Menopause

BY Dr. Mona Farooq

Definition

 Menopause is a biological stage in a woman's life when menstruation

stops permanently due to the loss of ovarian follicular activity. It
occurs with the final menstrual period and is usually diagnosed
clinically after 12 months of amenorrhoea.

 In the UK, the mean age of natural menopause is 51 years, although this can
vary between different ethnic groups.
 Perimenopause, also called the 'menopausal transition' or 'climacteric', is the
period before the menopause when the endocrinological, biological, and clinical
features of approaching menopause start. It is characterized by irregular cycles of
ovulation and menstruation and ends 12 months after the last menstrual period.

 Postmenopause is the time after a woman has not had a menstrual period for 12
consecutive months .
 Early menopause is the cessation of ovarian function occurring between the ages of 40 and
45 years, in the absence of other causes of secondary amenorrhoea.

 Premature menopause describes definitive loss of ovarian function before the age of 40
years, for example following bilateral oophorectomy.

 Premature ovarian insufficiency (POI, also known as premature ovarian failure) is a

clinical syndrome defined as the transient or permanent loss of ovarian function before the
age of 40 years, characterized by menstrual disturbance (amenorrhoea or
oligomenorrhoea), and potential spontaneous resumption of ovulation, menstruation, and
spontaneous pregnancy .
 Genitourinary syndrome of menopause (previously known as
vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy).
 It describes combined vulvovaginal and urinary tract symptoms caused
by thinning and shrinking of the tissues of the vulva, vagina, urethra,
and bladder caused by oestrogen deficiency 
CAUSES AND PREVALENCE

By Dr Rupa Bodalia
 WHAT CAUSES IT?
Menopause is a natural stage in a woman's life 

Women have a finite number of oocytes at birth. The number of oocytes is greatest
before birth and declines with each menstrual cycle. The menopause is characterized
by the eventual depletion of the oocyte store (and the cessation of menstruation)

During the perimenopause:

Ovarian follicular activity begins to fail.

Oestrogen and inhibin levels decrease and reduced negative feedback to the pituitary
causes follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels to
rise.
NICE CKS: Menopause
 Levels of FSH fluctuate markedly from pre- to postmenopausal values on an almost daily basis
during the transition to menopause.

 Decreasing oestrogen levels begin to disrupt the menstrual cycle and may cause other menopausal
symptoms (such as vasomotor symptoms including hot flushes and night sweats). These result from
minor increases in core body temperature that trigger an excessive thermoregulatory reaction and
promote heat dissipation by peripheral vasodilatation and sweating.

 Menstrual cycles tend to become anovulatory, and eventually follicular development stops. Estradiol
production, which occurs in the granulosa and thecal cells surrounding the oocyte, becomes
insufficient to stimulate the endometrium, and amenorrhoea occurs.

 Eventually, the menopausal pattern of low oestrogen and persistently high FSH and LH levels is
established.

NICE CKS: Menopause

 HOW COMMON IS IT?
Menopausal symptoms are extremely common but are likely to be under-recognized and under-
treated. A woman's ethnicity, cultural, religious, sociological, and nutritional factors may modify
the intensity and incidence of menopausal symptoms.

Vasomotor symptoms
 Vasomotor symptoms (hot flushes and night sweats) are the most commonly reported symptoms, occurring in about 80%
of postmenopausal women, with 25% of these reporting a severe impact on quality of life

Genitourinary syndrome of menopause (vulvovaginal atrophy, atrophic

vaginitis, or urogenital atrophy)
 An Italian multicentre cross-sectional study of 747 women aged 40–55 years found genitourinary syndrome of
menopause was diagnosed in 36.8% of women, and most signs and symptoms had an age-related increase in frequency
and intensity

 Similarly, expert opinion in a review article notes that genitourinary symptoms affect up to 50% of women during
menopause
NICE CKS: Menopause
Menopausal Symptoms

Dr.Widad Trifi
 Every woman’s menopause experience is unique.

 Can vary among women in terms of severity and duration

 Can begin months or even years before periods stop and last around 4 years or longer after the last
period

 Symptoms are usually more severe when menopause occurs suddenly or over a shorter period of time.

 Conditions that impact the health of the ovary( cancer or hysterectomy ) or smoking, tend to increase
the severity and duration of symptoms.
The Greene Climacteric Scale
 Lighter /heavier periods more common (blood
loss >80ml) especially with clots

less frequent menstruations / short cycles <21

days /skipped menstrual periods
1. Menstruation
changes:
Flow/Frequency
Duration of bleeding increased (>7 days or >
2 days longer)
 Prevalence 75 %

A sudden feeling of heat in the upper body (face, neck, and chest) that
spreads upwards and downwards or generalised in some cases.

Duration 2–4 minutes,

2. Vasomotor Associated with excessive sweating, palpitations, anxiety.

Symptoms Hot
flashes/night Can be embarrassing and distressing
sweats
Triggers : can include spicy food and alcohol
 Vaginal atrophy : vulvovaginal irritation,
discomfort, itching and/ or dryness: Dyspareunia

Vaginal dryness tends to increase in severity with

time since menopause

3. Urinary symptoms: dysuria, urinary frequency

Genitourinary /urgency / incontinence with recurrent UTI
syndrome of
menopause
Symptoms of urogenital atrophy can appear even
10 years after last menstrual period
  Insomnia is common in peri and post-menopause
 Decline in sleep quality may be multifactorial:
- General ageing effects (nocturnal urinations)
- Sleep-related disorders (apnoea) or other illness( chronic
pain, depression)
- Stress, negative mood
4. Sleep - Ovarian hormone changes
disturbance
 Hot flashes/ Night sweats trigger awakenings in the first half of
night
 Mood swings often associated with hormonal fluctuations in the
perimenopause and/or sleep disturbance

Low mood may be associated with negative beliefs about the

menopause and the reproductive status or aging effect with slow
metabolism and weight gain

5. Mood Anxiety and irritability associated with vasomotor symptoms

disorders/
Cognitive
impairment There may be poor concentration and memory, difficulties in
multi-tasking, causing social embarrassment.
Diagnosis

By FJ
 Routine investigations are not required to diagnose menopause in healthy women aged 45
years and over with typical menopausal symptoms.

 Nice recommends to diagnose the following without a laboratory testing:

 Perimenopause- in women with irregular periods and vasomotor symptoms.

 Menopause- absence of periods for 12 consecutive months or more in women who are not
using hormonal contraception.

 Menopause based on symptoms in women without a uterus.

 Serum FSH

Serum FSH should be considered to diagnose menopause provided the woman is not taking combined
hormonal contraception or hormone replacement therapy if she is:

 Over 45 years with atypical symptoms

 Aged between 40-45 years with menopausal symptoms including a change in menstrual cycle.
 in patients younger than 40 years with suspected premature ovarian insufficiency.

 Over 50 years of age and taking progesterone only contraception

 A single FSH level above 30IU/L indicate ovarian sufficiency but not necessarily
menopause
 The British Menopause Society recommends the following: If FSH is 30 IU/L or higher,
repeat the test 4-6 weeks apart. If still elevated and the woman has not had a period for 12
months then can confirm menopause.
 Premature Ovarian Failure

 Dr. Majid Habib Khan

GPST1
 Introduction

 Amenorrhea due to ovarian failure occurring spontaneously before 40 years of age

 The term "failure" means that ovarian function is not normal, but does not necessarily
imply total cessation of ovarian function
 A lady of less than 40 years age
has had amenorrhea (or oligomenorrhea) for 4 months or more,
with 2x serum FSH levels in the Menopausal range (>25 IU/L)
(obtained at least 1 month apart)

FSH Levels Normal value ranges in Women

Before puberty - 0 to 4.0 IU/L
Women who are menstruating - 4.7 to 21.5 IU/L
After Menopause - 25.8 to 134.8 IU/L
Incidence & Prevalence

The risk of Premature Ovarian Failure before the age of 40 years is 1%

The prevalence of Premature Ovarian Failure varies according to age, and it is

1 : 10,000 at the age of 18-25 years
1 : 1000 in women aged 25-30 years
1 : 100 in the age range 35-40 years
 Pathophysiology

Follicle Depletion
No primordial follicles left in the ovary
1. Production of inadequate initial pool of primordial follicles in intrauterine life
2. Accelerated expenditure of follicles
3. Autoimmune or toxic destruction of follicles

Follicle Dysfunction
Follicle remain in the ovary but some pathological process prevents its normal function
 Etiology
 Idiopathic
 Chromosomal Abnormalities
 Autoimmune Diseases
 Enzyme Deficiencies
 Chemotherapy or Radiotherapy
 Infections
 Iatrogenic
Chromosomal
Two intact X chromosomes are necessary for maintenances of follicles
 Turner syndrome (XO)
 Trisomy X (XXX)
 Fragile X syndrome

Metabolic
 Galactosemia (Deficiencies of Galactose 1 phosphate uridyl transferase)
high level of galactose toxic to oocyte
 17a Hydroxylase Deficiency
Autoimmune
Associated with women who have polyglandular failure including thyroiditis, hypoparathyroidism,
hypoadrenalism

Infections
 TB of the genital tract involving the ovaries
 Mumps Parotitis
 HIV & other viruses
Radiation and Chemotherapy
Reversible effect → ovary may resume ovulation and menstruation after about a year of amenorrhoea
Prolonged GnRH therapy
Surgical
Hysterectomy → kinking & blockage of ovarian vessels → POF (15-50%)
Induction of multiple ovulation
Exhaustion of follicles → premature menopause

Resistant ovary
Follicles fail to respond to gonadotropin stimulation due to receptor resistance

Smoking
Other environmental factors not yet studied
 Clinical Features
 Amenorrhea
 Hot flushes & Night Sweats
 Vaginal Dryness & Dyspareunia
 Low Libido
 Insomnia
 Headache
 Psychological disturbances
 Irritability
 Depression
 Lack of concentration
 Cancer phobia
 Pseudocyesis
 Investigations
 FSH level: 25 IU/l or more, repeat after 4 weeks
The FSH serum level is the gold standard test in POF diagnosis

 Serum Estrogen Level

 Autoimmune - Thyroid (TPO-Ab) & Adrenal Antibodies (21OH-Ab)
 Chromosomal study
 Thyroid Function Tests
 Blood sugar
 Prolactin level
 Pregnancy test
Complications

 Osteoporosis
 Cardiovascular Disease
 Management

1. Treat the cause first

2. Hormone Deficit
 Mirena IUCD or Estrogen Implant with progesterone offers long term HRT

3. Infertility
a) Oocyte Donation with IVF
b) Early Conception or Oocyte Harvesting
c) Ovulation Induction
Differential Diagnosis of Menopause

By Dr.Hajera Begum
 Differential diagnosis
 The following menopausal symptoms may also be caused by other conditions:
 Secondary amenorrhoea- Secondary amenorrhoea is defined as the cessation of menstruation
for 3–6 months in women with previously normal and regular menses, or for 6–12 months in
women with previous oligomenorrhoea.
 Causes - Causes of secondary amenorrhoea include:
 In those with no features of androgen excess — physiological causes (pregnancy, lactation, and
menopause), hypothalamic dysfunction (for example, due to chronic systemic illness or stress, weight
loss, and/or excessive exercise), and POI (for example, due to chemotherapy, radiotherapy, or
autoimmune disease).
 In those with features of androgen excess (such as hirsutism, acne, and virilization) — polycystic
ovary syndrome (PCOS), Cushing's syndrome, late-onset congenital adrenal hyperplasia, and
androgen-secreting tumours of the ovary or adrenal gland.
 Irregular vaginal bleeding-During the perimenopause, possible causes include endometrial polyps;
uterine fibroids; adenomyosis; endometrial hyperplasia or cancer; and vulval, vaginal, or cervical
lesions

 Hot flushes-Endocrine causes such as

1.hyperthyroidism and phaeochromocytoma
2.Tumours such as carcinoid syndrome (typically causes flushing without sweating), pancreatic
cancer, medullary thyroid cancer, renal cell cancer, lymphoma, mastocytoma and mast cell
disorders (usually with gastrointestinal symptoms), and paraneoplastic syndrome
3. Excess alcohol consumption, spicy food, food additives (such as monosodium glutamate and
sulphites)
4. Dumping syndrome (such as post-weight loss surgery)
5. Anxiety and panic disorders
6. Tuberculosis
7. Drugs such as opiates, nitrates, selective serotonin reuptake inhibitors (SSRIs), calcium-
channel blockers, levodopa, gonadotrophin-releasing hormone agonists, and anti-oestrogens
or selective estrogen receptor modulators (SERMs).

 Vaginal atrophy — trauma, infection, or lichen sclerosis may cause similar symptoms.
 The following symptoms associated with the menopause may also be caused by other conditions:
 Urinary incontinence — this is more likely to be due to mechanical factors, such as obesity,
gynaecological surgery, or multiparity, than the menopause.
 Mood changes (including anxiety, irritability, and depression) — these symptoms may not be due to
the menopause alone. General population studies suggest that most women do not experience major
changes in mood during the menopause transition.
 Sleep disturbance — may be associated with the normal ageing process
 Cognitive impairment (such as memory problems or difficulty concentrating) — cross-sectional
studies suggest that these symptoms are unlikely to be related to the menopause.
 Loss of libido — this may be attributed to androgen deficiency, however other non-hormonal
factors, such as insomnia, inadequate sexual stimulation, life stresses, and depression, may also
contribute to symptoms.
 Muscle and joint pains — pain and swelling resulting in restriction of mobility most often
affects the small joints of the hands and feet as well as the knees, elbows, and cervical spine.
These symptoms have been linked to a decrease in oestrogen levels, but other musculoskeletal
causes (such as osteoarthritis and rheumatoid arthritis) are possible
 Skin changes — it is difficult to separate skin changes due to ageing, smoking, and sun
exposure, from skin changes due to declining hormonal secretion and menopause. Soon after
the menopause, skin collagen content and skin thickness decrease, resulting in decreased skin
elasticity.
 Weight gain — this is unlikely to be solely due to the perimenopause or menopause. Body weight in
women tends to increase with age, especially beginning at or near the menopause (the average weight
gain ranges from 2.25–4.19 kg). Body fat redistribution to the abdomen also occurs with age
(independently of weight gain).
 THANK YOU
Assessment in a GP setting
 HISTORY:

Purpose of the detailed history is to:

 Clarify the symptoms:

 Are they menopause/perimenopause?
 What symptoms they are experiencing?
 What symptoms are the most problematic?
 Role out D/D if symptoms are vague like hypothyroidism, stress.
 If symptoms are vague then you may consider FSH/LH blood test.
 Identify contraindications absolute/Cautions.
 Identify the risk factors
PMH:
 H/O breast /endometrial cancer ,
 liver disease,
 VTE,
 migraine,
 DM,
 Endometriosis and fibroids (reactivate the problem),
 mental health problems (They can start as either worsening of pre-existing mental health
problem for which women can already be on treatment or emerge as new onset symptoms).
 Osteoporosis
 Family history : Breast /Endometrial cancer, mental health problems, premature ovarian
failure.

 Alcohol/illicit drug dependencies.

 Work/life balance /diet
Are they going through any stresses?
What else is going on at home and work?
Social connection- who do they live with, what are their hobbies?
 By the end of you history Identify their concerns

 Attitude to HRT?
 Expectations from HRT?

 Advise on using apps like balance to document their symptoms.

 Take home information/Leaflets/Websites e.g Menopause matters,

NON HRT TREATMENT
ALTERNATIVES TO HRT

Penelope Tom
 While some women may wish to take hormone replacement therapy to relieve their
symptoms, others will prefer to consider alternative treatments which may ease
menopausal symptoms.

 Hormone replacement therapy may not be suitable or safe for everyone.

  LIFE STYLE
 Healthy lifestyle behaviours can improve some symptoms of the menopause -  hot flushes and night sweats.
 Regular exercise, weight loss, wearing lighter clothing, turning down central heating, sleeping in a cooler
room, using fans, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and
alcohol).
 In addition, mindfulness and cognitive behavioural therapy can have also a mild-to-moderate effect on these
symptoms. The best activity is regular sustained aerobic exercise, such as swimming or jogging but any
activity is better than nothing.
 Wearing lighter-weight clothing, using a fan, opening windows, sleeping in a cooler room and reducing stress
may reduce the number of hot flushes. 
 Some women find that things such as spicy foods, caffeine (in tea, coffee, cola, etc), smoking, and alcohol
may trigger hot flushes. For some women, avoiding these things may help.
 Giving up smoking will help reduce hot flushes and your risk of developing serious health conditions, such
as heart disease, stroke and cancer.
 Complimentary and alternatives
 The following have been marketed - black cohosh, dong quai, red clover, evening primrose oil,
ginseng, soy and St John's wort. 

 Herbal medicines are not regulated by medicine authority, multiple products available on the market,
dose, purity and safety unknown. St john's wart is known to interact with a lot of medication-
tamoxifen, anticoagulants and anticonvulsants.

 The regulatory bodies have developed a system called Traditional Herbal Registration (THR). 

 Any herbal products that have been approved by this system have a THR logo on their packs. 
 • Antidepressants SSRI & SNRI

SSRI- citalopram, paroxetine, escitalopram, and fluoxetine.

SNRI -venlafaxine

• They provide relief from hot flushes almost immediately.

• A trial of one to two weeks is usually enough to find out whether it is going to work.
• If symptoms improve, a longer course may then be prescribed.  Beneficial effect is often short, does not
last for long. The main drawback is side-effects in some women e.g feeling sick, reduced sex drive,
reduced sexual response.
 Gabapentin
  Antiepileptic and used for neuropathic pain.

•  However, research has shown that it can ease menopausal flushing symptoms in some
women. Side-effects, are dizziness and tiredness.
• Gabapentin - not licensed for treating menopausal symptoms. However, many doctors are
willing to prescribe one of these treatments, with the patient's consent, to see if it works.
 Clonidine

 Clonidine used to be very popular for the treatment of  menopause.

   No good evidence that it is beneficial in improving symptoms.

  It frequently causes side-effects such as dry mouth, drowsiness, dizziness and feeling sick. It
is therefore not commonly used any more.
 HRT is trending at the moment
?????????????????????

Thank you!!!!!!
Hormone Replacement
Therapy

Olabisi Osisanya
GPST2
Introduction

 HRT is the use of exogenous hormone to replace declining levels of oestrogen/ progesterone .

 For symptomatic relief during the peri-menopausal/menopausal years.

 Symptoms- Early, Intermediate, Late

 Commonest symptoms are night sweats, vaginal dryness, headaches, low mood, reduced sex
drive, hot flushes

 Preventive treatment against osteoporosis and cardiovascular disease.

TYPES
 To decide which HRT is the most appropriate for each
Pessary
patient, there are a number of basic questions that need to be
answered, including: Cream

Local Oestrogen Tablet

Ring

Symptoms

Combined
NO Oestrogen/
progesterone
Hysterectomy/
Systemic
Mirena in-situ ?
Oestrogen
Yes
only
 Combined Oestrogen/
progesterone
Oestrogen only

If Peri-menopausal: If Menopausal:
Sequential/ cyclical Continuous HRT
Non-oral Oral HRT (period-free)

Oral Non-oral- Transdermal

 Oral: (gel/patch/implant)
Oestradiol or conjugated equine Oestrogens Advantages: Convenient Low dose oestriol,
Oral progesterone Cheap Avoid first pass metabolism
Easily discontinued Reduces triglycerides and
 Non-oral forms: thromboembolic risk
Transdermal- Gel/ Patch/implant
Disadvantages: Higher dose used Costly
 Bioidentical hormones First pass effect Allergic reaction
Oestrogen +/- progestin in a custom compounded base Daily intake, poor compliance Variable absorption
(not regulated/standardized, so not recommended)
Prescribing & routes
Oestrogen types:
Conjugated equine oestrogen, Oestradiol, Oestriol, Oestrone
Tablets can be taken daily, a twice weekly.
weekly patch, a daily gel or a daily spray.

Progestogens (to oppose the effect of oestrogen on the endometrium) :

C19 progestogens : norethisterone, norgestrel, levonorgestrel.
C21 progestogens – medroxyprogesterone, medroxyprogesterone acetate,
Dydrogesterone
Others: Utrogestan (micronized progesterone), Drospirenone

Sequential combined HRT- combined tablets (provides oestrogen only for the first
14 to 16 days, then oestrogen plus progestogen for the remaining 14 to 12 days)

Also available as a combined patch.

Can be used in separate forms where indicated. e.g. oestrogen patch, gel or spray,
with micronized progesterone (taken for 12 to 14 days per 28 day cycle)

Continuous combined
HRT- daily tablet or
patch.
Vaginal oestrogen- Oestriol
0.1% - 2-3 times weekly
(Gynest cream, ovestin)
Vagifem (oestradiol 10mcg),
oestrin vaginal ring(7.5mcg/24
hrs)- replaced every 3 months
Choice of route is
dependent on preference/
PMHx/ FHx eg DVT/
High BMI- (transdermal
carries less risk).
Oestrogen gel/ spray Intrauterine
combined with a daily Can be used as part of
progestogen e.g. HRT for 5 years, even
progestin e.g. Utrogestan Mirena provides if contraception is not
100mg (a micronized excellent endometrial needed.
progesterone) protection and bleeding
control.
Testosterone- can be used
in a small number of cases- Allows great flexibility of
Tibolone- synthetic derivative of
dose of oestrogen,
19 nortestosterone, has the loss of libido
combined effects of oestrogen, (hysterectomized women). provides adequate
progestogen and testosterone
Not commonly used as first endometrial protection
(Dose- 2.5mg or 1.25mg daily)
line for HRT. with any dose of
oestrogen.
- Use lowest effective dose
Can increase dose after 4- 6
- Duration depends on weeks based on
presence/absence of symptoms &
effectiveness. Ensure
SE. adequate dose of
- More benefits seen if started progesterone for
early (within the first 10 yrs of endometrial protection.
menopause). Benefits reduce after
60 yrs .
Risks, benefits, S/E &
contraindications HRT
By August Oji
Risks

 The benefits of HRT usually outweigh the risks for most women.
 The risks are usually very small and depend on the type of HRT, duration of treatment and your own
health risks.
 Breast cancer:
- Oestrogen only HRT is associated with little or no increase
- Combined HRT is associated with an increased risk of breast cancer. Risk reduces after stopping HRT.
- HRT does not affect the risk of dying from breast cancer.
* It's especially important to attend breast ca screening appointments if you're taking HRT.
 VTE:
- Greater for oral than transdermal preparations.
- The risk associated with transdermal HRT is no greater than baseline risk.
Risks

 Ovarian cancer: RR of 1.37, similar for oestrogen-only and combined oestrogen-progestogen

HRT
 Endometrial cancer: unopposed oestrogen increases the risk of both endometrial hyperplasia
and of endometrial carcinoma
 Lipids:
- Oestrogen replacement in HRT has tendency to increase serum triglyceride levels via an
increase in hepatic VLDL production
- Oestrogen in women with a pre-existing hyper triglyceridaemia can cause gross
hyperchylomicronaemia and predispose to acute pancreatitis
 Dementia
- The likelihood of HRT affecting the risk of dementia is unknown.
Risks

 Coronary heart disease and stroke:

- Varies depending on the presence of cardiovascular risk factors.
- HRT with oestrogen alone is associated with no, or reduced risk of CHD
- Combined HRT is associated with little or no increase in the risk of CHD
- The baseline risk of stroke in women younger than 60 years is very low
- Oral oestrogen is associated with a small increase in the risk of stroke
- HRT does not increase CVD risk when started in women younger than 60 years and does
not affect the risk of dying from CVD.
Benefits

 The main benefit of HRT is that it can help relieve symptoms of menopause such as hot
flushes/night sweats (vasomotor symptoms), mood disorders, urogenital symptoms, altered
sexual function, sleep disturbance, and fatigue.
 HRT can help prevent thinning of the bones, which can lead to fragility fracture.
Osteoporosis is more common after menopause.
 Starting hormonal treatment for women diagnosed with premature menopause reduces the
risk of chronic diseases, including cardiovascular disease and osteoporosis. HRT may have
a beneficial effect on blood pressure.
Summary of HRT
risks and benefits

 * during current use plus

post-treatment from age
of menopause up to age
69 years, per 1000
women with 5 years or
10 years use of HRT
 Side effects
 Oestrogen-related: Fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps, and
dyspepsia.

 Progestogen-related: Fluid retention, breast tenderness, headaches or migraine, mood swings, premenstrual syndrome-like
symptoms, depression, acne vulgaris, lower abdominal pain, and back pain.

 Vaginal bleeding problems:

- Unscheduled vaginal bleeding is a common adverse effect of HRT within the first 3 months of treatment.
- Monthly cyclical regimens should produce regular withdrawal bleeding towards the end of the progestogen phase.
- Continuous combined HRT commonly produces irregular breakthrough bleeding or spotting in the first 4–6 months of
treatment.
- Unpredictable or unexpected bleeding may also be due to non-adherence with treatment, drug interactions, or a
gastrointestinal disorder
- If serious gynaecological pathology has been excluded, altering the progestogen part of the regimen may improve bleeding
problems
Contraindications

 Current, past, or suspected breast cancer.

 Known or suspected oestrogen-dependent cancer.
 Undiagnosed vaginal bleeding.
 Untreated endometrial hyperplasia.
 Hx of VTE unless the woman is already on anticoagulant treatment.
 Hx arterial thromboembolic disease (for example angina or myocardial infarction).
 Active liver disease with abnormal liver function tests.
 Pregnancy.
 Thrombophilic disorder.
 Uncontrolled hypertension
Prescribe HRT with caution

 Diabetes mellitus (increased risk of heart disease)

 Factors predisposing to venous thromboembolism.
 History of endometrial hyperplasia.
 Migraine and migraine-like headaches.
 Increased risk of breast cancer.
Monitoring AND advise on stopping it 

By.R.Elmahgub
On Initiation of treatment :
3 Month review
Includes a review of the of symptoms
(Improved vs residual symptoms)

e.g vaginal oestrogen cream can be added

if urogenital symptoms are poorly controlled
Things to consider in a patient that is still symptomatic:

 Poor absorption - for example, due to bowel disorder (Alternative HRT product or delivery method ).
 Drug interactions reducing bio-available oestrogen - for example, carbamazepine and phenytoin.
 Problems with patch adhesion.
 Incorrect diagnosis - hypothyroidism or diabetes ……… consider invx further.
 Patient expectations - These may also need to be addressed.
 The dose of oestrogen in HRT may be too low.
12 month review
 Assess for side-effects
 Blood pressure and weight.
 Encourage breast and the importance of attending their mammograms and cervical screening .
 A review and discussion of an individual's risk:benefit ratio concerning HRT should occur at least
annually.
 consider switching cyclical HRT to continuous combined HRT
Referral
Treatments do not improve menopausal symptoms.
 Treatments cause ongoing troublesome side-effects.
 A woman has menopausal symptoms and contra-indications to HRT.
 There is uncertainty about the most suitable treatment options for a woman's menopausal
symptoms. 
Stopping HRT:

A study published in  The Journal of the American Medical Association found that stopping HRT results
in menopausal symptoms ~ 44% women 
25% having vasomotor symptoms, 25% urogenital complaints, and 5% mood-related symptoms
Withdrawal from HRT:
 women who have been using HRT for flushes should be advised that slow withdrawal is important
to avoid rebound flushes
 Gradual reduction of the estrogen over a period of 6 -12 weeks and continuing with the dose of
progestogen until the estrogen is stopped .
some women may require a longer period of time to reduce the dose
 mild flushes that appear during the withdrawal of HRT may be self-limiting and of short duration
 It is not known how long it takes for the CVD and VTE risk to return to baseline after stopping
combined HRT therapy
 increased risk of breast cancer disappears 5 years after unopposed estrogen therapy is discontinued.
It is not known how long it takes for breast cancer risk to return to baseline after stopping combined
HRT therapy
Strategies for reducing HRT doses gradually
 Using a lower dose HRT 
 a lower dose of the existing HRT can be used or change
to a lower strength brand. This lower dose can be used
for 2 -3 weeks, then you should alternate the pills with one
day on and one day off, then one pill followed by two
pill-free days and so on until the reduction is complete
 Cutting HRT pills in halfUsing a patch with reducing doses 
 The use of the matrix estrogen patch can be an effective way of reducing HRT. Small increments can be cut
off the patch each week so lesser amounts of HRT are applied. This may be easier for some women than
reducing oral HRT doses.
 staying off treatment for two to three months should be considered before deciding whether or not to
recommence.
Thank you