THE MENOPAUSE

AND HRT
 THE MENOPAUSE – WHAT IS IT?
Yunani Men (month) dan pausis (berhenti)
From the British Menopause Society:
• Permanent cessation of menstruation
• Only diagnosed after 12 months spontaneous amenorrhoea – a
retrospective diagnosis
• Climacteric/perimenopause – period of change leading up to the
menopause
 THE MENOPAUSE – WHY
DOES IT HAPPEN?
• Women are born with around 1.5m oocytes
• 1/3 are lost by the time of menarche.
• Most women menstruate about 400 times, and 20-
30 follicles start to develop each time.
• Eventually the supply of responsive oocytes in the
ovaries runs out
STAGES OF REPRODUCTIVE AGING WORKSHOP
(STRAW)
HOW COMMON ARE SYMPTOMS?
• 80% of women experience menopausal symptoms1
• 45% of these find the symptoms distressing1
• Most women manage the symptoms themselves – 10% seek
medical advice for their symptoms2

1) RCPE, 2003

2) Roberts; BMJ, 2007

 SYMPTOMS
• Menstrual irregularity
• Hot flushes/sweats
• Urinary/vaginal symptoms
• Sleep disturbance
• Mood changes
• Loss of libido
• Others
 MENSTRUAL
IRREGULARITY
• Cycle may lengthen to months, or shorten to weeks1
• Increase in blood loss is common1
• Majority of women experience irregularities, but 10% have a
sudden cessation of menstruation2

1) Nelson H; Lancet, 2008 Mar

2) “Menopause”; Clinical Knowledge Summaries

 HOT FLUSHES/SWEATS
• Common 70-80% of peri-
menopausal women1
• Tend to affect head, neck, face
and chest.
• Usually last for a few minutes
but can happen multiple times
during the day and night.
• Most common in the first year
after the last menstrual period2
1) RCPE 2003

2) “Menopause” Clinical Knowledge Summaries

 URINARY/VAGINAL
SYMPTOMS
• Dyspareunia
• Vaginal discomfort/dryness
• Recurrent UTI
• Urinary incontinence
• Occur in 30% in early post-menopausal period, rising to 47%
later in life1

1) Grady; NEJM, 2006

 SLEEP DISTURBANCE
AND MOOD CHANGE
• Sleep disturbance – commonly reported
symptom, probably related to mood changes –
anxiety, depression, memory loss, poor
concentration1
• Development of psychological symptoms has
been linked to high BMI, and low amounts of
physical activity2

1)Young T et al;. Sleep, 2003, Sep

2) Di Donato P et al;. Maturitis, 2005, Nov
 LOSS OF LIBIDO/OTHER
CHANGES
• Loss of libido may be related to hormonal changes, but also
psychological factors, vaginal dryness, partner
• Others (probably due to low oestrogen):
 Thinning of skin
 Hair loss
 Generalised aches and pains
 ASSOCIATED
PROBLEMS1
• Increased risk of cardiovascular
disease + stroke
• Increased risk of osteoporosis
• Redistribution of body fat
• Alzheimer’s Disease – more
common in women so may be
hormonal link, but no evidence
HRT reduces risk

1) British Menopause Society

 MANAGEMENT OF
MENOPAUSE
• Reassurance

• Education, lifestyle changes

• HRT

• Alternatives
 LIFESTYLE CHANGES
• Hot flushes and night sweats
• Regular exercise, lighter clothing, sleep in a cooler room,
stress management
• Avoid triggers
• Sleep disturbances
• Avoid exercise late in the day
• Maintain regular routine
• Mood and anxiety
• Adequate sleep, regular exercise, relaxation exercises
• Cognitive symptoms
• Adequate sleep, regular exercise
TREATMENT - HRT
 HRT
• Effective treatment for menopausal symptoms
• Previously used widely and for prolonged periods
• However:
Women’s health initiative (2002) – increased risk of
coronary heart disease, stroke, breast cancer, PE
Million women study (2003) – increased risk breast and
ovarian cancer
BAKOUR, SH; WILIAMSON J. LATEST EVIDENCE ON USING
HORMONE REPLACEMENT THERAPY IN THE MENOPAUSE. 2015.
 INDICATIONS FOR HRT1
• Treatment of menopausal symptoms where the risk
benefit ratio is favourable, in fully informed
women, in the lowest possible dose needed to
control symptoms and for the shortest possible time
• In women with premature menopause until the age
of natural menopause (50)
• For prevention of osteoporosis in women unable to
use other medications
• 1) “Menopause” Clinical Knowledge Summaries
 CHOICE

• Estrogen + progestogen
• estrogen alone
• Tibolone
 ROUTES OF DELIVERY
• Oral tablets
• Patches
• Creams/gels
• Nasal sprays
• IUS
• Oestrogen releasing vaginal ring
• S/C implants
 WHICH PREPARATION?
Questions:
1. Does the women have an intact uterus?
2. Are symptoms primarily vaso-motor or
urogenital?
3. Systemic or local treatment?
4. Combined or oestrogen only?
5. Cyclical or continuous?
 WHICH TYPE OF HRT??
HRT

With Uterus Without Uterus Urogenital Symptoms

Perimenopausal

Postmenopausa
al

Cyclical Continuous Unopposed Local

Combined Combined Oestrogen Oestrogen

Start at lowest dose possible for shortest period of time

 CONTRAINDICATIONS TO
HRT1
• Pregnancy and breast-feeding
• Undiagnosed vaginal bleeding
• VTE
• Active/recent angina or MI
• Suspected, current, or past breast Ca
• Endometrial Ca
• Active liver disease with abnormal LFTs

1) “Menopause”; Clinical Knowledge Summaries

RELATIF CONTRAINDICATION OF
HRT
• Epilepsy
• History of Breast Ca in Family
• Atypical Ductal Hyperplasia in mammae
• Cholelitiasis
• Myoma
• Endometriosis
 WHAT ARE THE RISKS?
• Venous thromboembolism
• Coronary heart disease
• Stroke
• Breast cancer
• Endometrial cancer
• Ovarian cancer
 PHYTOESTROGEN
• Merupakan konstituen dari tumbuh-tumbuhan yang
berikatan dengan reseptor estrogen ER and ER
• Senyawa mirip estrogen yang berasal dari tumbuh-
tumbuhan. erutama dari produk polong-polongan
(kedelai), gandum, dan kacang-kacangan
TIBOLONE
 FOLLOW-UP1
• Initial follow up after 3 months
• Thereafter, a minimum of annual checks
 Check effectiveness
 Side-effects
 BP + weight
 Breast examination – if appropriate
Review of risks/benefits

1) “Menopause”, Clinical Knowledge Summaries

 FOLLOW UP FOR CANCER

• Breast Ca - three years from 50-70

• Colorectal Ca - biannual from 60-69
• Cervical Ca – 5 yearly until 65
• Endometrial Ca – urgent assessment of
any bleeding
• Ovarian Ca – no programme
 WHAT ARE THE SIDE-EFFECTS?
• Estrogen: • Progestogen:
Breast tenderness Breast tenderness
Leg cramps Backache
Bloating Depression
Nausea Pelvic pain
Headaches

 Bleeding – cyclical preparations produce regular and

predictable bleeds, usually towards the end of the progestogen
phase
 BLEEDING – WHEN TO
REFER?
• Perimenopausal woman with intact uterus
 Change in pattern of withdrawal bleeds
 Breakthrough bleeding persisting for more than 6
months, or does not reduce on “long-cycle” HRT
 Persistent or unexplained bleeding after cessation of
hormone therapy for 6 weeks
 BLEEDING – WHEN TO
REFER?
 Postmenopausal women with an intact uterus
 Breakthrough bleeding persists for more than 6 months
after starting HRT
 Bleeding occurs after amenorrhoea
 Persistent or unexplained bleeding after cessation of
hormone therapy for 6 weeks
 STOPPING HRT
• General rule is to stop after 1-2 years to see if
symptoms have gone.

• If they recur, can try lower dose or try different

method.

• Stop HRT 4-6 weeks prior to major surgery.

• If started for early menopause, stop at age 50.

TREATMENT -
ALTERNATIVES
 MEDICATIONS1
• SSRIs/SNRIs – fluoxetine, paroxetine, citalopram
and venlafaxine have been shown to reduce
symptoms; unlicensed for this use
• Clonidine – evidence of efficacy in treating hot
flushes
• Gabapentin – evidence of efficacy for treating hot
flushes; for specialist use

1) Nelson HD et al; JAMA, 2006 May

 SUMMARY
• The menopause is a natural and inevitable part of
life
• Menopausal symptoms are very common but most
women never seek advice regarding management
• Although HRT carries risks, it is a good and
effective treatment for symptoms
• Patients should be fully informed and allowed to
make the decision themselves about whether to
commence HRT