Anita 44yrs 1 daughter age 6 trying to conceive for 2 years Periods now irregular every 61052 Says shes is under pressure from her husband who wants a son Does she want another child ID: 549313
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Slide1
Menopause scenariosSlide2
Anita 44yrs, 1 daughter age 6,
trying to conceive for 2 years.
Periods now irregular, every 6-10/52
Says she’s is under ‘pressure’ from her husband who wants a sonSlide3
Does
she
want another child?
Symptoms of menopause, flushes, libido?Mood?How is her relationship with her husband, think about abuse.What does she know about the menopause?FH, menopause/VTE/breast cancerPMH, breast disease, VTE, liver disease
What questions are you going to ask her?Slide4
What investigations will you do?
FSH
Consider FBC, TFT, HbA1c,
Vit D, Lipids, LFTCheck smear, consider swabsbp, BMI,
Smoking
Breast examSlide5
If she is
perimenopausal
what treatment would you offer?
Sequential combined HRT, will have regular bleedsCan be monthly or 3 monthlyOral first line as cheap eg
Prempak
C
Patch avoids first pass effect and does not effect clotting/VTE risk
eg
Evoral
sequi
If she needs contraception
Mirena
plus
oestrogen
tablet, gel or patch is an optionSlide6
What advice will you give about contraception?
Needed for 2
yrs
after last period if <50y1 yr after period if >50yPOP licensed
can use
coc
up to 50y if fit non smoker, consider low dose
www.fsrh.org
has section on contraception over 40Slide7
Belinda,
49yrs single 2 teenage kids.
Works
as HCA, 12hr shifts, money tight and worries re kids. Sleep poor. Recently started a relationship with a man, no sex yet, she is anxious about it. Lmp 13/12 ago.Slide8
What do you need to explore further?
What does she know about menopause?
Mood?
Sleep disturbance, night sweats?Libido, what are worries re new relationship
?Think
about atrophic vaginitis
FH re menopause/breast cancer
PMH re breast disease, VTE, liver diseaseSlide9
What investigations will you do?
NOT FSH
Consider FBC, TFT, HbA1c,
vit D, lipids, LFTCheck smear, bp, BMI, smoking, advice re breast exam
Advice re STI screening
Slide10
What advice will you give her?
Contraception…
Continuous combined HRT, no period 2yrs < 50y, 1yr if > 50y
Again oral or transdermal available, no bleedRefer if still bleeding after 6/12 treatment or after period of amenorrhea
Can consider
tibolone
, better for libido, more likely to bleed.
Vaginal
oestrogen
,
eg
Vagifem
no
inc
risk VTE or cancer can use long termSlide11
Cathy 58
yrs
, head teacher lives with
husbandStruggling at work due to hot flushes, poor sleep, worries she is being ratty with her husband who recently retired. Fell on ice in Jan and had Colles left wrist.
Hysterectomy
3
yrs
ago.
Declined
HRT last year as worried about SE. Slide12
What do you need to explore?
What are her worries about HRT?
Libido? Mood?
Self medication eg herbal remedies, alcoholHas fragility fracture been followed up? See NICE osteoporosis guidelines Slide13
What advice will you give her?
Oestrogen
only HRTRemember transdermal has NO increased VTE riskWill reduce fracture risk while she is taking it.
HRT started < 60yr no increased IHD risk, ? benefit
Breast cancer risk negligible with
oestrogen
only
HRTSlide14
Alternatives to HRT
www.menopausematters.co.uk
SSRI for flushes,
topical testosterone for libido, both off licenseSt Johns WortVaginal lubricant Replens, Yes,
Sylk
CBT, antidepressants
Vaginal
oestrogen
,
eg
Vagifem
no
inc
risk VTE or cancer can use long termSlide15
Key Messages about risk
Oestrogen
increases VTE risk but not if transdermal.
Also increases risk of endometrial cancer if not given with progesterone.Progesterone increases risk of breast cancer but only slightly with long term use.Combined HRT may protect against IHD if started under 60yr, increases risk slightly over 60yr.Slide16
Combined HRT, 3/1,000 extra cases in women 50-59 with 5
yrs
use.
Risk comparison, alcohol, obesity, HRT > 2-3 units alcohol/day 1.5xPostmenopausal obesity 1.6x> 5yrs HRT 1.35x
Breast cancer riskSlide17
The future
Bio identical
progesterones
may not have increased breast cancer riskAre anxiolytic/hypnotic steroidsE.g. Utrogestan licensed for use with
oestrogen
as combined preparationSlide18
Useful resources
www.fsrh.org
has section on contraception over 40
http://www.gwh.nhs.uk/media/163808/wiltshire_hrt_guidance_2014.pdf very useful summarywww.menopausematters.co.uk
patient info leaflets
www.nice.org.uk
latest menopause guidelines