HRT Alternatives
CBT
Low mood and anxiety
Isoflavones (Soy) and Black Cohosh
May help flushes - preparations vary in content / safety
SSRI / SNRI
Indications
Women who cannot / do no wish to have HRT
Councel regarding s/e
Venlafaxine more likely to be beneficial than SSRIs
Clonidine
Hot flushes
Tibolone
MOA
Weakly oestogenic, progestogenic and adrogenic
Indications
Hot flushes
Low mood
Reduced sex drive
Only indicated in postmenopausal woemn - can cause iregullar bleeding pattern
Testosterone
Consider in low libido if HRT alone not effective
Definitions
Menopause
Permanent cessation of menstruation resulting from loss of ovarian follicular activity
Occurs at median age 51
Recognised to have occured after 12 consecutive months of amenorrhoea
Retrospectivity diagnosed and refers to a single event
Perimenopause
TIme beginning with the first features of the approaching menopause, such as vasomotor symptoms and mesntrual irregularity, and ends 12 months after the last menstrual periods
Premature Ovarian Failure / Primary Ovarian Insufficiency
Menopause occuring before the age 40
Affetcs 1% of women
Most cases no cause found
HRT indicated until 50y/o
Early Menopause
Menopause occuring between ages of 40-45
Effects 5% of Population
Prescribing HRT
Lowest Risk
Transdermal oestrogen + Mirena coil
Regimen:
Start as close to perimenopause as possible
Stop after 5 years
Benefit of contraception
Second best : Transdermal oestrogen + Utrogestan (miconized progesterone)
Combined Continuous HRT
Regimen
Oestrogen + Progesterone daily
OR
Ostreogen daily + Mirena coil
Indications
Post menopausal
LMP > 1 yrs
Preparations
Combined Continuous
Oral
Femoston Conti
Elleste Duet COnti
Patches
Evorel Conti
Femseven Conti
Separate Combined
Oestrogen
Oral
Estradiol 1mg ↑ to 2mg
Patch
Estradiol 25mcg ↑ in 25mcg
increments. Change twice a week.
Gel
Oestrogel® 1-2 pumps daily ↑ up
to 4 pumps max.
Progesterone
Oral: Micronised Progesterone 100mgs nocte or Utrogestan® (off license 200mgs alt nights vaginally)
Oral: Medroxyprogesterone 5mgs od
Mirena® coil: 4yrs (5yrs FSRH)
Combined Sequential HRT
Indications
Perimenopausal
Still having periods
LMP<1 yrs
Under 53
Preamture ovarian insufficiency
Regimen
Oestogen daily
Progesterone 12 per month OR Mirena coil
Preparations
Combined Sequential
Oral
Elleste Duet® 1mg ↑ to 2mg
Femoston® 1/10 ↑ to 2/10
Patches
Evorel Sequi
Femseven Sequi
Seperate Sequential HRT
Oestrogen
Oral
Estradiol 1mg ↑ to 2mg
Patch
Estradiol 25mcg ↑ in 25mcg increments. Change twice a week.
Gel
Oestrogel® 1-2 pumps daily ↑ up
to 4 pumps max.
Progesterone D14-28
Oral
Micronised Progesterone 200mgs nocte or Utrogestan® (off license use vaginally 14 nights) Improves sleep
Medroxyprogesterone 10mgs od
Mirena Coil
4 years ( 5yrs FSRH)
Prescribing Flow Chart
Uterus intact
Combined sequential
Combined continuous
No utertus
Oestrogen only HRT
Assessment
History
Suspect Perimenopause in
Change in Periods
Heavier / lighter
Longer / shorter
IMB or PCB still needs to be investigated
Other Symptoms
Hot flushes / night sweats
Brain fog and mood disorders
Urogenital symptoms
ALteral sexual function ( low libido, unresponsive to stimuli)
Sleep disturbance
Joint and muscle pains
PMHx
Breast cancer
DVT / PE
Clotting
Migraine
Breast lump
CVD
Shx
Smoking
Contraceptive Needs
Cervical Screen up to date
Examination
BP
BMI
Must be controled prior to HRT
Breast exam if indicated
Investigations
Not usually indicated
Bloods
FSH
Over 50: FSH>30 indicated menopause
Under 50: 2 FSH levels of > 30 iu/dl a few weeks apart
TFTs
CVD risk factor screen
Lipids
U&E
LFTs
HbA1c
Management of Menopause
Lifestyle
Exercise
Healthy BMI
Smoking cessation
Alcohol reduction
Avoidance of triggers (spice, heat, stress)
Relacation techniques
Sleep hygiene
Medication
HRT
HRT alternatives
Psychological Supports
Talking therapies
Support groups
Follow up
Routine Reviews
3 months
6 months
Annually
Review if
Heavy bleeding
Settles on cessation of HRT
Consider alternative prep
Does not settle
Investigate as post menopausal bleeding
Education
Written information
Document counselling risks
Causes of Menopause
Iatrogenic
Surgical
Bilateral oophorectomy
Medical
Chemotherapy
Physiological
Physiology of Menopause
Perimenopause
Ovaries age, response to FSH&LH decreases
Shorter follicular phase - with shorter and less regular menstrual cycles
Fewer ovulations
Decreased progesterone production
Menopause
Ovaries become unresponsive to FSH
FSH and LH increase
Fewer follicles recuited
Ovaries continuously become unresponsive to FSH
Decrease in Estrogen
Amenorrhoea
Diagnosos of Menopause
Clinical Diagnosis
Only consider FSH measurement if
Pt age 40-45 or <40
Pt with IUCD in place and want to know if menopause has taken place
2 spereate readings 6 weeks apart
FSH >30 indicative of menopause
Do not use if pt on combined hormonal contraception or high dose progesterone
Treatment for Vaginal Symptoms
Hormonal options
Vaginal Oestrogen alone OR with HRT
Types
Ovestin cream x2 / week
VAgifem up to 5x / week
Estring changed every 3 months
Non Hormonal
Vaginal moisturiser 2x / week
Vaginal lubricant for intercourse
Stopping Contraception
