Menopause

Premature menopause (before age 40)

Complex medical history (VTE, MI, breast cancer etc.)

Persistent problems with side effects, lack of efficacy

Bleeding problems –see separate PMB guidance

History of hormone dependent cancer

Diagnosing menopause:

Diagnosing menopause should be based on the woman’s symptoms and age.

Healthy women >45 years with menopausal symptoms, diagnose without laboratory tests if:

The woman has vasomotor symptoms and irregular periods

Or

No period for 12 months

Or

Based on symptoms in women without a uterus.

 

Consider using FSH if

The woman is 40-45 years with menopausal symptoms.

Or

The woman is younger than 40years with suspected premature menopause.

 

Fluctuations in levels of FSH in perimenopause limit its use. FSH should not be done if taking the combined pill or high dose progestogen.

 

Indications for HRT treatment

Consider HRT to manage menopause symptoms including vasomotor symptoms, psychological symptoms (including low mood that arises as a result of menopause), and altered sexual function.

The benefits of HRT are likely to outweigh the risks for women with disruptive symptoms below the age of 60 or within 10 years of the menopause.

In women with premature ovarian insufficiency (below the age of 40), systemic HRT is indicated until the age of the natural menopause (51 years) to prevent the early onset of osteoporosis and cardiovascular disease.

HRT may be appropriate for prevention of osteoporosis related fractures in women below the age of 60 years or within 10 years of the menopause if there are menopausal symptoms or other bone protection medication is contraindicated.

There is no clear evidence that SSRIs or SNRIs ease low mood in menopausal women who have not been diagnosed with depression.

Initiating and managing HRT

The option of taking HRT is an individual decision made after a consultation with the woman which addresses quality of life, health priorities, risks (including time since menopause) benefits and personal preference.

Assessment includes:

• History of menopause and symptoms
• Menstrual history (if still having periods)
• Contraceptive needs (HRT is not contraceptive)

 

Personal and family history of medical problems including:

• Cancer- breast/bowel/ovarian
• Osteoporosis
• Venous thromboembolism
• Cardiovascular risks
• Check blood pressure and BMI

 

Choice of HRT

Route:

Tablets are considered the first-choice formulation as they are more cost-effective and avoid problems with detachment from skin and local side-effects.

Patches may be appropriate in patients in whom there is a clinical need to avoid first pass metabolism of oestrogens (e.g. patients with liver disease, or diabetes), in those who are at risk of venous thromboembolism and those who cannot tolerate tablets or express a strong preference for patches

Avoid oral HRT if:

BMI >30

History of gallstones

VTE risks (first degree relative with provoked or unprovoked DVT. If personal history refer to secondary care)

Poor symptom control with oral HRT

Bowel disorder/ absorption problems/gastric banding

On a hepatic enzyme inducing agent

 

Contraindications to HRT

• Current, past or suspected breast cancer
• Known or suspected estrogen sensitive cancer
• Undiagnosed abnormal vaginal bleeding
• Untreated endometrial hyperplasia
• Venous thromboembolism – current or past
• Angina or myocardial infarction
• Untreated hypertension
• Active liver disease with abnormal liver function tests
• Porphyria cutanea tarda
• Dubin Johnson and Rotor syndromes
• Pregnancy

 

Cautions with HRT

First degree relative with VTE- use transdermal HRT

Migraines- start transdermal with low dose, gradually increasing to control symptoms.

 

Which HRT to start

Non hysterectomised:

Perimenopausal (ie still menstruating or last period < 12 months ago)- combined cyclical

eg Elleste duet 1mg or 2mg (oral), Evorel sequi (transdermal), Femseven sequi (transdermal)

Change to continuous combined when 54 or after 5 years of use 9this reduced the risk of endomtrial cancer)

Or

Estrogen only plus Mirena

 

Postmenopausal (At least 12 months since last period) Continuous combined

eg Kliovance 1mg or Kliofem 2mg/ Femoston conti 1mg (oral)

Evorel conti (transdermal), Femseven conti (transdermal)

Estrogen only plus Mirena

Mirena

Note that when Mirena is used with estrogen only HRT it should be changed at least every 5 years. (Licence is for 4 years, but can be used for up to 5)

Tibolone- this is a synthetic steroid compound derived from soy. It is for women who are postmenopausal and has estrogenic, progestagenic and androgenic actions. It treats vasomotor, psychological, and libido symptoms. Risks are similar to those of continuous combined HRT but stroke risk may be higher.

It may have less effect on fibroids /endometriosis than other HRTs

 

Hysterectomised

Total hysterectomy, no endometriosis

Oestrogen only HRT

Eg  Elleste solo 1mg, 2mg(oral); Estradot, Estraderm, Oestrogel, Sandrena gel (transdermal), Lenzetto

Hysterectomy (total or subtotal) with history of severe endometriosis- treat as if still has uterus.

Subtotal hysterectomy

As there may be a small amount of endometrial tissue within the cervix, give sequential HRT for 3 months. If no bleeding can change to estrogen only preparation.

Can also use continuous combined HRT, but breast risk may be higher.

Dose

The dose and duration should generally be the lowest effective for symptom control. Women who are newly menopausal may need higher doses than older women

Review after 3 months as symptom control and side effects can take time to settle. Thereafter review annually or sooner if concerns.

The dose of progesterone should be in proportion to the estrogen dose, please see the table below.

Click for full sized image

How long does HRT take to work?

Vasomotor symptoms- some improvement after 1 month, maximal by 3 months

Psychological symptoms- variable

Stopping HRT

As women get older, generally lower estrogen doses are sufficient for symptom control. The lowest effective dose should be used.

Gradually reducing the dose may limit the recurrence of symptoms in the short term but will not affect long term symptoms

Consider reducing the estrogen dose if changing a woman from cyclical to continuous combined HRT. Lower the dose to the minimum rather than extending dosing frequency.

Matrix patches can be cut so the dose can be reduced slowly.

Offer topical vaginal estrogen when discontinuing systemic HRT in women who have a history of urogenital problems or who are still sexually active.

 

Topical estrogens for urogenital atrophy

These can be given as pessaries, creams or a vaginal ring (Estring)

These are given initially once daily for two weeks, then twice weekly thereafter for as long as needed. No additional monitoring is required.

Vaginal estrogen is useful in treating vaginal atrophy and can also prevent recurrent UTI type symptoms in postmenopausal women

Caution is required for women with a history of breast cancer. Estriol cream or pessaries may be prescribed in women on tamoxifen after checking with the breast oncologist. These should not be prescribed in women taking aromatase inhibitors (letrozole).

Creams and pessaries may affect condom integrity.

 

Risks of HRT

There is an up to date risk table at the start of the HRT section in the BNF

 

Breast cancer

Estrogen only HRT is associated with little or no increased risk of breast cancer

Combined HRT can be associated with an increased risk of breast cancer, generally the risk is considered low. (1 in 70 extra women in their 50s with 5 years HRT use for sequential (over the next 20 year), 1 in 50 for the same group on continuous combined.

 

Cardiovascular disease

The risk is not increased if starting HRT before 60 years of age

The presence of CVD risk factors are not a contraindication to HRT, if optimally managed.

 

Diabetes

HRT is not associated with an increased risk of developing type 2 diabetes

HRT is not generally associated with an adverse effect on blood glucose in women with type 2 diabetes

A transdermal preparation should be used.

 

Ovarian Cancer

HRT may be associated with a small risk of ovarian cancer (1-2 extra cases /1000 women over 5 years)

 

Problems on HRT

Unscheduled bleeding- please see section on postmenopausal bleeding and British Menopause society guidance

Check compliance- remind patient sequential patches need to be applied in the correct order.

Management of unscheduled bleeding on hormone replacement therapy (HRT) - British Menopause Society

 

Lack of response

Consider the following:

Too soon for symptom response- maximal response at 3 months

Estrogen dose not high enough- consider changing to higher dose/ transdermal preparation/ Premarin 1.25mg plus supplementary progestagen.

Patient compliance problem

Symptoms not menopausal

 

Side effects

Estrogen and progestagen can both cause side effects.

Generally, progestagen side effects are more problematic than estrogen- note that there are different types of progestagens and women may tolerate one better than the others (see below).

There is no evidence that HRT causes weight gain, but on average women gain 10kg between the ages of 40 and 60, whether on HRT or not.

 

Estrogen side effects

Breast tenderness

Bloating

Leg Cramps

Nausea/Heartburn

Headaches

 

In general, the best approach is to wait and see- most estrogen side effects settle in 3 months.

If side effects severe, reduce dose or change route ie from oral to transdermal

 

Progestagen side effects

PMS type symptoms

Breast tenderness

Bloating

Headaches

Mood changes

Acne/Greasy skin

 

Consider changing to oral micronised progesterone (utrogestan)

Consider Mirena plus estrogen only HRT

 

When to refer to secondary care

Premature menopause (before age 40)

Complex medical history (VTE, MI, breast cancer etc.)

Persistent problems with side effects, lack of efficacy

Bleeding problems

History of hormone dependent cancer

 

Libido issues

Options are either referral to psychosexual therapy

Or

Hormonal treatment.

 

Consider tibolone if no cardiovascular/VTE risk factors (slightly more thrombogenic but has androgen action)

 

Consider testosterone supplementation.

Indication is for libido problems

Unlicensed for use in women in UK

Use in conjunction with HRT

Contraindications same as for HRT

No good evidence on long term health risks in women

Use Tostran gel 2%- 2 times per week in divided doses

Alternative is testogel 1%- I sachet in divided doses over 10 days. 

Keep in fridge between doses

Check testosterone level before starting to make sure this is not higher than the normal female range

Apply to lower half of body.

Change application area regularly (or it will get hairy!)

Check testosterone levels at 3 months to ensure in normal female range. If higher than the normal range testosterone can cause irreversible coice changes, male pattern baldness and clitoromegaly

If all well yearly testosterone blood levels thereafter

National and local websites for further information

For factsheets in English and other languages on menopause, health risk and benefits of HRT, testosterone for women, hair loss, CBT in menopause and many others:

WHC factsheets and other helpful resources - Women's Health Concern

 

Obsandgynae.mailbox@borders.scot.nhs.uk