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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)
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.
About 75% of women experience
menopausal symptoms
Many women will suffer significant
symptoms for a significant amount
of time.
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.
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 ?
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
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