MENOPAUSE
AND HRT
Definition
The menopause is
defined as the permanent cessation of menstruation as a result of ovarian
failure. The average age of the menopause is about 50 years although there is
significant inter-individual variation.
Clinical
presentation
• Menstrual cycles vary in length from about 3–4
years before the menopause and become increasingly anovulatory.
Oligome-norrhoea is commonly present before full amenorrhoea.
• Vasomotor symptoms, including hot flushes and
night sweats, affect some women more than others. Most will resolve
spontaneously within 5 years of the menopause.
• Mood changes include irritability, anxiety and
difficulty in concentration.
• Sexual dysfunction can occur as a result of
vaginal dryness, leading to dyspareunia, in addition to reduced libido from a
fall in androgen levels.
• Urinary symptoms, including incontinence and
increased frequency of urinary tract infections, can occur as a result of
atrophy of the bladder and urethral mucosa (Figure 27.1).
Assessment
The history should
assess symptom severity, and review risk factors for vascular disease,
osteoporosis, thrombo-embolic disease and breast cancer if HRT is being
considered. Blood pressure should be checked and the breasts also examined
under such circumstances. Diagnosis is usually based on clinical assessment
with no requirement for blood tests. Indeed, FSH levels tend to vary
significantly in the peri-menopausal period and do not correlate well with
symptoms. However, if measured, a low oestradiol and significantly raised FSH
are consistent with the diagnosis.
Treatment
Many women do not
require treatment but HRT can be considered for alleviation of menopausal
symptoms when these are troublesome. The choice of HRT formulation, including
oral, transdermal, intranasal or subcutaneous preparation, should be considered
on a case-by-case basis according to symptoms and health risks. Patients on
systemic HRT with an intact uterus should be prescribed oestrogen in
combination with a progestogen to reduce the risk of endometrial cancer.
Locally administered intravaginal oestrogens, delivered as creams, gels, rings
or tablets, can improve genitourinary symptoms, and offer an alternative to
systemic HRT when this is contraindicated. Non-hormonal therapies such as
clonidine for flushing or cognitive behavioural therapy for low mood are useful
alternatives in patients for whom HRT is contraindicated or not tolerated.
Side effects of HRT
include breast tenderness, mood changes and irregular vaginal bleeding, and may
necessitate a change in dose or preparation, or discontinuation.
Long-term risks
and benefits
There have been
conflicting reports regarding the long-term safety of HRT. The current evidence
suggests that HRT increases the risks of the following (Figure 27.1a).
• Venous thromboembolic disease, although the
absolute risk is still low. This risk is greater for oral than transdermal HRT
preparations.
• Breast cancer, in women taking combined
oestrogen and progestogen. The risk relates to treatment duration and reverts
to background risk when HRT is stopped.
• There is a small increased risk of stroke in
women taking oral (but not transdermal) oestrogen, but it should be recognised
that the population risk of stroke in women under age 60 is low.
HRT does not
increase the risk of cardiovascular disease when started under the age of 60
years, nor is there an effect on diabetes risk. The risks in relation to
dementia are not known.
The long-term
benefits of HRT include reduced risk of osteoporotic fragility fracture,
although the population risk of fragility facture in women around the menopause
is low. A decision to prescribe HRT in an individual patient should thus take
into account the woman’s personal and family risk of these conditions in addition
to symptoms. Active breast or endometrial cancer, and active deep venous
thrombosis are absolute contraindications to HRT.
Pre-menopausal
oestrogen replacement
In patients with
premature ovarian failure or other causes of low oestrogen in young women, sex
steroid replacement with either HRT or a combined oral contraceptive pill may
be considered. Treatment should be continued until the age of the natural
menopause, not only to alleviate symptoms, but also to maintain bone mineral
density. The risk of breast cancer and cardiovascular disease in this age group
is very low.
