Menopause and HRT made easy Anita Juliana MBBS

Menopause and HRT- made easy Anita Juliana MBBS, MD, FRCOG Consultant Obstetrician and Gynaecologist Menopause Lead for NUH

Setting the scene ‘They thought I was a hypochondriac. It’s taken me years to convince them that there was something else besides neurosis’ ‘I didn’t feel like a ‘real woman’. I felt inferior’ ‘I felt like a new person. I was reborn, even though they were brought on by tablets’ ‘Most people say; ‘At my age’, ‘I’m at the age’ and I think, ‘well, I’m not, not at all, I’m half the age’………………

Objectives Refresh and strengthen the basics Clarify myths NICE Update Case discussions

Menopause- Basics What is Menopause? Symptoms Treatment – Yes or No Myths around HRT

What is Menopause? Meno - pause ( Cessation of periods) 12 months after last Menstrual period Average in UK is 51 years Peri Menopause – Irregular periods +Symptoms (45 -55 age range) Premature Menopause – Below 40 years (1% of women) Early Menopause is below 45 years (Around 5%-20%)

Menopause – Why ? Fixed number of eggs when a girl baby is born. 2, 000 oocytes at birth 25000 at 37 years 1000 oocytes at the age of 50 Rate of decline is variable

Menopause - Process Climacteric Perimenopause Post menopause

Menopause

Premature menopause Aetiology - Various Elevated FSH levels > 30 IU/L (two samples 4 -6 weeks apart) Fertility issues Osteoporosis - Increased risk Need HRT until 51 years Refer for expert opinion

Primary care challenges One third of women's life is post menopause Post cancer survivors Quality is priority Risks versus Benefits Role of Media Time limit Too many visits. .

Yes You Can Prescribe HRT in 45+ year old women Symptoms obvious No contraindications Initial investigations Premature Menopause

Primary care Dilemmas Premature / Early menopause Not so obvious peri -menopause Post cancer, post surgical menopause Older women Unsettled with HRT Contraindication for HRT Increased risks Media wise customers ( Bioidenticals, Natural hormones)

Menopause-How does it affect? Not everybody suffers with symptoms 70% - Vasomotor symptoms (Hot flushes, sweats) Varies – familial , Ethnicity Duration – 6 months – 20 years (Average 7. 4 years) Crucial time (45 -55 years) After 60, requirement for estrogen reduced

What to do? Awareness Coping mechanisms (Diet, lifestyle, Exercises) If severe, consider HRT

Diet, Exercise, Lifestyle Diet – Healthy eating ( Fruit, Veg, Dairy, Fish, Low fat, high fibre) Managing Optimal weight and BMI ( Reduces risk of CHD, Type 2 diabetes, Osteoporotic Fracture) Exercise (Weight bearing, Fast walking, Tai chi, Pilates ) Helps to reduce risk of heart disease, osteoporotic fractures by increasing bone mineral density Stop smoking Limited alcohol

Hormone Replacement Therapy - HRT Estrogen (Main), Progestogens (Endometrial protection) and Testosterone (Rarely used) Truly effective to reduce symptoms and long term benefits for bones Variable preparations More than 50 different types, doses, routes)

HRT - Continued Women with uterus Estrogen and Progesterone Still having periods or within 1 year of LMP Women without uterus Cyclical/Sequential Estrogen only More than one year of LMP or after 54 years Continuous Combined After 1 year of Cyclical Change to Continuous Combined

HRT - Continued Estrogen preparations Progestogen preparations Ethinyl estradiol Norethisterone Conjugated estrogen Levonorgesterol Dydrogestrone Estradiol Estrone MPA Mirena IUS Micronised Progesterone – Utrogesterone ( Natural)

Doses & routes Oral 0. 5 mg, 1 mg, 2 mg (once a day) Patches 25, 37. 5, 50, 75, 100 mcg (twice weekly) – below waist Gel/Pessary/Cream Progestogens - variable Mirena (20 mcg LNG/day) Natural progestogen (utrogestan) 100 or 200 mcg Testosterone (gel, cream) Implants no longer available in UK

HRT – Side effects Headaches Breast tenderness Fluid retention Bloating Nausea Mood swings

HRT – Contraindications Very few category of women Estrogen dependant malignant tumor ( Breast, Endometrial) Undiagnosed vaginal bleeding Current DVT/PE Pregnancy

HRT - Concerns Myths Increases Breast cancer risk Increases Coronary heart disease Published by Media widely in 2003 Is this true?

HRT – Risks Two studies in early 2000 Women's Health Initiative (WHI) Million Women study (MWS)

HRT – Risks Women's Health Initiative (WHI) USA (1993 -2002) 16600 women (50 -79) Average 63. 2, BMI 28. 5 Randomised HRT Vs Placebo Increase in Breast cancer and coronary events, stroke, DVT in HRT group Study stopped early in 2002 HRT in under 60 – Protective In over 70, not beneficial could be increased risk Risk is duration dependant, more risk with combined than for estrogen only. Million Women study (MWS) UK (1996 -2003) One million women attending NHS Breast screening clinic over 50 years old Questionnaire sent out Large number of drop outs Screening women are already high risk Study methodology has been criticised Oestrogen only increases risk of breast, womb and ovarian cancer Combined more risk than estrogen only

HRT – Risks ( Latest analysis) Breast cancer risk – 4 extra cases /1000 women after 5 years (This is less risk than smoking 10 cigs/day) 45/1000 – population risk 49/1000 – HRT (5 years) 51/1000 – HRT (10 years) Ovarian cancer – No increased risk Endometrial cancer – Adding progestogen decreases risk

HRT – Risks ( Latest analysis) Risk of heart disease not increased if started between 50 and 59 Stroke – not increased if started under 60. More risk with Smoke and Over weight Weight gain – RCT no evidence Osteoporosis – Useful more in Premature menopause, but not a first line for prevention in older Do not use HRT In Breast or Endometrial cancer, Stroke or DVT, Severe liver disease.

Alternative options Tibolone (Livial) – oestrogenic, progestogenic & androgenic properties SERM - Raloxifene SSRI/SNRI - Venlafaxine/Fluoxetine/Paroxetine Clonidine - not very effective Complementary - soya, red clover, black cohosh, evening primrose, acupuncture, homeotherap Insufficient data for safety & effectiveness Non –Pharmacological - CBT

Bio-identical Hormones Identical to those produced by body 17 – beta estradiol or Micronized progesterone Claimed to be safe than traditional hormones Same risk and benefit as traditional Not regulated Not enough evidence for safety Salivary hormones – not representative of serum levels

NICE Menopause – Diagnosis and Management Nov 2015

Diagnosis of perimenopause and menopause Challenge is to reduce the use of FSH in diagnosing perimenopause and menopause No periods for at least 12 months & not using hormonal contraception = menopause Women without uterus but has menopausal symptoms = menopause DO NOT use FSH test to diagnose menopause if on COCP or high dose progestogen Consider using FSH test as a diagnostic test for menopause: Age 40 -45 years with menopausal symptoms including irregular periods < age 40 with a suspicion of early onset of menopause

Diagnosis of perimenopause and menopause DO NOT use the following test to diagnose menopause > 45 years old Inhibin A and inhibin B Estradiol Anti-Mullerian hormone Antral follicle Ovarian volume

Vaginal oestrogens Can be used in HRT contraindicated women after expert advice Increase dose if needed after expert advice (Up to 5 times a week) Used along with vaginal lubricants and moisturisers

Altered sexual function v v v HRT If HRT alone not effective, consider testosterone supplementation In younger women where ovaries are absent, testosterone is considered.

HRT and Contraception Age 40 Women using HRT should not rely on this as contraception POP can be used with HRT to provide effective contraception (must be combine HRT) Can use oestrogen replacement therapy + MIRENA to provide endometrial protection

Women with, or at high risk of breast cancer v v v Give information on all treatment options Paroxetine and Fluoxetine should not be offered to patients with breast cancer on tamoxifen Refer for expert advice

Stopping HRT Advice regarding stopping HRT v v v 2 choices – gradually reducing or immediate cessation Gradually reducing HRT may reduce the recurrence of symptoms in the short term No difference of symptoms in long term

Case discussion

Case study 52 year old secondary school teacher No relevant medical history Always calm and organised Recently irritable and struggling to cope with minor challenges Exploited by school children of her weakness Unable to sleep, asking GP for more sleeping tablets

How to approach? Relevant history LMP 6/12 ago, before that 3/12 ago Night sweats with severe chills sometimes, occasional day time flushes Often wakes then sweats No interest in sex, often it hurts

What to do next? Explanation Information www. menopausematters. co. uk www. womens-health-concern. org. uk www. menopause-health-concern. org. uk www. daisynetwork. org. uk

What do we choose now? Sequential combined HRT Elleste duet 1 mg Estradiol 1 mg plus NET 1 mg from day 17 -28 NHS cost £ 9. 72 for 3 months

Review in 3 months Persistence of symptoms Any new symptoms/side effects? When do they occur in the cycle? Bleeding pattern BP Review of risk analysis

3 months later Symptoms and sleep better in the first 2 weeks of the pack Not so good and tearful when pill colour changes Bleeding is fine 2 - 3 days in to the new pack Would like to improve things

Modify treatment Increase estrogen Change progestogen preparation Femoston 2: 10 ( 17 B estradiol 2 mg plus 10 mg dydrogesterone) Cost £ 13. 47 for 3 months

HRT- Dilemmas More Case Discussions

Case 1 33 year old, Aplastic anemia ( when she was 25), had chemo, No periods for many years. Now, random periods, terrible menopausal symptoms

Case 1 - Discussion Possible Premature Ovarian Insufficiency Confirm with FSH Combined, sequential HRT until 51.

Case 2 52 years old, post Lap BSO for BRAC 2. On Tamoxifen for Chemo prevention of breast Cancer Low mood, tiredness, night sweats, Vaginal dryness, No sex drive Type 1 diabetic, high BMI, High BP

Case 2 - Discussion Clarify Tamoxifen HRT? If so what type?

Case 3 59 year old, police officer, been on HRT for 7 years. Trying to come off it. GP advised to stop. Severe symptoms. Back on it. Better now. Advised to come off it gradually. How?

Case 3 - Discussion How to stop HRT? Doses Choices

Case 4 For patients with endometriosis who had a TAH BSO Choice of HRT 36 year old, Had TAH+BSO, 2 years ago, HRT stopped after caution from pelvic pain. Want are the options?

Menopause clinic at NUH Service offered by Anita Juliana MBBS, MD, FRCOG Special interest in Menopause RCOG Accredited Started service at NUH from June 2015 Weekly clinic with Senior nurse support

What's on offer? Individually tailored advice, care and support 30 minutes minimum, sometimes longer Careful risk assessment Necessary investigations ( DEXA Scan, blood tests and scans when needed ) Life style advice, information leaflets/web info Clear plan of management and communication

Referrals Choose and Book Oncologists Gynaecologists Breast cancer service Family history clinics

Outside Menopause clinic NUH - Staff awareness sessions on Menopause Run quarterly, alternates both sites Tea party talks for BRCA positive patients Both are very well received and popular with high demand

We are partners in Women's health Think of Menopause service at NUH Safe, Reliable, Gold standard care

Feedback from our patients Finally, somebody listened to me Got my life back Excellent service All questions answered Put my mind at rest Very happy. . Took a long time to reach here. .

Questions?

Thank you