Manchester Menopause Draft Guidelines - PowerPoint Presentation

Slide1

Manchester Menopause Draft Guidelines &Case discussions

Dr Manju

Navani

June 2021

Slide2

Discussion

Diagnosis

Why menopause matters ?

HRT consultations: Risk Assessment before prescribing HRT

Basic Principles of HRT Prescribing

HORMONES

Choosing the right HRT- Why Progestogen matters?

Body identical HRT – When & Why?

Local HRT preparations

Case Studies

(including Metabolic Syndrome)

Take Home messages , resources

Q&A

Slide3

Why Menopause matters ??

Menopause is a CV risk factor

Consequences

CVD and Metabolic Syndrome

Diabetes Mellitus

Hyperlipidemia

Hypertension Central obesity Prothrombotic state Hot flushes Life style intervention

Slide4

Diagnosis of menopause (Section 1.1)Menopause is a retrospective diagnosis

PERIMENOPAUSE

( Climacteric)

MENOPAUSE

POSTMENOPAUSE

Period after menopause

The phase immediately prior to the menopause

Irregular ovulation,change in menstrual cycles

Also includes the first year after menopause

1

Permanent cessation of menstrual periods for 12 months

Median age 51 in UK

Over age 45 : Clinical diagnosis

Under age 45 – Serum FSH x 2 ( both >30IU/L)

Under age 40- Premature Ovarian Insufficiency ( RX till age 51 at least)

Slide5

Signs and Symptoms

Vasomotor Symptoms

Sleep Disorders

Mood Changes,

Joint pains, aches, tired

Forgetfulness

Anxiety , migraines, Dry skin, hair loss

Urogenital Atrophy(50%)

Reduced sex drive

Osteoporosis

Coronary Heart Disease

Anxiety/Depression

Dementia-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

ROCKMYMENOPAUSE.COM

Slide6

When to Say No…..No to HRT?(Section 1.3) Breast Cancer

E2 dependent cancers- Endometrial Cancer beyond Stage 1

Current thromboembolic disease/ IHD

Active severe liver disease

- (Refer to Section 8.3)

Migraine with aura

Hypertension. DM , HyperlipidaemiaPast Hx of VTE/Family Hx of VTEEndometriosisOver 60 yrs

CAUTION

Slide7

Symptom reliefPrevention & RX of osteoporosis under 60

In early post menopausal years: window of opportunity & protects from CVD

1

Prevents metabolic syndrome

Prevents dementia in POI

Reduces risk of colorectal cancer

VTE: Oral E2 doubles risk Risk with Transdermal E2 no greater than baseline risk VTE risk: type of progestogen Risk of Ovarian cancer low 1:5000Focal migraines , unRxed HT - ↑stroke risk RISKS SECTION 2 1. COCHRANE review 2015: Hormone therapy for preventing CVD in post menopausal women www.bms.org.uk, NICE Clinical Guidance (2015) Menopause Diagnosis and Management

Slide8

HRT and breast cancer risk HRT has similar risks to late menopauseWoman’s risk breast cancer with late menopause2.8% increase per year With HRT: 2.3% increase per year

E only HRT: fewer cases of breast cancer

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

www.ibisikinopedia.com

Slide9

Refer to Familial Breast Cancer - NICE Guideline (CG164)

One relative

– Female 1st degree with breast ca <40

– Male 1st degree with breast ca at any age

– Female 1st degree with bilateral breast ca <50 – 1st degree with breast and ovarian ca

Two relatives

– 1st/2nd degree with breast ca at any age– 1st/2nd degree with breast and ovarian cancer– With breast and/or ovarian cancer on paternal side Three relatives:– 1st or 2nd degree with breast cancer at any age

Slide10

Principles of PrescribingSection 1.4

Slide11

Tele-Consultation History – New

Diagnosis of menopause – clinical > age 45

Menstrual Hx – Changes in cycles , Heavy periods ?

Obstetric Hx

Gynaecological

Hx – Hysterectomy , BSO , Endometriosis Does she need contraception? Life style factors- BP, BMI, Alcohol, exercise , Smoking Indications for Transdermal HRT – Migraines +/- aura , BMI>30 VTE risks , etc Medical History – Personal/Family History - Why?? Green Climacteric Scale www.pcwhf.co.uk

Slide12

Slide13

Why & What Risk Assessment?

Personal & Family Hx

Migraines +/- aura

CVS & metabolic risk factors

Venous Thrombo-embolism ( VTE)

Cancer – Breast , Bowel , Uterine, Ovarian

Risk of osteoporosis, if Family Hx-mum refer for DEXA scan Mental Health Exclude other causes of symptoms ( FBC,TFTs if required) www.bms.org.ukwww.menopausematters.co.ukwww.womans-health-concern.org.ukwww.rockmymenopause.com

Slide14

Check LIST for HRT prescribing ( Section 1.4)

1. Dose of

Estrogen

in HRT should be tailored to

individual patient circumstances (

Age

, VTE/CVS Risks )2. Oral /Transdermal HRT 3. Type of Progestogen in HRT matters due to effects on CVS/VTE/ /Metabolic/ Breast cancer4. Sequential or Continuous Combined HRT 5. Contraception INDIVIDUALISE RX & PERSONALISE RISKS /BENEFITS

Slide15

Indications for transdermal HRTSection 3.2Migraines/focal Poor relief with oral HRT

BMI>30

Hypertension

Diabetics with BMI>30

CVS risk factors

VTE risk factors

On Thyroxine, anti-epilepticsCrohn`s diseaseHypertriglyceridemiaGall Bladder disease Patches (twice /week)25, 37.5 mcg , 50 mcg ,75 mcg , 100 mcg Gels Oestrogel ™Sandrena™ gel ( sachets)Spray

Lenzetto ™(Estradiol1.53 mg/spray)

17B Estradiol (Section 3.1)

Slide16

ORAL : 17 ℬ Estradiol

Tablets

– 1mg , 2 mg

Advantages

Inexpensive

Improves Insulin sensitivity >transdermal E2 Lipid friendlyDisadvantages Higher risk of VTE > no HRT /Transdermal HRT ↑binding proteins : TBG, SHBG ↑TriglyceridesDrug interactions : Liver enzyme inducers

Slide17

Estradiol Equivalent doses (Conversion table) Section 3.3

LOW (50-60

yrs

)

STANDARD (40-50yrs)

HIGH (<40

yrs) POIStart at 2 mg & ORAL 1 mg 2mg 3-4 mg PATCH 25 Ug 50 Ug 75-100UgGEL PUMP 1 measure 2 measures 3-4 measuresEstradiol spray Lenzetto 1 spray 20 Ug 2 sprays 29 Ug

3 sprays 40 Ug

Practical Prescribing

www.bms.org.uk

Slide18

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

What is

Lenzetto? Lenzetto2

1 spray21 mcg2 sprays29 mcg3 sprays40 mcg

Matrix Patch

2

25 mcg ug/d

37.5 mcg ug/d

50 mcg ug/d

Lenzetto

®

is a

novel transdermal HRT spray

, delivering

metered doses

of

estradiol

.

Each spray or actuation delivers 90 µL of transdermal spray and consists of:

1,2

Estradiol

(1.53 mg)

2.

Octisalate

(permeation enhancing)

3. Ethanol

Invisible, no residue /irritation like with patches

Each Lenzetto device costs £6.90

and contains 56 sprays 2 min to dry

X1- 3

Slide19

Progestogens in HRT

1. PROGESTERONES

Retroprogesterone

:

Dydrogesterone

(DG) (Femoston range)Micronised Progesterone (MP) : Utrogestan 2. PROGESTINS (Androgenic) Norethisterone (NET) Medroxyprogesterone acetate (Provera™)3. Mirena™: Levonorgestrel (52mg)

Slide20

Why Progestogen matters? Section 3.4

Type of Progestogen

PMS/ Androgenic effects

VTE Risks

2 Metabolic effects1 Breast Cancer risk 3Dydrogesterone Utrogestan Lower Lower NeutralLower NorethisteroneMPAHigherHigherUnfriendly (Neutralises beneficial effect of E2 on insulin , lipids)Higher

LNG (MirenaTM )

Local effect ,

minimal

Local effect

Local Effect

Local effect

(lack of safety data

)

1.

. Menopause and Diabetes : EMAS Clinical Guide .

Slopein

R , et al.

Mauritas

2018

2.

Vinogradova

et al. Use of HRT & Risk f VTE , nested case control study using QR research and CPRD database. BMJ 2019:364 k4810,

3.

Vinogradova

Y . Use of HRT and risk of breast cancer : nested case-control studies using

QResearch and CP RD databases . BMJ2020: 371

Slide21

Which HRT? Alogrithim 4

Systemic HRT

Local HRT

Has UTERUS – needs endometrial protection

YES

E+P

Periods<1 yr

Sequential HRT (Period HRT)

E + IUS

Periods

>1 yr or

age 54/55

Cont Combined HRT-no period

Tibolone

E+IUS

After 2 years – <50

After 1 year – >50

Slide22

Types of HRT

Oestrogen

Estrogen

Only( no uterus)

Oestrogen

17-28

(Sequential HRT)Monthly bleeds

Oestrogen

Continuous combined HRT (CCHRT) but

irreg

bldg. x 6 months

No Bleed HRT

Estrogen

Progestogen

Progestogen

Bleed

dd

Slide23

HRT Preparations ( Combined) E2 + P Section 6.0

1.

SEQUENTIAL HRT

Femoston

™

1/10Femoston ™ 2/102. CONTINUOUS COMBINED HRT Femoston Conti ™ 1/5 mg

Femoston Conti

™

0.5/2.5 mg

1. ORAL (

FEMOSTON

™

)

E2 +

Dydrogesterone

1. SEQUENTIAL HRT

Elleste

Duet

™

1/10,

Elleste

Duet

™

2/10

2. CONTINUOUS COMBINED HRT

Elleste

Duet Conti

™

2 mg

Kliofem

,

Kliovance

ORAL(ELESTE DUET

™

)

E2+

Norethisteron

e(NET)

2. Oral

Tibolone

CONTINUOUS COMBINED HRT

Oestrogenic

, progestogenic, androgenic effect

Improves sex drive

Endometriosis

Increased risk of stroke above 60

3. (

PATCHES )

E2+

NET

twice a w

eek

1.Evorel

Sequi

™

(50 Ug)

2.

Evorel

Conti

™

www.bms.org.uk

. BMS update

on HRT supply shortages (2021)

Slide24

Tailor made HRT ( Mix& Match)

ESTRADIOL

(Transdermal)

➕

MIRENA™

MICRONISED PROGESTERONE

Estradiol patch

Estrogel

™

Sandrena gel

™

Lenzetto spray

™

Medroxy Progesterone acetate

➕

➕

Body identical

HRT

*

Not licensed for use

as part of HRT

Slide25

SEQUENTIAL HRT CONTINUOUS COMBINED HRT

Transdermal E2 +

Micronised

Progesterone (

Utrogestan

)capsule

100mg x 2(200mg) for 12 daysLicensed use – D15-D26E2 + MPA (medroxyprogesterone acetate)10 mg for 2 wks x month Unlicensed use Transdermal E2 + Micronised Progesterone(Utrogestan) daily100 mg (daily)Licensed use – D1-D25 E2 + MPA ( 5 mg ) daily, if side effect can reduce to 2.5 mg daily monitor bleeding Unlicensed use Oestrogen

Progestone

D1

D28

D14

Oestrogen

Progestogen

www.bms.org.uk

MIX & MATCH

Bodyidentical

HRT

Slide26

Recommended HRT Preparations

1. Transdermal HRT

Micronised

Progesterone

(

UtrogestanTM) 2. Transdermal HRT(gel/patch/spray + Mirena (x5 years)3. Evorel Sequi, Evorel Conti patches ( NET) 4. Combined Oral preparation (Dydrogesterone) Femoston 1:10, 2:10 Femoston Conti. 1 mg, 0.5 mg 5. Tibolone ( Livial) once daily Body Identical HRT Oral HRT

Slide27

BODY IDENTICAL HRT- Recommended Indications Transdermal E2 + Micronised Progesterone https://thebms.org.uk/publications/consensus-statements/bioidentical-

hrt

/

1. Patients with

poor symptom control

2.

Androgenic s.e with other HRT (PMS, acne, w

eight

gain)

3. Can help with Insomnia

4. If shortages – of other HRT

History of focal

migraines, aura

5

High Cardiovascular risks ,

e.g. Q Risk score 5-10%, metabolic syndrome ,

Diabetes with BMI>30

4

Patients on

hepatic enzyme inducing agents

(e.g. anticonvulsants)

VTE Risks

2,

3

Breast Cancer Risk factors

1

Limited data from observational study

1.Fournier A,

Berrino

F,

Clavel-Chapelon

F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat 2008;

107

(1): 103-11

2.

Vinogradova

Y, Coupland C,

Hippisley

-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the

QResearch

and CPRD databases. BMJ

2019;

364

: k4810

3.

Scarabin

PY. Progestogens and venous thromboembolism in menopausal women: an updated oral versus transdermal estrogen meta-analysis. Climacteric 2018;

21

(4): 341-5

4.

Slopien

R,

Wender-Ozegowska

E,

Rogowicz-Frontczak

A, et al. Menopause and diabetes: EMAS clinical guide.

Maturitas

2018;

117

: 6-10 ,KEEPS, ELITE study

5.Migraines and HRT.

https://thebms.org.uk/publications/tools-for-clinicians/migraine-and-hrt/

Slide28

1. Sandra

Age 52, Para 2 , actor, hot flushes, upset , low mood, insomnia, low self esteem, - 12 months

Citalopram x 12 months , no effect

Periods are irregular, every 2-3 months in last year

Past Hx of PMS , Post natal depression

BP-120/80, BMI=26, non smoker

Drinks 10 units /week She requests a blood test for menopauseDose of HRT : E2 ( Section 3.3) 50-60 – 1 mg E2

Slide29

Decides to start oral HRT

Why Sequential HRT?

DE

Oestrogen Oestrogen Oestrogen

17-28

Prog

17-28

😊

😡

(E2 1mg +

Dydrogesterone

) (E2 + NETA)

Elleste

Duet

TM

Why?

1.

Femoston

™ 1/10

2.

Mirena ™

and oral

Estradiol

tablet 1mg/ patches

1. Started

Femoston

- 1/10 ( 1mg E2 + 10 mg DG)Contraception: add a mini pill (

DSG/levonorgestrel), barrier

Month 1

Month 2

Month 3

Ref:

https://thebms.org.uk/wp-content/uploads/2018/08/HRT-Practical-Prescribing-AUG2018.pdf

( for doses)

Slide30

Follow up

FU-3 months

Still hot

Check BP

Femoston

Conti 1 mg

Irreg

bldg. x

4 /12

Age 58

Femoston

Conti 0.5 mg

Femoston 2/10

Age 53

Fed up with periods

Benefit/Risk Analysis , Life style, Ca & Vit D

Age 52

Periods every 3/12

Can change from Seq to CCHRT after 1

yr

Sandra asks how long can I take HRT for?

Yearly FU, BP check , Review changes in Hx

50-60 benefits outweigh risks in her case

Before starting HRT

Side effects

Benefits/Risks

Yearly

FU

Femoston

1/10

What Rx option if she was NIDDM on Metformin , BMI=28

Slide31

(Option 2) IUS + Estradiol

IUS + E2 from age 52-57. Advantages of IUS

Unlicensed as part of HRT (x 5

yrs

)

Reduces heavy periods

Local Hormonal effect with minimal side effectsData on Breast safety are sparseAt 57 , Remove IUS and change to Femoston Conti 0.5 mg or 1 mg ™ Mirena SPC: Bayer plc Lyytinen et al. A case control study on hormone therapy as a risk factor for breast cancer in Finland: IUS carries a risk as well. Int J Cancer.2010; 126:483-489

Slide32

Melanie

51

yrs

, very hot , insomnia, low mood tired , joint pains weight gain &

No Periods – 1 year

Has tried herbal remedies – not seen much benefit

BP - 130/88 , BMI=34 , central obesity , non - smoker , doesn’t drink CVS Risk factors BMI= 34 , HT, DM , raised Chol & TG- on statin , Metformin, LisinoprilNon alcoholic fatty liver Q risk score = 5 Advise Life style interventions – diet , exercise , Calcium and Vit D1. Does she need contraception? 2. What are her HRT options ?? Personalise Risks and benefitsEvaluate her CVS risks before starting HRT (Q Risk >10% avoifd HRt)If high risks – Alternatives to HRT Boardman et al . Cochrane Database Syst Review 2015 . Hormone therapy for preventing CVD in post menopausal women . Ref: World J of Gastroenterology 2015: Carla W Brady , July 7 21(25)7613-25

Slide33

Effect of E2 HRT – in early and established atherosclerosis ( Menopause & CVD )

Menopause and CVD : Dr Louise Newson , Post Reproductive Health J, 17.01.2018

Higher doses of E2- thrombogenesis ,

Effect on vascular

remodelling

Embolisation of plaques

Slide34

Body identical (Regulated)

No periods x 1

yr

- CCHRT

Unregulated Oestrogel ™

1 measures daily Sandrena gel™(0.5 mg )

Lenzetto spray ™

1 spray can ↑2 sprays in 4-6 weeks if required

Estradiol

patches

(17B oestradiol)

25,

mcg twice a week

Utrogestan™

(Micronised Progesterone)

CONTIUOUS COMBINED

Licensed

100 mg cap D1-D25

Unlicensed ( daily)

At bedtime, on empty stomach

Vaginal insertion if s.e

Drowsy, somnolence

Slide35

Migraines and HRT Increased prevalence- fluctuating E levels, transdermal HRT

HRT is not a CI – migraine with aura

2 fold increased risk of ischemic stroke,- Migraines with aura

Continuous HRT preferred to cyclical

Preferred Progestogens-

Mirena

TM, UtrogestanTM, transdermal norethisterone in combined patches ( Evorel Sequi/Conti patches) Use lowest effective dosewww.bms.org.uk FACT sheet Anne MacGregor . Migraine, menopause & HRT . Post Reprod Health 2018 ; Vol 24(1) 11-18

Slide36

Alternatives to HRT Included in NICE recommendations( unlicensed – not to be used as 1st line RX for low mood, VMS)

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 Sertraline 50 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, Pregablin

Lifestyle

advice

Slide37

Herbal Remedies & Diet Red Clover : Promensil

Black Cohosh:

Menoherb

,

Menomood

Sage, alfa alfaS Johns Wort Phytoestrogens in diet

Slide38

Non Hormonal TherapiesLubricants

Pjur

Med ( silicone based)

Yes: oil based , water based lubricant

Water based –

Sylk

, not so effectiveMoisturisersYes Vaginal Moisturiser , Replens, Hyalofemme , Vagisan cream Laser Rx – CO2 , Erbium laser, NdYAG laser , Mona Lisa TouchWith Tamoxifen- can have very low dose local E but need to liase with Breast cancer surgeons

Slide39

Vaginal Oestrogens – Rx of Genitourinary syndrome GSM (LOCAL EFFECT ONLY) Section 7.2

Estradiol

Pessary )

Estriol cream 0.1% /pessary /gel

DHEAS(

Prasterone

RingSmall to insert, licensed for long term use For vulva, can be messy , can insert in vagina For moderate to severe atrophy not responded to other Rx Remains in vagina x 3 months , licensed for 2 years Nightlyx2 wks foll by twice a wk Gel/pessary -Daily x3/52 foll by twice a week Daily and re-asess in 6, 12 months Changed 3 monthly Vagirux 10 mcg Blissel gel 50Ug, Imvaggis pessary (30Ug)Estring 7.5 mcg /day

Slide40

Role of Testosterone

Dose recommended in post menopause with or without HRT

equal to premenopausal concentration

- Post menopausal

- BSO ( Surgical menopause) Testosterone

Premature Ovarian Insufficiency (POI) Baseline tests – Serum Test < 1.7 nmol/L, FAI <1Preparations (unlicensed, off Label use )Testogel® (1%) 1 sachet x 10 days ( 0.5 ml =5 mg /day) shortages currently Tostran gel® (2%) 1 measure on alternate days or 2-3 times a weel Testosterone Implant® 100 mg yearly ( in pts with TAH with BSO) Side effects Androfeme® 1 cream – 0.5 ml daily( only available on private prescription , imported from Australia) Check Baseline Testosterone , FAI , Repeat in 3 months, followed by annually Davis et al. Global Consensus Position Statement on the use of Testosterone Therapy for Women. Maturitas. 2019;128:89-93.

Slide41

Duration & F/U of systemic HRT POI - until age 51 at least>51 yrs : Informed choices , No arbitrary time limit Discontinue gradually- makes no difference Individualise Rx:

- 50-60

yrs

- Benefits outweigh risk

- 60-70 Benefits = risk,

- Over 70 Risk outweigh benefits

411 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??

Slide42

When to refer for an Expert Opinion( Section 9.1)

Multiple Rx failures

Side effects on HRT

Premature Ovarian Insufficiency ( POI) <40

yrs

Complex medical problems - CVS/stroke etc

Personal /Family Hx of VTE & Breast Cancer Safety concerns/Contraindications to HRTAbnormal bleeding on HRT

Slide43

HRT and contraceptionContraception not required ifOver 50: LMP 1 yr back Under 50: LMP 2 yrs back On CCHRT – post menopausal

SEQUENTIAL HRT is not a contraceptive – till age 55

POP- norethindrone/levonorgestrel/

desogestrel

IUS will be best option

Implant or Depo Provera- avoid Barrier Method

Slide44

Take Home Messages

Menopause is a CV risk factor - Life style intervention

Over 45 : No need for Blood test (FSH)

HRT within 10 years of menopause or under 60 – benefits outweigh risks, cardioprotective

Oe

strogen matters : Consider dose, Transdermal : BMI>30, HT , Thyroxine, Migraines , VTE /CVS risk factors

Progestogen matters : Advantages of

Dydrogesterone

and

Utrogestan

in DM, CVS

risks , VTE Risk factors, Breast cancer risk factors

6. Local E2 for GSM – can be added to systemic HRT

Slide45

Training

BMS Principles & Practice Menopause care

www.bms.or.uk

www.pcwhf.co.uk

Primary Care

Womans

Health Forum)www.emas-online.org IMPART online learningwww.imsociety.orgwww.ims.org ( Excellent webinars) www.mywayhub.co.uk webinars (Viatris)BMJ learningManagement of The Menopause- 6th edition -BMS Patient info leaflet ( NICE)Menopause & me leaflet www.menopausematters.co.ukwww.womens-health-concern.org.ukwww.bms.org.ukwww.managemymenopause.co.ukwww.menopausedoctor.co.ukwww.nice.org.ukRockmymenopause.com

Slide46

Thank you for your attention

Continue to Stay Safe

International menopause society

Slide47

Cases – Which HRT ?Age 47 , TAH with BSO for endometriosis 1 year back, hot flushes , sweats, low sex drive

CCHRT x 1 year , Tibolone, or

Femoston

Conti ,

Evorel

Conti , can add Testosterone if no improvement in sex drive

inspite of HRT2. Age 52 , Mirena fitted at 47 for contraception ,menopausal symptoms , on Thyroxine , BMI =30, not keen on IUS replacement E2 patches 25 mcg + Utrogestan 100 mg daily 3. Age 53, Hx of breast cancer 3 years back, had mastectomy followed by RT and chemotherapy. Currently on Tamoxifen. Has severe hot flushes , night sweats and dyspareunia

Slide48

Cases Which HRT ?

4.

52

yr

old , no periods on POP , BMI=28 , Mother VTE in her 40s post delivery

IUS + transdermal E2 , Body identical HRT

6. Age 60 , periods stopped at 53 ,tried alternatives to HRT , BMI=25, BP – 130/80 mm of Hg Femoston Conti 0.5 mg, Body identical HRT 7. Age 52 , on steroids for asthma , severe eczema , osteoporosis hip , hot flushes , sweats , no periods- 2 years , BMI=25, BP -120/80- Femoston Conti 1 mg / Mirena + E2 patches/gel/spray + Utrogestan / Evorel Conti patches

Slide49

HRT &

CHD

M

eta-analyses

Cochrane review

2014RCTS HRT vs placebo / no treatment36,838 postmenopausal womenHRT exposure 0.6-10.1 yearsmenopause <10 years (n=9,088)menopause >10 years (n=27,750)CHD (CV death + non-fatal MI)

0

0

.5

1

1

.5

RR

Boardman et al. Cochrane Database

Syst Rev

2015;

DOI:

10.1002/14651858.CD002229.pub4

>10

years

<10

y

ears

Slide50

50

Bleeding problems ON HRT

50% stop HRT in 6-12 months due to bleeding problems

Abnormal bleeding: when to investigate

On SEQUENTIAL HRT –

bleeding >6 months

Withdrawal bleed at wrong time (on cyclical HRT)

Bleeding between periods

2.

On CCHRT

Persistent bleeding after 6 months on CCHRT

Spotting/bleeding on CCHRT after 6 months of

amenorrhoea

3. Exceptionally heavy bleeding

Slide51

https://pcwhf.co.uk/wp-content/uploads/2020/05/PCWHF-Menopause-Management-remote-consultation-tool_V4.pdf

Rx strategies in first 6 months ( Refer to

www.bms.org.uk

)

Modifying doses of Progestogen will reduce abnormal bleeding on HRT in first 6 months

On CCHRT

containing progestogen can add MPA, Utrogestan or NET to their HRT regime .If bleeding after switching from Seq HRT to CCHRT and doesn’t settle after 6 months can change back to Sequential HRT for 1 more year On Sequential HRT : Increase dose of Progestogen or duration of Rx from 14 days to 21 days IUS and E : Add Progestogen ( Refer for scan to check placement of coil)If continue with bleeding beyond 6 months or risk factors : Investigate , and obtain advice from local Hysteroscopy service

Slide52

Investigating unscheduled bleeding - TV Ultrasound , EB, Hysteroscopy if indicated

SEQUENTIAL -HRT

COMBINED HRT

<

5mm

5-8mm> 8mmNormalDay1-D5 ? RescanBiopsy? Biopsy >= 5mm

ET >= 5mm

ET< 5mm

Biopsy

-Change back to Sequential or E +IUS

-Reassure , monitor

?REFER if persists

Smith –Bindman et al . Endovaginal USG to exclude endometrial cancer and other endometrial abnormalities . JAMA 1998:280;1510-17

Slide53

Daisy (Premature Ovarian Insufficiency)Age 39 , No periods for 12 months, battery has ran out , flushes , sweats, low mood, low sex drive – 12 months 2 failed IVF pregnancies , adopted 2 children

FHx

– early menopause mother & sister in 40`s, mother had MI at 45

BMI =26, BP 120/80

Blood tests – FSH x 2 levels done 6 weeks apart = 35, 55 IU/L

Slide54

Premature Ovarian Insufficiency (POI)ESHRE Guidelines 2016

Menopause < 40 years ( 1%)

Causes: Idiopathic,

F/

Hx

, chromosomal , Auto-immune, iatrogenicInvestigations- Baseline BMD, repeat if osteopenia/osteoporosis, Thyroid peroxidase antibodies, coeliac screen, Karyotype under 30 Consequences- QoL, IHD, Osteoporosis, Dementia, Parkinsonism Untreated POI is asstd with reduced life expectancy due to CVD54

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Rx options (ESHRE guidelines on POI) COC ( Qlaira/Zoely) / HRT ?

Need higher doses Of E2 ( 75- 100 mcg E2 patches or 2-4 mg oral dose)

HRT Regimes

Oral HRT –

Femoston

2/10 ™

IUS + E 2 patches 50 - 100 mcg twice a week 3. Evorel Conti patches – 50 mcg twice a week Tailor made HRT - Biodentical HRT (Transdermal E2 + Utrogestan)Role of TestosteroneContraception needed till age 55 ( mini pill/IUS)Ca and Vit D