1. Know how to make the diagnosis
Age 45-55, menstrual change, and symptoms predominately vasomotor indicate a menopause diagnosis, but abnormal thyroid function can mimic menopausal changes. If in doubt measure FSH and oestradiol levels. FSH levels may provide just a snapshot but are a snapshot in time, but a level over 30 IU/l supports a menopause diagnosis. Consider taking two FSH levels six weeks apart. For younger patients an ultrasound demonstrates follicular activity and endometrial thickness. Anti-Müllerian hormone is indicative of ovarian reserve at any time of the cycle.
2. Be aware of the treatment options
Lifestyle, dietary and exercise advice, as well as alcohol and smoking interventions, should be explored. Alternative and non-hormonal therapies may be considered but in the light of current evidence from the re-evaluation of WHI data, patients should be offered HRT for symptoms control.1,2 Absolute contraindications to hormone use are venous thromboembolic disorder, undiagnosed abnormal bleeding, recent stroke or cardiovascular events. A risk benefit assessment is mandatory.
3. Understand the various HRT options
Choose a combined preparation for any non-hysterectomised patients including subtotal hysterectomy. Sequential progestogen preparations are for perimenopausal patients – continuous combined (bleed free) is preferred for patients over 54 or with one to two years of amenorrhoea. Unscheduled bleeding is permitted for up to eight months after starting treatment, with bleeding becoming progressively lighter and less frequent. A variety of progestogens is available for ‘opposition’, including Mirena. For patients intolerant of C19 and C21 progestogens, consider micronised progestogen (utrogestone) which is now available in the UK and the additional benefit of drowsiness makes it a good option for sleep-disturbed patients.
4. Take into account the patient’s preferred route of administration
Patients usually have a preference, so ask them. Get to know one brand of oral and a transdermal therapy with a range of dosing. Thromboembolic events are not increased with transdermal preparations so are safest, and suitable for patients with GI problems.2 Some patches do not stick, can irritate sensitive skin and are more expensive. Gels are appealing but need time to dry and require a progestogen if uterus intact. Oestradiol implants are available again as Estrapel, but not on all hospital formularies.
5. Don’t forget to ask about vaginal dryness
50% of women have significant vaginal dryness some four years post-menopause and 25% have dyspareunia. Mucosa may be dry, dusky, hyperaemic or very pale. Exclude vaginal pathology such as lichen sclerosis and opportunistic infections which an atrophic vaginitis will facilitate. There is a range of vaginal moisturisers and lubricants available at pharmacies and adult shops, such as Ann Summers.
Lubricants facilitate intercourse and are used by inventive patients to improve warm up.
Moisturisers are safe and should be used regularly.
Consider local oestrogen replacement – insertable vaginal tablets in a 10µg format do not need progestogenic opposition.2,3 Absorption is negligible, after an initial peak, and they are best used long-term rather than short courses of higher dose therapy.
6. In premature ovarian failure, use HRT until the expected age of menopause
Around 1% of women have menopause before the age of 40, which in addition to symptoms impacts on sexuality and fertility. Long-term physiological sequelae include reduced life expectancy, doubling of cardiovascular events, risk of osteoporosis, Parkinson’s and effects on cognition and memory tests unless on HRT.4 These women should continue HRT until at least the expected age of menopause – some young patients are mistakenly taken off HRT after five years.4,5 ACOC with 12 weekly pill-free breaks is an option but conventional HRT is physiologically preferable.
7. Know the options for loss of libido
Consider and treat local vaginal symptoms – there is little point in improving libido if sex is painful. Make sure to adequately replace oestrogen, and consider psychosexual counselling too. If oestrogen is replete, the relationship is robust and if your patient is anorgasmic consider testosterone replacement, although this is trickier now testosterone patches are not available. Tibolone has androgenic activity – as well as progestogen and oestrogen as a gonadanomimetic – and is suitable for postmenopausal patients. Off-licence use of testosterone in the form of Testogel or Testim may be considered but dosing requires one seventh of a gel sachet per day and many GPs are reluctant to prescribe off-licence.
8. Watch out for osteoporosis
Bone density rapidly declines around the menopause – one in three women has an osteoporotic fracture in her lifetime. In women under 60, who do not have risk factors for heart disease, stroke, breast cancer or VTE, the best treatment is HRT (Endocrine Society Statement).2,5,6 Bisphosphonates and even denosumab are increasingly associated with fragility fractures, and effects of long acting drugs in young woman are of concern.
9. Women who have survived cancer need special consideration
Cancer survivors’ menopausal needs are delayed until the impact of the cancer treatments decline – patients do not recognise menopausal symptoms whilst they are trying to cope with the trauma of their cancer diagnosis. They benefit from attending a specialist clinic where lifestyle advice, alternative and non-hormonal therapies are on offer. HRT is safe and should be considered for cervical, most ovarian, and early endometrial cancers. Most breast cancers are hormone receptor positive, and one in five are premenopausal, and HRT is contraindicated except in extreme situations.2 Non-hormonal therapies help with hot flushes and mood disturbance, but avoid paroxetine in patients on tamoxifen – citalopram and venlafaxine are fine.3 Receptor negative breast cancers and receptor positive cancer patients on tamoxifen can be considered for HRT.
10. Safety update
A re-evaluation of Women’s Health Institute evidence by 10 year cohorts1, and a recently published Danish study indicate that HRT is safe for patients in their 50s and early 60s7,8, strengthening the window of opportunity theory.2 This means it is safest to start treatment around the perimenopause, or no later than 1-2 years after the last missed period. Some studies indicate that oestrogen-only therapy may reduce your risk of breast cancer, and although taking combined HRT for more than five years beyond expected date of menopause increases your risk of breast cancer, so does alcohol and obesity, and cancer risks revert to baseline when HRT is stopped.1,2
Dr Jane Woyka is a GP at Harrow Health Care Centre and associate specialist at the Menopause Clinic, Northwick Park and St Marks Hospital Harrow
The British Menopause Society’s next meeting is May 23-24 at Stratford – a two day event for GPs, nurses and hospital doctors.
1 Shapiro S, Farmer RDT, Mueck AO, Seaman H, Stevenson JC., (2011) Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies. Family planning and reproductive healthcare 37 (3); 165-172
2 International Menopause Society, Global consensus statement on menopausal hormone therapy. 15.03.2013
3 International Menopause Society. Consensus statements. 2011
4 Mayo Clinic 2008 3
5 Santen RJ, Alldred DC, Ardoin SP, Archer DF, Boyd N, Braunstein GD, Burger HG, Colditz GA, Davis SR, Gambacciani M, Gower BA, Henderson VW, Jarjour WN, Karas RH, Kleerekoper M, Lobo RA, Manson JE, Marsden J, Martin KA, Martin L, Pinkerton JV, Rubinow DR, Teede H, Thiboutot DM, Utian WH., (2010) Postmenopausal hormone therapy: an Endocrine Society scientific statement. Journal of Clinical Endocrinology and Metabolism 95 (7)
6 National Osteoporosis Society. Hormone replacement therapy for the treatment and prevention of osteoporosis. December 2010
7 Schierbeck LL, Rejnmark L, Tofteng CL, Stilgren L, Eiken P, Mosekilde L, Kober L, Jensen, JEB., (2012) Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ 2012;345:e6409
8 Manson JE. Plenary Symposium #1. Presented at: The North American Menopause Society; October 3-6, 2012; Orlando.