menopause and hormonal replacement treatment

Women now adays tend to live longer in their menopause years than ever before. thus management of their gynaecology and other health issues are of paramount importance to practicing clinicians. adding to the difficulty in management of their health issues are the controversies and dilemmas that surround menopause and hormone therapy. specially with the increased risk of certain cancers.
starting hormone therapy needs carefull assessment of the risk and benefits comparison and should be well discussed with the patient.
on the other hand alternative treatment options are also gaining much popularity in the management of common troublesome symptoms of menopause. this presentation in tends to discuss these issues that surrounds menopause and its treatment options.

1. Menopause and Hormone Replacement T herapy Dr Chandana Jayasundara MBBS, MD( Obs and Gyn ), MRCOG( UK ) Consultant Obstetrician and Gynaecologist Base Hospital, Bibile

2. Introduction The term menopause is derived from the greek menos (month) and pauses (cessation) Average age of menopause has not changed for years but the life expectancy has increased enormously. Life expectancy in roman times were 29 yrs Want mejority now will spend 1/3 of their lives in menopause.

3. Pathophysiology Primodial follicles decline drastically prior to menopause Towards menopause Progesterone levels decline but oestrogen levels des not decline as quickly. This result in DUB Oestrogen (E) levels decline dramatically at the menopause and menstruation ceases. It is the lack of E that causes the majority of symptoms and pathology of menopause.

4. Consequence of menopause Immediate Seventy percent of Caucasians and Afro- Caribbeans suffer from hot flushes and sweats It is thought that noradrenaline and serotonin mediate this activity Obese women are protected from these symptoms due to their production of large amounts of oestrone Other typical immediate menopausal symptoms include insomnia, anxiety, irritability, memory loss, tiredness and poor concentration. Perimenopausal depression can be due to various reasons The menopause transition can also be associated with a significant reduction in sexuality and libido Loss of lubrication Reduction in androgen levels

5. Intermediate Oestrogen deficiency leads to the rapid loss of collagen which contributes to the generalized atrophy In genital tract this will cause dyspareunia and vaginal bleeding from fragile atrophic skin. There is loss of rugations and occasionally stenosis . In the lower urinary tract, atrophy of the urethral epithelium occurs resulting in dysuria , urgency and frequency, commonly termed the urethral syndrome. A similar loss of collagen from ligaments and joints may cause many of the generalized aches and pains.

6. Long term Osteoporosis This is a disorder of the bone matrix resulting in a reduction of bone strength There is a significant increased risk of fracture. This is due to excess of bone resorption relative to formation Women lose 50% of their skeleton by the age of 70 years, but men only lose 25% by the age of 90 years.

7. CARDIOVASCULAR Women are protected against cardiovascular disease before the menopause After menopause the incidence rapidly increases reaching a similar frequency to men by the age of 70 years There is a rapid increase in CV morbidity and mortality after menopause. In post menopausal women the HDL/LDL ratio becomes much closer to male ratio. E may well have a direct effect on vessel wall But the WHI trial showed a increase in CV event in HRT group

8. CNS Oestrogen also appears to have a direct effect on the vasculature of the central nervous system and promotes neuronal growth and neurotransmission In the long term this may prevent diseases with a vascular aetiology such as vascular dementia and Alzheimer’s

9. Patient assessment Clinical history of hot flushes and night sweats is reliable and enough If in doubt a repeated FSH level above 15nmol/l will confirm the diagnosis Once diagnosis made annual checking of Weight Blood pressure Routine cervical cytology Lipid profile Mammography and endometrial biopsy done if indicated

10. Therapeutic options HRT = oestregen (E) Dose There is general agreement now that patients should be started on the minimum effective dose of oestradiol lower doses of oestrogen are less likely to produce breast tenderness and bleeding problems Route of administration Oral Patches Intranasal Trans dermal gel Silicone ring

11. Local ( vaginal ) oestrogen This avoids the problem of endometrial stimulation These preparations can be used without progestogenic opposition but are only licensed for 3 months use PROGESTOGEN/PROGESTERONE Regimen Oestrogen was originally used unopposed in non hysterectomized women. It was noted that this led to endometrial hyperplasia in up to 30% of cases Progestogen has therefore been added to oestrogen therapy It is generally accepted that women commencing HRT should start on a sequential regimen, that is, continuous oestrogen with progestogen for 12 to 14 days per month.

12. Bleeding problems with HRT If bleeding is heavy or erratic the dose of progestogen can be doubled or duration increased to 21 days. Persistent bleeding warrant investigation with ultrasound scan and endometrial biopsy After 1 year of therapy women can switch to a continuous combined regimen which aims to give a bleed free HRT regimen Progesterone intolerance Main cause discontinuation Symptoms of fluid retention Androgenic side effects such as acne and hirsuitism Mood swings and PMS-like side effects

13. THE HRT CONTROVERSY Breast The data from the WHI study suggested an excess risk of breast cancer with combined hormone therapy of 4 cases per 1000 women after 5 years. The MWS showed a RR of 1.66 for breast cancer compared to non users ( E only 1.3 and E and P= 2.0) The press reported this as doubling the risk but actual numbers were 1.5 additional cases in E alone and 6 additional cases per 1000 in E and P. CVS Its not proven to reduce the incidence of CV disease, in fact it may increase the risk if started late after menopause

14. Dementia HRT has not proven to reduce the risk of alzeimers or dementia. Endometrial cancer Increased risk with Oestregon only preparations, Reduced risk with continuous combined preparations. Venous thromboembolism It is clear from studies including HERS and WHI that there is a two to three fold increase in risk of venous thromboembolism (VTE) with oral HRT with the greatest risk occurring in the first year of use

15. Osteoporosis HRT prevents against hip and spine fractures. Colorectal cancer HRT reduces the risk of colorectal cancer.

16. Contraindications for HRT Coronary heart disease, Stroke Venous thromboembolism Past Breast Cancer Past endometrial cancer Fibroids may increase Endometriosis may recur in 4%

17. OFFICIAL PRESCRIBING ADVICE Medicine’s and Healthcare Products Regulatory Agency (MHRA) It is recommended that HRT be used merely for symptom relief in the short term at the lowest effective dose and alternatives should be considered in the long term for prevention of osteoporosis.

18. Symptoms Hot flushes Night sweats Headaches Depression, lack of concentration and energy Hot flushes are the commonest and may last from 1 yr to even 5 yrs. Depression may be pathological so may need psychiatric evaluation Loss of reproductive potential, lack of feminity , empty nest syn , sex problems.

19. Alternatives for HRT Non of which has proven benefit and if at all the benefit is minimal Lifestyle measures There is some evidence that women who are more active tend to suffer less from the symptoms of the menopause The best activity is aerobic sustained regular exercise Avoidance or reduction of intake of alcohol and caffeine can reduce the severity and frequency of vasomotor symptoms

20. Non-pharmacological alternatives GELS FOR VAGINAL SYMPTOMS, E.G. REPLENS Pharmacological alternatives PROGESTOGENS ALPHA 2 AGONISTS = Clonidine BETA BLOCKERS SELECTIVE SEROTONIN REUPTAKE INHIBITORS SSRIS/SELECTIVE NORADRENALINE REUPTAKE INHIBITORS (SNRIS) GABAPENTIN

21. Complementary therapies PHYTOESTROGENS The most important groups are called isoflavones and lignans Isoflavones are found in soybeans, chick peas, red clover and probably other legumes (beans and peas). Oilseeds such as flaxseed are rich in lignans , and they are also found in cereal bran, whole cereals, vegetables, legumes and fruit Soy Red clover Black cohosh Evening primrose oil Dong quai Ginkgo biloba St John’s Wort VITAMINS AND MINERALS HOMEOPATHY ACUPUNCTURE