Dr Laura Patterson MBChB BA (Hons)

MRCGP Cert Med Ed DCH DFFP

Gloucestershire GP

Appraiser NHSE

Faculty registered Trainer FSRH

Fellowship Advisor PCTH

The menopause and HRT

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Learning Objectives

At the end of this session you will

Understand the menopause and perimenopause and the effect on women.

Have a broad understanding of HRT and how it is used

Understand how to guide women using local vaginal hormone replacement therapy

Be able to explain and guide ladies with regards to contraception during the

perimenopausal time.

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Opportunities to discuss menopause and

HRT

Contraceptive consultations

Smear consultations Especially when having a smear is uncomfortable for women

Ladies in there 40’s presenting with episodes of urinary symptoms

Ladies with recurrent thrush symptoms

Ladies in there 40’s presenting with multiple symptoms

Just while you are syringing ears !

1 in 4 women have perimenopausal / menopause symptoms and only 12 % of women receive HR

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What is the menopause

The last period !

For those having natural periods…..

1 year after your last period > 50 years and 2 years after your last period < 50

years

Average age is 51-52 years

For those using contraception or HRT it’s difficult to assess the last period

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Diagnosis of menopause

‘Normal menopause’ = 45-55 years of age

‘Early Menopause’ = 40-45 years of age

‘Primary Ovarian Insufficiency’ = < 40 years of age

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What is the peri-menopause

Perimenopause is the time leading up to the menopause

Its also known as the ‘climacteric’

Can be months to years

Accompanied by menopausal symptoms relating to fluctuating hormones

levels

Can be asymptomatic

Characterized also by changes in periods (shorter, longer, heavier, closer

together, further apart)

These ladies still need contraception

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Symptoms of the perimenopause

Hot flushes, night sweats

Changes in periods

Mood changes, anxiety

Hair and skin changes

Fatigue

Brain fog

Vaginal symptoms

Lack of libido

Memory problems

Poor sleep

Joint pains muscle aches

Dry eyes and mouth

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Menopause at work

Women over 50 years make up a larger part of the workforce than before

Women may have decreased performance because of symptoms

They may take time off

They may end of working part time

They may take early retirement

Guidance on ‘ menopause and the workplace’ from Faculty of Occupational

Medicine

ACAS has guidance on ‘menopause at work’ but this archived

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The Headlines

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Information and advice

Discussion of the perimenopause/menopause and managing any mis

information.

Menopause matters

Menopause doctor

Women’s health concern

Rock my menopause

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Lifestyle Management

Lifestyle advice is important

Offer support for smoking cessation, weight loss, diet and exercise

Many really benefit from just reduction in ETOH and caffeine.

Yoga and Thai Chi

Calcium and Vitamin D

Sleep and relaxation

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Alternatives to HRT

Isoflavones

Black cohosh

Red Clover

St John’s Wort

Natural progesterone creams

Bioidentical hormones

Preparations vary and there are many available

The safety of these preparations is uncertain

Interactions with other medicines has been reported

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Bio identical HRT

Plant based and marketed as a safe alternative

Unregulated product

Often given through private clinics

Often not enough progesterone in the product or the progesterone is given as

a cream

Do ask ladies if they are taking anything OTC or buying anything on line

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What is Hormone replacement therapy

HRT

HRT replaces hormones that are that naturally fall to a lower lover during the

perimenopausal time

The ovaries normally produce oestrogens, progesterone and testosterone

As you enter the perimenopause the ovaries start to produce less of these

hormones

Follicle stimulating hormone (FSH) form the pituitary gland works harder to

get the ovaries to produce more hormones. This FSH fluctuation is what

causes most of the symptom's women experience.

HRT consists of oestrogen and progesterone replacement

It might also consist of testosterone

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HRT Oestrogen

Hormone replacement therapy replaces the female hormone oestrogen which

is declining during the perimenopausal time

All ladies with hormonal symptoms of the menopause will need oestrogen in

some form to relieve their symptoms

Oestrogen comes as transdermal gel, spray or patch or as oral oestrogen

Oestrogen on its own does not increase the risk of breast cancer

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So which women need progesterone

Women with uterus

Need oestrogen and

progesterone

Women without uterus

Just need oestrogen

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How much progesterone ?

Half the time

Bleed version

Cyclical

Sequential

All the time

No bleed version

Continuous

Continuous combined

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How do we decide which regime of

progesterone to use ?

Menopause has fluctuating hormones levels

The hormonal fluctuations lead to an unstable endometrium

An unstable endometrium will bleed

We give bleed HRT to provide a predicable bleeding pattern

Women early in the menopause are more likely to have the huge hormone

swings and therefore benefit from bleed HRT

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When do we move from bleed HRT to no

bleed HRT ?

There is different guidance here

Some say aged 54 years or perhaps a year after the last period

Some say several years after starting HRT

We have already said it is safest to have continuous progesterone with

oestrogen

Its down to discussion with the women and some guess work

If you swap too early and the endometrium is not ready, they will just have

unpredictable bleeding

If the endometrium is not ready just swap back to bleed HRT for a bit longer.

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Vasomotor Symptoms

HRT is by far the best treatment for

vasomotor symptoms

SSRIs – like sertraline and citalopram

SNRIs- Like venlafexine

Clonodine

tamoxifen

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Psychological symptoms

HRT is recommended first line for anxiety and

mood symptoms associated with the menopause

Consider CBT also here to alleviate symptoms

No clear evidence for SSRI’s or SNRI’s to ease low

mood and anxiety in menopausal women that

have not been diagnosed with depression

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Genitourinary syndrome of the

menopause

Very common – about 80% of women going through the menopause

Vaginal soreness, dryness, burning

Urinary symptoms

Painful and sore sexual intercourse

Can be painful sitting down

1/3 do not seek medical advice

50 % have symptoms for three years before seeking advice

You will really help these ladies with a couple of weeks of oestrogen before there smears !

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Vaginal Lubricants

Provide short term relief of vaginal symptoms

Typically used before sex

Useful if only time women is aware of symptoms is during sex

Care as some oil based which may damage condoms

Can also be used with local oestrogenbut ideally at different times

KY Kelly or Astroglide/replens/sylk

Vaginal moisturisers

Once or twice a week and can be used on regular basis if they help

These attach to vaginal wall cells and help to retain water

They balance PH

Can be used with local oestrogen but preferably at a different time

Replens or Sylk

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Vaginal Oestrogen

Will restore the normal PH

Restore the vaginal tissues

Improve vaginal lubrication

Restore normal flora

Takes a few weeks to a few months for symptoms to settle

Creams pessaries gels and ring

No increase risk of breast cancer or endometrial cancer

No risk of DVT

Contraindicated in active breast cancer and also if on an aromatoase inhibitor

Contraindicated if undiagnosed vaginal bleeding

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Benefits of HRT

It Improves symptoms

It has potential health benefits

Cardiovascular system protection

Bone protection

It reduces all cause mortality

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Risks of HRT

Breast Cancer

DVT (sometimes)

Cardiovascular disease ( sometimes)

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Which HRT

Transdermal oestrogen is safest ( No VTE risk and probably

a lesser risk of breast cancer )

Mirena coil OR

Body identical micronized progesterone -Utogestran

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HRT patches

Patches should be applied to clean, dry, healthy intact skin

Avoid any contact between the fingers and the adhesive part of the patch

Each use rotate to a different part of the skin

Apply to the skin below the waist, most women use buttocks

Do not apply near or on the breast tissue

You can bath or shower with the patch on

If they have issues with the patch unsticking on exercise or swimming they

can use Tegaderm

If sticking is an issue try and different brand of patch or use the twice weekly

patch

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Oestrogen gel

Usually applied to the outer part of the upper arm or inner thigh

2 pumps is normal starting dose

If needs 4 pumps for symptoms split the dose between morning and evening

Avoid the breast tissue

Rubbing it in gently aids absorption

Let it dry before putting on clothes Takes about 5 minutes

Do not apply other products over it for one hour

Wash hands after use

Contact with a male partner should be avoided up to 1 hour after administration

There are 64 pumps in each pump pack

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HRT Spray Lenzetto

Apply to clean dry healthy skin

Apply to the inner forearm or inner thigh

Absorption is lower if applied to the abdomen

Do not apply to the breast area

Spray needs to dry to 2 minute

Common dose is between 1-3 sprays

Each spray delivers 56 sprays

Do not apply other products over until after 1 hour

Contact with a male partner should be avoided for one hour

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Mirena Coil

T shaped coil with 52 mg of levonorgestrel on its stem

Licensed for 4 years for the progesterone part of HRT

Accepted practice supported by FSRH to use for 5 years

Will also provide contraception for 5 years

Women will often be amenorrheic or have lighter less

regular bleeding

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Utrogestan

Micronised progesterone

Body identical

Tolerated better than other synthetic progesterone

Natural sedative and can make some women drowsy

Needs to be taken on an empty stomach

No increase risk of blood clot or heart disease

Risk of breast cancer is not increased in the first 5 years and thereafter is

very low

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HRT check

Initial check should be at 3 months and then annually thereafter

Review the treatments they are using and alleviation of symptoms (try the menopause symptoms questionnaire)

Ask specifically about vaginal dryness symptoms and bleeding pattern

Are they on the safest treatments

Any side effects

Any change in their medical history or medications that may impact on the HRT (safety, effectiveness etc)

BP (home readings are fine) and BMI is good practice

Make sure they are taking part in cervical screening and mammography

Check they have contraception if needed.

Remind them about lifestyle

Make sure HRT on repeat prescription

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Stopping HRT

The NICE guidance now states there is no maximum duration of HRT

If a women is benefiting from HRT she can stay on it

No upper age limit

Many women will have menopausal symptoms on stopping HRT

Older women may be ok on lower doses

Women can either stop immediately or reduce dosage slowly

Reducing the dose slowly helps the women assess whether her symptoms are

going to come back

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HRT IS NOT

CONTRCEPTION

Please think of them separately

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Contraception in the perimenopause

HRT is NOT contraception

Effective contraception is needed until the

menopause or until the age of 55 years

Contraception may mask menopausal symptoms

but will not change the onset or duration

Mirena coil will provide contraception AND

progesterone part of HRT (if changed every 5

years for the later)

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What of the other methods of

contraception

COCP until the age of 50 years cyclical or extended regime use with 20mcg (

instead of HRT)

POP up until the age of 55 years

Implant until the age of 55 years

Depo Provera/ Sayana Press until 50 years

All ladies can stop contraception at 55 years

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Further readings

British menopause society website

Fourteen fish course (1 course free to every GP in the practice)

NICE Guidance Menopause

NICE Guidance GUSM

https://www.acas.org.uk/archive/menopause-at-work

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References

https://www.nice.org.uk/guidance/ng23

https://www.menopausematters.co.uk/ (lots of adverts )

https://www.menopausedoctor.co.uk/

https://www.womens-health-concern.org/

https://www.rockmymenopause.com/

https://www.menopausedoctor.co.uk/news/menopause-symptom-sheet

Menopause doctor is part of Louise Newsom educationWomen’s health concern is the patient part of the British menopause societyRock my menopause is from the primary care women’s health forum

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