What is the menopause?

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1 Dr Robyn Leake

2 What is the menopause? Permanent cessation of ovarian production of follicles and female hormones Clinically no periods for 12 months Can be assessed by day 2 FSH and LH Perimenopause is harder to define That time leading up to the menopause when ovarian activity is less dependable/more erratic. (average 4 yrs)

3

4 When can I stop the pill, doctor? Suggest FSH and LH on day 7 of the placebo pills. If they have risen, stay off pill and repeat in a month. Use other methods meanwhile. Mirena don t rush to remove may be useful beyond contraception If in doubt, put another Mirena in.

5 Peri-menopausal cycles may be: heavier (higher estrogen surges) lighter (less estrogen) closer together, (luteal phase defect) further apart (delayed ovulation) There may be episodes of menopausal Sx Breast tenderness, PMS, headaches can worsen.

6 The challenges of perimenopause. Hormones go on a rollercoaster ride. Ups are usually ok

7 but the downs really suck Some cycles might be relatively normal while others aren t The unpredictability upsets women

8 When oestrogen is low Hot flushes Insomnia Vaginal atrophy Irritable bladder, UTIs Cognitive disturbance Aches and pains Anxiety, depression, new or recurrence of Skin sensation changes

9 7 dwarves of menopause

10 Fuzzy headedness Not being able to find words, forgetting names, not being as sharp as usual

11 Misplacing things And finding them again

12 Middleaged spread As female hormones diminish, fat distribution tends to be more male Metabolism slows.

13 Does HRT cause weight gain? No, being 50 does. Studies comparing 50 yr olds on HRT vs placebo most gained weight. HRT may keep the distribution more female in type, but studies conflict.

14 Bedroom dramas Bedclothes on, bedclothes off. Bedclothes sopping wet Poor libido Vaginal dryness

15 Sleep disturbance May be unrelated to flushes, though flushes are more common at night Occurs in 30-40% of patients Don t forget sleep apnoea and depression

16 Vaginal symptoms Dryness, itch, poor lubrication, dyspareunia UTIs or urgency without infection Often self-treated as thrush BUT topical estrogens can predispose to Candidiasis Appearance in post-menopausal patients differs, so do a swab if in doubt Good quality lubricants Sylk, Pjur, Wet Stuff

17 What if they don t respond? Vaginal atrophy is exquisitely sensitive to estrogen replacement SO consider - dermatitis, lichen sclerosus, inflammatory vaginosis in non-responders Sometimes low dose systemic therapy penetrates poorly. Symptoms of menopause don t really affect the labia minora much, and the labia majora at all, so if these are the problem, reconsider your diagnosis.

18 Hot flushes Occur in 80% patients, trouble approx30% May be accompanied by anxiety, chills and palpitations Most stop within 5 yrs 9% have them indefinitely

19 Hot flushes cont. Worse in smokers Worse in obese pts Don t occur in Turner s syndrome (need exposure to estrogen to miss it) Respond well to estrogen replacement 50mcg patch or 1mg estradiol, but may respond to less

20 Mood disturbance Depression and anxiety may recur or occur for the first time in the perimenopause Sometimes difficult to know whether to use HRT, antidepressants or both.

21 Other symptoms Joint aches and pains Breast tenderness in perimenopause Pre-menstrual migraines in perimenopause.

22 How to manage all that? Lifestyle factors - important Medications

23 What helps? Breast tenderness evening primrose oil, flaxseed oil, tamoxifen, pill Migraines suppress cycle with pill, add estrogen when it seems to be missing, use antimigraine drugs like Imigran, avoid other triggers such as alcohol, caffeine, chocolate (OMG)

24 Exercise Good for flushes Good for bones Good for brain Good for heart Reduces risk of cancers incl breast cancer What s not to love?

25 Menstrual disturbance Complicated. Periods will not be suppressed by HRT, so best not used at this stage for this problem. Low/normal dose pill or Nuva ring is safe for low risk women Mirena marvellous for periods, but not hormonal Sx Intermenstrual bleeding, new onset of menorrhagia or dysmenorrhoea should not be blamed on perimenopause or menopause and need Ix. Remember to check for thyroid dysfunction

26 Hot flushes Respond to estradiol 1mg or 50mcg patch May respond to lower doses Progestins may also help some women

27 Hot flushes cont What about those who absolutely cannot have estrogen? SSRIs such as venlafaxine. Work well but evidence suggests not sustained long term. Great if anxiety/depression are present. Some SSRIs interact with tamoxifen, so beware. Venlafaxine and citalopram best. Clonidine limited by drowsiness. 0.1mg daily Gabapentin limited by cost and initial drowsiness. Best dose 900mg daily (but can start lower) The menopause after cancer clinic at KEMH is a great resource (and the menopause clinic, too)

28 Treatment resistant hot flushes Consider hepatic interactions Measure serum levels if in doubt about absorption May need to stop then restart (esp with implants) Tachyphylaxis esp w implants Other causes malignancy, SSRIs, neurendocrine tumours, pheochromocytoma, hyperthyroidism

29 Sleep disturbance Exercise helps (not too close to bedtime) Cognitive behavioural techniques Address any exacerbating factors such as anxiety or depression Beware sleep apnoea Responds very well to estrogen replacement

30 Vaginal dryness May start before periods cease. Loss of elasticity combined with lack of lubrication can result in pain. Lack of estrogen in the urethra may predispose to UTIs. Vaginal estrogen is safe and effective Use Ovestin if previous breast cancer, consult with oncologist.

31 Who needs HRT? Women whose symptoms cannot be adequately controlled by lifestyle measures AND whose symptoms are distressing to them Each woman needs to weigh up the risks and benefits as they apply to her Use a dose that works Review regularly and discuss cessation.

32 What about those big studies? Examined whether HRT given to healthy women for the prevention of heart disease was worthwhile Mean age of patients was >60 There was an excess of heart disease, stroke VTE and breast cancer in these studies. Women in their 40s and 50s seeking relief of menopausal symptoms are a different group. Nevertheless, the suggestion is that combined therapy be limited to 5yrs of use, or less

33 What are the advantages of estrogen given on its own? Greatly reduces bone mineral resorption Markedly improves menopausal symptoms Reduces slightly colon cancer Slightly reduces/neutral to breast cancer. Often helps vaginal/bladder symptoms Helps keep blood vessels healthy in healthy women if given at the commencement of menopause.

34 What about e2 + progesterone? Still good for bones Still helps menopausal symptoms Reduces risk of uterine cancer Increases risk of breast cancer Not as good for bladder irritability, still helps reduce UTIs Still helps vaginal atrophy Not as good for cholesterol/vessels

35 The Risks: for women in 50s Not as much data avail as the WHI cohort were older Lower risk of CHD (0.9/1000 EP, 3.8/1000 E 5yrs use) Lower overall mortality (5/1000 5yrs use) Less fractures (5-6/1000 5yrs use) LESS breast cancer (1.5/1000 in E 5yrs use) MORE breast cancer (6.8/1000 EP 5yrs use) Less Type 2 diabetes (11/1000 5yrs use) Less colorectal cancer (1.2/1000 EP only) More strokes (1/1000 ).?less w transdermal route

36 The risks cont Increased VTE 5/1000 EP, 2/1000 E 5yrs use Possibly more gallstones Since the studies above, further studies of young women starting HRT in their 40s suggest no increased risk of heart disease and stroke.

37 Tibolone Good for flushes, bones, libido, vaginal symptoms Increased risk of stroke Doesn t stimulate endometrium Same risk of breast cancer as estrogen and progesterone in combination.

38 Vaginal therapy Useful for symptoms of atrophy and for recurrent UTIs Little systemic absorption (but not nil) Most relevant for women with breast cancer. Discuss with oncologist Generally safe (esp Ovestin) for women at low risk of recurrence who are not on aromatase inhibitors/tamoxifen.

39 Cases Anne, 48, presents with worsening PMS, breast tenderness, premenstrual headaches, poor sleep. Periods are still regular, heavier. Wonders if it is the menopause. What to do? Investigations? Mx options?

40 Anne Probably perimenopause with no added extras. Consider TSH Consider U/S Options include low or usual dose COCP, Nuvaring Exercise, fish oil, may help. If unwilling/unable to take estrogen Mirena +/- SSRI, triptans, evening primrose oil.

41 Emma 45 yr old woman with past history of hysterectomy for adenomyosis. Known to have severe endometriosis as well, controlled with Provera post-hysterectomy. Now having hot flushes, poor sleep. Mother and grandmother osteoporosis Options?

42 Emma cont Is at risk of endometriosis recurrence Need to either continue the Provera or use tibolone to avoid that Small risk of endometrioid adenocarcinoma as well, progesterone may protect

43 Jan 51 yrs Terrible symptoms Desperate for something despite family history of breast cancer. Options?

44 Jan cont. Lowest risk with estrogen alone, but with uterus must have endometrial protection Mirena plus estrogen a good choice Non-hormonal options such as SSRIs, gabapentin depending on Sx

45 Jackie 45 yrs old Sent in by husband to have hormones sorted out. Poor libido, dyspareunia Tearful, labile mood Still having periods, PMS prior, feels suicidal and homicidal prior to periods Headaches Poor sleep

46 Jackie cont Is this perimenopause or depression? Ask about diurnal mood variation, appetite, hair and skin changes, sleep pattern. Family history of mental illness? Probably benefit from lifestyle changes, counselling and probably SSRI. May not be much role for any hormonal therapy, though suppressing cycle might help.

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