MENOPAUSE AND HRT
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.
• 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).
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.
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.