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Management of menopause

Management of menopause. OS Tang Department of Obstetrics and Gynaecology University of Hong Kong. Climacteric. The phase in the aging process of women marking the transition from the reproductive stage of life to the non-reproductive stage. Menopause.

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Management of menopause

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  1. Management of menopause OS Tang Department of Obstetrics and Gynaecology University of Hong Kong

  2. Climacteric The phase in the aging process of women marking the transition from the reproductive stage of life to the non-reproductive stage

  3. Menopause The final menstrual period and occurs during the climacteric. The average age of menopause is 51.

  4. Life expectancy and age of menopause

  5. Menopause • Premature menopause • Surgical menopause • Natural menopause

  6. Target organs of oestrogen • Bone • Urogenital • Vasomotor • Heart • Eyes • Teeth • Breast • Colon

  7. Consequences of oestrogen loss

  8. Menopausal symptoms • Vasomotor symptoms: hot flushes, night sweats and palpitation • Urogenital atrophy: vaginal dryness, dyspareunia, pruritus vulvae, urinary frequency, urgency, and recurrent cystitis • Psychological symptoms: irritability, nervousness, depression, insomnia and anxiety

  9. Osteoporosis • Oestrogen deficiency • Peak bone mass at 30-35 years old • Bone loss at a rate of 0.5-1% per year afterward • Bone loss at a rate of 2-3% per year for 10 years after menopause • Osteoporosis is associated with fracture ( femoral neck, vertebral body and distal radius)

  10. Risk factors of osteoporosis • Family history • Ethnicity • Early menopause • Hypoestrogenism (excessive exercise, anorexia, bulimia) • Hyperthyroidism, excessive thyroxine therapy • Cigarette smoking • Caffeine • High alcohol intake

  11. Cardiovascular disease • Rapid increase in mortality and morbidity from cardiovascular disease after menopause • Epidemiological evidence suggests that HRT is associated with 50% reduction in cardiovascular risk in menopausal women • There is no prospective randomised data to show that HRT is effective in the primary prevention of cardiovascular disease.

  12. Management of menopause • Advise on a healthy life style • Psychological support • Hormone replacement therapy

  13. Management of menopausal symptoms • Understand menopause • Strengthening of self-image • Avoid spicy food, alcohol, strong tea and coffee. • Healthy life style • Hormone Replacement Therapy

  14. Prevention of osteoporosis • Change lifestyle risk factors • Exercise • Adequate calcium / vitamin D intake • Hormone Replacement Therapy • Alendronate • Raloxifene

  15. Prevention of cardiovascular disease • Healthy life style • Diet • Avoid smoking • Control of hypertension, diabetic and hyperlipidaemia • ?Hormone Replacement Therapy (Not effective for secondary prevention. ? Primary prevention)

  16. Possible mechanism of cardioprotection by HRT • Favourable lipid profile:  HDL,  LDL,  Lipoprotein (a) • Other effects:  insulin sensitivity, vascular dilatation,  coagulation factors

  17. Hormone replacement therapy • Informed choice • Risks and benefits of taking HRT • Role of doctor: weighing up the pros and cons for individual woman

  18. Prescribing HRT

  19. Indications for HRT • Relief of menopausal symptoms • Long term prevention of osteoporosis

  20. Absolute contraindications

  21. Absolute contraindications • Existing breast cancer • Existing endometrial cancer • Venous thrombo-embolism • Acute liver disease

  22. Routes of administration of oestrogen • Oral • Transdermal • Implants • Local vaginal preparation

  23. Oral therapy • Natural occurring oestrogens: includespremarin and various oestradiol preparations. These oestrogens are metabolised in the liver to the weaker metabolite oestrone and then converted to oestradiol in the peripheral circulation and in the target tissue. • Tibolone: a steroid hormone that has oestrogenic, progestogenic and androgenic properties. • Synthetic oestrogens: such as mestranol or ethinyl oestrodiol are not generally prescribed for older women for HRT.

  24. Transdermal therapy • Patches (oestrogen only or combined preparation) or oestrogen gels • Women’s preference • Skin irritation may be a problem but new matrix patches and the gels are usually well tolerated • Route of choice for women with risk factors for venous thrombo-embolism, liver disease or gastro-intestinal problems

  25. Oestrogen implants • Now less widely used • Implants should be given no more than every 6 months • Not commonly used in HK

  26. Local vaginal therapy • Useful for local vaginal dryness and symptoms of urgency • Contraindication to systemic HRT but require oestrogen for local symptoms

  27. HRT regimens • Women who have had a hysterectomy only need to take oestrogen • Women with an intact uterus must take progestogen for endometrial protection to prevent endometrial cancer or hyperplasia • Regular surveillance of endometrium is required for women (extreme intolerance of progestogen) on unopposed oestrogen

  28. The Hong Kong College of Obstetricians and Gynaecologists

  29. HRT regimens • Sequential preparation: progestogen added for 12-14 days each month. Some women will not bleed on sequential preparations and this is not a cause for concern provided that the progestogen is taken correctly. • Continuous combined HRT: give oestrogen and progestogen daily. These preparation induces endometrial atrophy. Intermittent bleeding and spotting are common in the first few month of use. More suitable for women who are at least one year since their last spontaneous period.

  30. Progestogen • Oral or transdermal form • Levo-norgestrel releasing intra-uterine system

  31. Oral progestogens • C21 progesterone derivatives : dydrogesterone or medroxyprogesterone acetate • C19 nor-testosterone derivatives: norethisterone acetate or levonorgestrel

  32. Side effects of HRT • Nausea • breast pain • heavy or painful withdrawal period • premenstrual syndrome type of side effects • weight gain

  33. Risk of HRT • Breast cancer • Thrombo-embolism

  34. HRT and breast cancer

  35. HRT and breast cancer • Breast cancer is a hormone dependent cancer and its relationship with HRT is a complex one. • The chance of a woman developing breast cancer is 1 in 24 in HK

  36. HRT and breast cancer • No data from randomised trial of any significant size • The Collaborative Group on Hormonal Factors in Breast Cancer reported in Lancet in 1997 is now widely accepted to represent the present situation.

  37. Findings of the Collaborative Group on Hormonal Factors in breast cancer Collaborative Group on Hormone Factors in Breast Cancer Lancet 1997;350:1047-59

  38. For women aged 50-70 years not using HRT, about 45 in every 1000 will have breast cancer diagnosed over the next 20 years. Collaborative Group on Hormone Factors in Breast Cancer Lancet 1997;350:1047-59

  39. The extra risk of developing breast cancer on HRT does not persist beyond about 5 years after stopping treatment. • Women taking HRT diagnosed with breast cancer are less likely to have tumours with metastatic spread and therefore have an improved prognosis. • Regular mammography is indicated for women on HRT after 50 years old. • There is no indication to arrange mammography routinely for women commencing HRT under the age of 50 years.

  40. HRT and venous thrombo-embolism

  41. HRT and venous thrombo-embolism • Natural oestrogens • Women taking HRT have a 2-4 fold increase in risk of venous thrombo-embolism (VTE). • Overall risk remain small: 1 in 5000 and mortality from VTE is around 1-2%. • Women with significant past history of VTE should have a thrombophilia screen before commercing HRT

  42. Duration of treatment

  43. Indication of HRT

  44. Menopausal symptoms • Duration of treatment will depend upon the women’s preference and the presence of risk factors • In the absence of risk factors, HRT can be stopped after 2 years

  45. Prevention of Osteoporosis • 10 years after HRT has been stopped, bone density and fracture risk are similar in women who had used HRT and those have not • Long term treatment (>10-15 years) is required to prevent osteoporosis • Constant reassessment (general health, risk factors and life expectancy) is required.

  46. Monitoring of women on HRT • Compliance of treatment, symptoms control, side effects and bleeding pattern • Cervical smear

  47. Monitoring of women on HRT Recommendation by the Hong Kong College of Obstetricians and Gynaecologists

  48. Bleeding pattern

  49. Management of irregular bleeding • Sequential regimen: bleeding should occur at around the time of progestogen withdrawal (on or after day 11). Bleeding occurs at other time or persistent irregular bleeding should be investigated. • Continuous combined regimen: amenorrhoea should be achieved 4 months after start of treatment. Spotting during the first few months is common. Spotting which occurs after a period of amenorrhoea should be investigated.

  50. Other options for management of menopausal symptoms and prevention of osteoporosis

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