HRT and Menopause - PowerPoint Presentation

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HRT and Menopause Urinary incontinence Polycystic ovarian syndrome

Miss Sujata Gupta

(Risk lead and Endometriosis specialist)

Consultant Gynaecologist

Stepping Hill Hospital, Stockport

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Life expectancyLife expectancy at older ages is the highest it’s ever been

From:

Public Health England

First published: 12 February 2016men can now expect to live for a further 19 years at age 65, 12 years at 75, 6 years at 85 and 3 years at 95women can expect to live for a further 21 years at age 65, 13 years at 75, 7 years at 85, and 3 years at 95

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MenopauseDefinitionPerimenopause

Diagnosis- Women less than 45 vs women over 45- Serum FSH test only in under 45s but useful in women on hormonal treatments.

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Effects of menopausevasomotor symptoms (for example, hot flushes and sweats)musculoskeletal symptoms (for example, joint and muscle pain)

effects on mood (for example, low mood)

urogenital symptoms (for example, vaginal dryness)

sexual difficulties (for example, low sexual desire

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CureAcceptanceLife-styleHerbal remedies

Non hormonal remedies

HRT

Contraception

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NICE GUIDANCE

Altered sexual function

1.4.8 Consider testosterone

[1] supplementation for menopausal women with low sexual desire if HRT alone is not effective

Urogenital atrophy

1.4.9 Offer vaginal

oestrogen

to women with urogenital atrophy (including those on systemic HRT) and continue treatment for as long as needed to relieve symptoms

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NICE GUIDANCE

the

BNF states "..continuous combined preparations or

tibolone are not suitable for use in the perimenopause or within 12 months of the last menstrual period, women who use such preparations may bleed irregularly in the early stages of treatment - if bleeding continues endometrial abnormality should be ruled out and consideration given to changing to cyclical HRT

..“

vaginal bleeding whilst on

ccHRT

Less than 6/12- reduce

estrogen

, increase/ change progesterone-

abnormal

bleeding starts when using continuous combined HRT, in women >54 or > 1 year after their last period, within 6 months of starting treatment then initially a trial of oestrogen reduction should be attempted. If bleeding recurs then refer for routine hysteroscopy as benign pathology would be

anticipated

More than 6/12- Hysteroscopy

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NICE GUIDANCE

1.5.2 Consider transdermal rather than oral HRT for menopausal women who are at increased risk of VTE, including those with a BMI over 30 kg/m

2

.1.5.3 Consider referring menopausal women at high risk of VTE (for example, those with a strong family history of VTE or a hereditary thrombophilia) to a haematologist

for assessment before considering HRT.

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Review3 months then annualCheck for side-effects -

eg

, breast tenderness or enlargement, nausea, headaches or bleeding - and manage appropriately (see 'Management of side-effects', below).

Check blood pressure and weight.Encourage breast awareness and participation in screening mammography and also cervical screening if appropriate for age.A review and discussion of an individual's risk:benefit ratio concerning HRT should occur at least annually.

If appropriate, consider switching from cyclical HRT to continuous combined HRT (see below

).

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Urinary incontinence

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HistoryType of incontinence- Stress, Urge, MixedRule out UTI

Pelvic floor assessment- refer physio,

Refer-

persisting bladder or urethral painclinically benign pelvic massesassociated faecal incontinencesuspected neurological diseasesymptoms of voiding difficulty

suspected urogenital fistulae

previous continence surgery

previous pelvic cancer surgery

previous pelvic radiation

therapy

PROLAPSE

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ManagementBladder diaryPhysioUrodynamic

testing

Not needed for conservative management or pure SUI

symptoms of OAB leading to a clinical suspicion of detrusor overactivity, symptoms suggestive of voiding dysfunction

or

anterior compartment

prolapse

had previous surgery for stress

incontinence

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ManagementConservative- Pads, CathetersGeneral

principles when using OAB drugs

When offering antimuscarinic drugs to treat OAB always take account of: the woman's coexisting conditions use of other existing medication affecting the total anticholinergic load, risk of adverse effects.

the

likelihood of success and associated common adverse

effects

the

frequency and route of administration,

that

some adverse effects such as dry mouth and constipation may indicate that treatment is starting to have an effect,

and

that they may not see the full benefits until they have been taking the treatment for 4 weeks.

[new 2013]

Prescribe

the lowest recommended dose when starting a new OAB drug treatment.

[new 2013]

If

a woman's OAB drug treatment is effective and well‑tolerated, do not change the dose or drug.

[new 2013]

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Choosing OAB drugsDo not use

flavoxate

,

propantheline and imipramine for the treatment of UI or OAB in women. [2006]Do not offer oxybutynin (immediate release) to frail older women[7

]

.

[new 2013]

Offer

one of the following choices first to women with OAB or mixed UI:

oxybutynin (immediate release),

or

tolterodine

(immediate release),

or

darifenacin

(once daily preparation).

[new 2013]

If

the first treatment for OAB or mixed UI is not effective or well‑tolerated, offer another drug with the lowest acquisition cost

[

8

]

.

Offer

a transdermal OAB drug to women unable to tolerate oral medication.

[new 2013]

For guidance on

mirabegron

for treating symptoms of overactive bladder, refer to

mirabegron

for treating symptoms of overactive bladder

(NICE technology appraisal guidance 290).

[new 2013

]

1.1

Mirabegron

is recommended as an option for treating the symptoms of overactive bladder only for people in whom

antimuscarinic

drugs are contraindicated or clinically ineffective, or have unacceptable side effects.

1.2 People currently receiving

mirabegron

that is not recommended for them in 1.1 should be able to continue treatment until they and their clinician consider it appropriate to stop.

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Review4 wks – face to face or telephone

6 monthly in over 75s

Annual in under 75s

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Referral to MDTInvasive treatment for SUI or OAB ( Botox, sacral nerve stimulation, augmented cystoplasty

, urinary diversion)

SUI- Synthetic tapes, autologous tapes, colposuspension), intramural bulking agents

Surgeons undertaking continence surgery should maintain careful audit data and submit their outcomes to national registries such as those held by the British Society of Urogynaecology

(BSUG) and British Association of Urological Surgeons Section of Female and Reconstructive Urology (BAUS‑SFRU).

[2006]

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PCOS

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PCOSIncidence-26%

The symptoms of polycystic ovary syndrome (PCOS) include menstrual cycle disturbance and features of

hyperandrogenism

(hirsutism, acne and alopecia), with associated fertility problems, obesity and psychological issues. Obesity has a major impact on the expression of PCOS The management of

anovulatory

infertility involves lifestyle modification and therapies to induce ovulation, namely

clomifene

citrate, gonadotrophin therapy and laparoscopic ovarian diathermy.

management

of menstrual problems requires prevention of endometrial hyperplasia and

adenocarcinoma.

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Symptoms Hyperandrogenism

(hirsutism, acne, alopecia)

Menstrual disturbanceInfertilityObesityPossible late sequelae Type II diabetes mellitusDyslipidaemiaHypertension

Cardiovascular disease

Endometrial carcinoma

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Diagnosis( ESHRE 2003) Rotterdam criteria- two out of three criteria

clinical

or biochemical features of

hyperandrogenism, ( A total testosterone level of greater than 5 nmol/l (depending upon the assay) or rapid onset of signs of

hyperandrogenism

 requires further investigation. Non‐classic (late onset) congenital adrenal hyperplasia (CAH) is not common in the UK but is more prevalent in certain ethnic groups (e.g. Mediterranean, South American and some Jewish populations).

oligo‐ovulation

or anovulation

(i.e.

menstrual

cycle disturbance) and/or

polycystic

ovaries on ultrasound

, once appropriate investigations have been performed to exclude other causes of menstrual disturbance and androgen

excess

Exclude-

hyperprolactinemia, acromegaly, congenital adrenal hyperplasia, Cushing's syndrome and androgen‐secreting tumours of the ovary or adrenal gland), which could predispose to similar ultrasound and biochemical features and also the exclusion of other causes of menstrual cycle irregularity secondary to hypothalamic, pituitary or ovarian dysfunction.

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TreatmentSymptomatic- life styleHirsutism-

Dianette

®

(Bayer PLC, Newbury, Berkshire, UK), which contains ethinyloestradiol (35 μg) in combination with cyproterone acetate (2 mg). The addition of higher doses of

cyproterone

acetate (50–100 mg) does not appear to confer additional benefit. The effect on acne and seborrhoea is usually evident within a couple of months. Sometimes additional topical antibiotic and anti‐inflammatory preparations may be helpful.

Spironolactone is a weak diuretic with

antiandrogenic

properties that may be used in women in whom the combined oral contraceptive pill is contraindicated at a daily dose of 25–100 mg

.

Drosperinone

is a derivative of spironolactone and is contained in the combined oral contraceptive pill Yasmin

®

(Bayer PLC, Newbury, Berkshire, UK), which may also be beneficial for women with

PCOS

The management of alopecia is difficult but may be stabilised by the anti‐androgen preparations mentioned above. Iron deficiency may have an impact on hair loss and so ferritin levels should be assessed.

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Menstrual irregularitywomen with PCOS shed their endometrium at least every 3 months.

For those women with oligo/amenorrhea who do not wish to use cyclical hormone therapy, we recommend an ultrasound scan to measure endometrial thickness and morphology every 6–12 months (depending on menstrual history).

An endometrial thickness greater than 10 mm in an amenorrheic woman warrants an artificially induced bleed, which should be followed by a repeat ultrasound scan and endometrial biopsy if the endometrium has not been shed.

Another

option is to consider a progestogen‐secreting intrauterine system, such as the

Mirena

®

(Bayer PLC, Newbury, Berkshire, UK

).

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