Elaine Stephens

Senior Menopause Clinical Nurse Specialist

June 2016

AHFSN160235

Date of Preparation: May 2016

Normal Physiological event.

Average age for Natural Menopause 48-

52years

Twelve Consecutive Months Amenorrhoea.

Can Result in Distressing Symptoms

Possible Long Term Health Implications

1900s

Age of menopause - 45 yrs.

Life expectancy - 45 yrs.

2014

Age of menopause - 51 yrs.

Life expectancy - 82 yrs.

> 30% life postmenopausal

1/3 UK pop’n >50yrs (Age UK 2014)

Age

Menstrual History

Oestrogen deficiency symptoms

Routine FSH measurements not needed

Nice 2015 recommendation Consider using a FSH test to diagnose

menopause

Only in women aged 40 to 45 years with

menopausal symptoms, including a change

in their menstrual cycle

In women aged under 40 years in whom

menopause is suspected.

May be a sudden event

Surgical Menopause , Removal of Ovaries

May happen much sooner than expected

Premature Menopause before 40 years

Premature Menopause PM

Premature Ovarian Failure POF

Premature Ovarian Dysfunction POD

Premature ovarian insufficiency POI

Terms are used interchangeably

debate over which term is best.

Take into account the woman’s clinical

history medical or surgical treatment and family history

important when diagnosing premature ovarian

insufficiency.

Diagnose premature ovarian insufficiency in

women aged under 40 years based on: menopausal symptoms, including no or infrequent periods

Elevated FSH levels on 2 blood samples taken

4–6 weeks apart.

FSH > 30 on both occasions

Menopausal Changes affect women in different ways Some experience few or no symptoms Others may experience moderate to severe symptoms.

Changes in the menstrual cycle prior to stopping Long term health implications particularly important in

women who have early menopause or those who have increased risks of heart disease or osteoporosis.

Can be a devastating event if early.

No medical treatment is required for many

women

Need to understand and respect a women's

views

Good opportunity for education regarding

healthy lifestyles, weight loss and exercise.

Offer choices according to needs.

Vasomotor Symptoms.

Psychological Symptoms

Urogenital Symptoms

Musculoskeletal Effects

Hot Flushes.

Night Sweats.

Headaches.

Low mood and Mood Changes

Tiredness

Irritability

Forgetfulness

Insomnia

Loss of Libido

Lethargy

Vaginal Dryness

Painful Intercourse

Vaginal Infections.

Urinary Frequency/Nocturia

Loss of Libido

Joint Pains

Stiffness

Acceleration of Bone Loss

About 75% of women experience

menopausal symptoms

Many women will suffer significant

symptoms for a significant amount

of time.

Osteoporosis

Heart Disease

Clin Endocrinol 1990. 33(51 653-682)

Attainment of peak

bone mass

Consolidation Age-related

bone loss

Males

Females

Fracture threshold

Menopause

0 10 20 30 40 50 60 70

Module 1 • Slide 18

Mosca et al. Arch Fam Med 2000.

Breast cancer

Cancer

Other problems

Cardiovascular disease

Don’t know/ no answer

34%

27%

16%

7%

16%

Figure 5: Percentage of deaths for the 10 leading causes of death for females, 2002 and 2012 England and Wales

Source: Office for National Statistics Notes:

1. The cause of death groups used here are based on a list developed by the WHO, modified for use in England and Wales (Griffiths et al, 2005).

2. Figures for 2002 are given for the top 10 causes of death in 2012 as a comparison.

120,000 women die due to CVD per year

12,000 women die due to breast cancer per

year

Existing medical history

Family History

Diet and lifestyle

Stressors culture and attitude

Work factors

support

How bad are the symptoms?

Will HRT help?

Is HRT safe for her?

How long will she need it?

Is there anything else that will help?

What are the possible consequences of not taking HRT ?

Lifestyle advice and changes

HRT

Prescribable Non HRT

OTC products

Alternative therapies

Normal age at menopause no significant symptoms of oestrogen deficiency.

Lifestyle advice

Normal age at menopause and symptomatic Lifestyle advice

HRT

OTC Preparations/Alternative therapies

Premature Menopause regardless of symptoms HRT(up to age 52)

Life style advice

Menopausal symptoms but HRT contra indicated Lifestyle advice

Non HRT Prescribable medication

Alternative therapies

Oestrogen deficiency symptoms. Poor quality of life.

Increased risk of osteoporosis

Increased risk of Cardiovascular disease.

Cognitive decline

Loss of fertility

Loss of fertility, loss of femininity.

Isolation from peer group

Loss of status, Majority of societies elevate the status of parenthood.

Rejection by partner

Concerns about long term health. Concerns about Hormone replacement therapy

especially if she has previous Cancer or has no menopausal symptoms.

Pre pubertal POF: To induce secondary sexual characteristics and development.

To relieve menopausal symptoms and improve quality of life.

To prevent long term consequences of oestrogen deficiency

To create an environment conductive to the successful replacement of embryos

Managing premature menopause

Offer sex steroid replacement with a choice of HRT or a combined hormonal contraceptive to women with premature ovarian insufficiency, unless contraindicated (for example, in women with hormone-sensitive cancer)

Explain to women with premature ovarian insufficiency:

The importance of starting hormonal treatment either with HRT or a combined hormonal contraceptive and continuing treatment until at least the age of natural menopause (unless contraindicated)

Managing premature ovarian insufficiency

Give women with premature ovarian insufficiency and contraindications to hormonal treatments advice, including on bone and cardiovascular health, and symptom management.

Consider referring women with premature ovarian insufficiency to healthcare professionals who have the relevant experience to help them manage all aspects of physical and psychosocial health related to their condition.

HRT should always be considered and

encouraged in the majority of POF cases.

HRT can be considered for peri or post

menopausal women presenting with

menopausal symptoms.

HRT may also be considered for the

prevention or treatment of Osteoporosis in

young women or those for whom other

Osteopororosis treatments are not suitable.

All women considering HRT use should be given a full risk / benefit profile appropriate to them individually.

Discuss and explain;

Menopause and symptoms

Impact of menopause on long term health

Types and routes of HRT therapy and side effects.

Realistic expectations of HRT therapy .

Lifestyle issues, impact on long term health and impact of menopause.

Alternatives/Complimentary therapies

Oestrogen dependent malignant tumours

Undiagnosed vaginal bleeding

Active or recent thromboembolic disease

Acute liver disease

Pregnancy

Caution starting in over 60s

There are almost no women who should be told that they can never have HRT

• Fibroids

• Uncontrolled hypertension

• Migraine

• Epilepsy

• Endometriosis

• VTE family history

Personalised risk / benefit profile

Realistic expectations

Realistic goals

Personal responsibility

Improved future health

Proven Benefits

Control of Menopausal Symptoms

Maintenance of BMD (bone mineral density) and

reduced risk osteoporotic fractures

Additonal Potential benefits Reduced risk of Coronary heart disease

Reduced risk of Colorectal Cancer.

Reduced risk Type 2 Diabetis Mellitis (DM)

.

Endometrial Cancer

Thrombosis DVT/PE

Coronary heart disease

Stroke

Breast Cancer

Increased incidence Gallbladder disease

Endometrial Cancer

Thrombosis DVT/PE

Coronary heart disease

Stroke

Breast Cancer

Increased incidence Gallbladder disease

The baseline risk of breast cancer for women around menopausal age varies from one woman to another according to the presence of underlying risk factors

HRT with oestrogen alone is associated with little or no change in the risk of breast cancer

HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer

Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT.

Individual baseline risk

No increased CVD when HRT started under 60

Does not effect risk of dying from CVD

Presence of risk factors is not a C/I

E alone-no or reduced risk CHD

E + P-little or no increased risk CHD

Oral but not transdermal-small increased risk stroke (baseline population risk small under age 60)

Per 100 women using any HRT for at least 10 years

19 fewer CHD deaths

7 fewer stroke deaths

mikkolaTS,TuomikoskiP,lyytinenH et al.Estradiol-basedpostmenopausalhormone therapyand risk of cardiovascularand all cause mortality.Menopause 2015 Mar 23

Systemic or local therapy

Estrogen only or combined therapy

Cyclical or continuous combined therapy

Oral, transdermal, subcutaneous or

intrauterine

Tablets Patches Gels Implants, Vaginal

preparations.

Which Regimen?

Hysterectomised

Intact Uterus

Unopposed

oestrogen

Perimenopausal

LMP < 1 yr

Postmenopausal

LMP > 1yr or 54yrs

Sequential Combined

Therapy (SCT)

Continuous

Combined (CCT) or

Gonadomimetic

Guidelines Northwick Park 2010 - Adapted.

Ovarian

conservation

Bilateral salpingo-

oophorectomy

Unopposed oestrogen

Consider Testosterone

Systemic therapy will be required for women

who present with a wide range of symptoms.

Local therapy may be needed in addition to

systemic therapy or as stand alone. To treat

vaginal symptoms

No/minimal systemic absorption/side effects

Exerts local effect on vagina and urethra, treats vaginal dryness dyspareunia, may help urinary symptoms of urgency and recurrent UTIs

Cyclical progestogens unnecessary.

May be acceptable when systemic estrogens are contraindicated.

Some products with long term use license.

Creams Tablets Rings

Vaginal Moisturizers Replens available on prescription. Can be used

as and when required for vaginal dryness. Water based product

Hyalofemme

Regelle

Vaginal Lubricants Astroglide, Sylk, Yes, used at time of sexual

activity as a lubricant. Safe to use on partner too !

Oestrogen component required for

symptom relief.

Progestogen component primarily for

protection of the endometrium.

Exceptions ?

Cyclical Therapy also known as Sequential therapy.

Needed for Peri menopausal women who still have a menstrual cycle. Monthly or three monthly regimens available

Progestogens given for 12-14 days of each cycle for monthly bleed and are most often mixed with estrogen within one tablet.

Withdrawal bleed in response to progestogens.

Suitable for post menopausal women 12

months since last menstrual period

Age 53-54yrs

Daily dose of estrogen and progestogen

Maintains an atrophic endometrium Consider changing to continuous combined

to reduce risk of endometrial cancer after 5 yrs of cyclical therapy.

CHC can be prescribed for young women with

premature ovarian dysfunction.

Controls menopausal symptoms.

Protects against long term health issues from

oestrogen deficiency.

Offers Contraception.

Free.

In keeping with peers.

www.womens-health-concern.org

www.menopausematters.co.uk

www.patient.co.uk

www.daisynetwork.org.uk

Individual women need individual

assessment and individual treatment.

Informed Choice

Thank you