MHT is the most effective treatment for vasomotor symptoms and urogenital symptoms
The impact of symptoms on quality of life is an important decision
Diagnosing
DO NOT
Check FSH, LH, oestradiol or testosterone levels in a woman with symptoms at the normal age of menopause (over 45 years) because these results are unlikely to change your management
The indications for intervention are clinical
Management
Great website for patient information is Jean Hailes
Lifestyle modification
Dietary supplementation
Hormone Replacement Therapy
“Alternative Therapies”
Initiation of HRT
Does the patient have an intact uterus?
Yes
How long has it been since their last period?
Less than 12-18 months
Peri-menopausal patient with an intact uterus
Cyclical MHT, switch to continuous therapy at around 12 months
Requiring contraception
Low dose COCP
Vaginal Contraceptive ring
LNG IUD + oral or topical oestrogen
Cyclic HRT + barrier method
Not requiring contraception
Not requiring contraception
Combined OCP
Cyclic MRT
LNG IUD + oral
More than 12-18 months
Continuous combined hormone treatment
Tibolone
No
Oestrogen therapy alone
Endometriosis is a different matter – may do better with some pregesterone as well
Benefits
Decreased risk of
OP / fractures
Heart disease
Endometrial cancer
Colorectal cancer
T2DM
Cataracts
Symptoms relief / improved quality of life
Risks
Thrombosis
Stroke
Gall stones (oral oestrogen)
Endometrial cancer (if given oestrogen alone with intact uterus)
Breast cancer – 1 extra case per 1,000 women treated using MHT per year
Breast cancer and MHT
Not taking HRT = 3 in 1,000 risk/yr
Taking MHT for >5 years = 4 in 1,000 risk/yr
After 5 years of stopping MHT the increased risk is lost
Bigger risk factors than MHT include
2+ Standard Drinks of alcohol/day
Being overweight or obese
Having first child when >35 years of age
Menopause in your late 50’s
Contraindications
Breast cancer
Osterogen dependent cancers
Undiagnosed vaginal bleeding
Current thrombosis
Thrombophilia
Untreated hypertension
Acute liver disease
CVD
When to stop
There is no set time
Mean duration of menopause is 8 years
20-25% of women may still experience symptoms into 60’s and 70’s
10% will still experience symptoms for 10yrs+
Ongoing use should be reviewed yearly
If premature menopause – continue until 50yrs
Additional non hormonal options?
Black Cohosh
Phytoestrogens
Low dose SSRI
Clonidine
High dose progestogens
Pregabalin, Gabapentin
Alternative therapies
Hypnosis
Limited number of studies may be of benefit in sleep and hot flushes
Acupuncture
Small numbers of studies with mixed results
Vitamin E
No benefit in women with breast cancer
Evening Primrose Oil
Small numbers of studies with results showing no benefit
Black Cohosh
Recent review concluded insufficient evidence to support use for hot flushes
Phytoestrogens
Possible small effect on hot flushes, varied evidence and no good long term studies – but good for cardiovascular health!
Wild Yam cream
Limited data, probably not beneficial on current evidence
Bio-identical hormones – these are NOT Body Identical HRT
Combinations of hormones in a troch (lozenge)
Manufactured in compounding pharmacies
Not approved for use in Australia by TGA
Medico-legal indemnity questionable
Minimal data on safety or efficacy
Some concerns regarding endometrial carcinoma
Expensive, marketing is misleading
Testosterone
No clear definition of female androgen deficiency, no single blood test to make diagnosis
Several studies have demonstrated improved sexual satisfaction and wellbeing with premonopausal and postmenopausal treatment with testosterone.
Not approved for use in women in Australia
Need to monitor rigorously
Ask for advice and look at the research before prescribing
MBBS, BBioMedSci(Hons), DipParamedSc(Ambulance).
Kane is a father, husband, nerd and all round nice guy. He founded several Meducation sites, including Critically Caring, Ward Ready and of course Generally Practicing. In his spare time he enjoys playing with his son, wife and two greyhounds. He lives in Mildura, Victoria, Australia and is passionate about online medical education platforms.
