Ask Dr Shihaan » Menopause

Management of the Patient Receiving Hormonal Replacement Therapy for Menopause

Dr Shihaan — Sun, 18 Jan 2009 10:51:10 +0000

The patients should be educated about the start-up symptoms of HRT.

These inclede:

-Breast tenderness

-Nipple sensitivity

-Rise in appetite

-Weight gain

-Cramps in the calf

Patients should be informed that during starting the HRT symptoms similar to early pregnancy will be common.These symptoms usually remit at about 12 to 14 weeks of gestation.

Patients receiving HRT should ideally be reviewed Annually

Blood pressure:

Blood pressure should be checked.

Breast:

Patients should be taught how to self examine her breast. Should should also have regular mammography.

Pelvic examination:

This is especially very useful for unscheduled bleeding, especially if it is prolonged,heavy or recurrent. In cases of bleeding that is unscheduled a specialist consultation with a view to hysteroscopy and biopsy if indicated.

Ultrasound examination either transabdominally or vaginal (preferable) is also very useful as fibroids and endometrial polyps may be identified.

Use of local estrogens:

Symptoms originating in the lower genital tract (Bladder and urethra) may be treated with locally-applied estrogens.

Locally applied estrogens may be in the form of cream, pessary or vaginal tablet.It should be inserted/applied to the upper vagina where it will disperse to nearby local estrogen receptors.

Even patients who have had a past history of breast cancer can receive local vaginal estrogens for genitourinary symptoms.

References:

Pages 2209 to 2212.Chapter 327. The menopause transition and postmenopausal hormone therapy.Harrisons Principles of Internal Medicine. Volume II.16th edition. Kasper,Braunwald,Fauci,Hauser,Longo and Jameson.

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Pages 760 to 762. Chapter 17. Menopausal syndrome.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

Hormone Replacement Therapy in Menopause

Dr Shihaan — Sun, 18 Jan 2009 03:14:11 +0000

Weather to take postmenopausal hormonal therapy or not is one of the most complex health care decisions facing women. It is also a complex decision for doctors to determine which of their patients will benefit from postmenopausal hormonal replacement therapy.

In the United States about 30% of postmenopausal women use hormonal replacement therapy.

Please do not forget to read my post on the benefits and risks of postmenopausal hormone therapy.

History and Examination prior to commencing hormonal therapy

A thorough history should be taken .Symptoms that are due to estrogen deficiency should be noted. The impact of these symptoms in the patients life should also be noted.

It is also important to ask tactfully about difficulties in sex life such as dyspareunia and loss of libido.

The history should include cardiovascular disease (such as angina pectoris, stroke and myocardial infarction) and skeletal system (history of fracture of the wrist,hip etc). History of osteoporosis in relatives is also important.

History of the gastrointestinal tract and liver disease is important because it might interfere with the pharmacodynamics of estrogen therapy.

A thorough gynaecological history should include medical and surgical interventions, history of irregular bleeding, history of previous biopsy etc. One should also ask specifically for history of breast disease.

All patients being considered for hormone replacement therapy (HRT) must have a physical examination by an experienced physician.This will help to identify potentially estrogen sensitive tumours in the pelvis and breast. A thorough breast and pelvic examination should be done. On pelvic examination one should look for masses suggestive of fibroids, endometriosis (past and present) and adnexial masses suggestive of ovarian tumours.

Contraindications to Hormonal Replacement Therapy:

Absolute

-Present or suspected pregnancy

-Suspected breast cancer

-Suspected endometrial cancer.

-Active acute liver isease

-Diagnosed venous thromboembolism

-Uncontrolled hypertension

Relative

-Migraine

-Uterine fibromyomata

-Past history of benign breast disease

-Chronic liver disease

-undiagnosed but suspected venous thromboembolism

Methods of administering hormonal replacement therapy

i) Oral:

The oral route is the most common route in the United Kingdom.

estrogen should be given daily,mimicking the perimenopausal daily release by the ovary.

The commonly used oral estrogen’s are:

-Oestradiol valerate 1mg or 2mg.

-Oestrone 1.25mg

-Conjugated equine estrogen 0.625 mg or 1.25mg.

The oral route cannot mimic the normal physiological ratio of oestradiol:oestrone, which should be 2:1 but it is exactly the opposite ie 1:2.

ii)Transdermal estrogen:

Patches are available in varying strengths of 28 micro gram to 100 microgram of oestradiol per day. Patches for one week are now available.

The estrogen being lipid soluble passes across the epidermis into the systemic circulation avoiding the first pass metabolism by the liver.

This route maintains the normal physiological ratio of oestrodiol:oestrone of 2:1.

Percutaneous gel with a similar mechanism of action of transdermal estrogen is also available.

iii)Subcutaneous implantation:

This is usually restricted to those who have undergone hysterectomy with or without oophorectomy. A pellet is placed in the subcutaneous tissue of the lower abdomen with local anesthetic under sterile conditions. Implants are available at strengths of 25,50 and 100 mg and reviewed at intervals of six months.

iv)Gonadomimetic therapy:

Tibilone, a synthetic steroid which exhibits progestogenic, estrogenic and androgenic activity. It is given in a dose of 2.5mg per day to women for a least one year. It supresss the symptoms and prevents bone loss

References:

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Menopause-Causes and Pathophysiology

Dr Shihaan — Sat, 17 Jan 2009 10:09:14 +0000

1)Natural Menopause

Fertility and ovarian mass declines sharply after the age of 35 years. There is depletion of primary follicles (a process that begins before birth) steadily until menopause.

The primodial follicles are about 1.5 million at birth. Most of these primodial follicles become atretic. Only about 400 to 400,000 follicles at puberty will progress to ovulation.

It is important to note that the circulating estradiol in a premenopausal woman is produced by these developing follicles. The granulosa cells which form the internal lining of the follicles converts testosterone and androstenedione to oestradiol. This conversion is catalyzed by the aromatase enzyme cascade which is promoted by FSH (follicle stimulating hormone). The theca cells also produces estradiol from androgens and the process is stimulated by LH (Leuteinizing hormone).

2)Surgical Menopause

If the ovaries are removed surgically, there is immediate onset of menopause.

Patients who have undergone hysterectomy are also likely to suffer from premature menopause, even if their ovaries are conserved during the surgery. In hysterectomised patients the median age of menopause advances by about 2 to 3 years.

There is continued debate as to weather oophorectomy should accompany hysterectomy in women over the age of 45. This could prevent ovarian cancer.

This abrupt decrease in the hormones can result in severe vasomotor symptoms(eg hot flushes) and rapid onset of dyspareunia (pain during coitus) and osteoporosis if not treated immediately.estrogen replacement therapy should be started immediately after surgery. Conjugated 1.25mg,estrone sulphate 1.25mg or estradiol 2mg should be given for 25 days of each month. After the age of45-50 years this dose should be tapered off to 0.625mg of conjugated estrogens (or equivalent).

3)Premature ovarian failure

This is also an important cause of menopause.

Premature ovarian failure is defined as failure of the ovary before the age of 45 years to generate estrogen leading to secondary amenorrhoea. Patients also have symptoms other symptoms suggestive of estrogen deficiency.

Lab tests reveal a low plasma E2 (less than 150pmol/L and high levels of follicle stimulating hormone (FSH), luteinizing hormone (LH).

On microscopic examination of the ovary in premature ovarian failure, it appears like a postmenopausal ovary.

In resistant ovary syndrome the biological appearances of the ovary are normal, with abundant primodial follicles

4) Other causes of Menopause

The management of malignant diseases in young women may induce menopause. In fact radiation of the ovary is used to suppress estrogen output from the ovary (This will soon be replaced by estrogen antagonists in the future).

Chemotherapeutic drugs used in the management of cancer (er breast cancer), lymphomas etc may suppress and arrest ovarian cyclic activity. Patients who are going in for such treatments must be counseled properly, before consent is obtained for treatment.

References:

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Postmenopausal Hormone Therapy-Benefits and Risks

Dr Shihaan — Sat, 17 Jan 2009 05:52:38 +0000

Benefits of Postmenopausal Hormone Therapy

i) Symptoms of menopause:

estrogen therapy is very effective in reducing vasomotor (eg hot flushes)and genitourinary symptoms.

For genitourinary symptoms (such as vaginal atrophy), vaginal estrogen is as good as transdermal or oral estrogen.

Vasomotor symptoms may be reduced by venlafaxine, 75 to 150mg/d, clonidine 0.1 to 0.2 mg/d or vitamin E (400 to 800 IU/d). The consumption of soy-based products or other phytoestrogens may also reduce vasomotor symptoms. Generally these are less effective than estrogen therapy.

ii)Osteoporosis:

estrogen reduces bone turnover and resorption. This slows the aging-related bone loss in postmenopausal women.It is well established that postmenopausal estrogen therapy (with or without progestin), increases bone mineral density at the spine (by 4 to 6%) and hip (by 2 to 3 %). This increase is also maintained during treatment.

Reduced incidence of fractures

There is a 50 to 80% lower risk of vertebral fracture among current estrogen users. There is also a 30% reduction in the risk of hip, wrist and other peripheral fractures. However once the estrogens are discontinued the protection is diminished.

Bisphosphonates (eg alendronate, 10mg/d or 70mg once a week,residronate 5mg/d or 35mg once a week) and selective estrogen receptor modulator (eg raloxifene 60mg/d) increases bone mass and density (randomized trials) and reduces fracture rates.

The risk of osteoporosis related fractures may be reduced by increasing physical activity, taking adequate calcium (1000 to 1500mg/d in two to three divided doses) and vitamin D (400 to 800 IU/d).

Risks of Postmenopausal Hormone Therapy

i) Endometrial cancer:

In short term users of unopposed estrogen (1-5 years) there is a three fold increase risk of endometrial cancer. In long term users (10 years or greater) there is nearly a 10 fold increased risk of endometrial cancer.

In the postmenopausal estrogen/progestin intervention trial (PEPI) up to 24% of women developed atypical endometrial hyperplasia (a premalignant lesion) after being assigned to take unopposed estrogen for 3 years. Only 1% of women assigned to placebo developed endometrial hyperplasia. Progestin eliminates these risks by opposing the effects of estrogen in the endometrium.

ii) Venous thromboembolism:

According to a recent meta-analysis of 12 studies. There was a two-fold increase risk of venous thromboembolism in postmenopausal women.

iii) Breast cancer:

There is an increased risk of breast cancer among estrogen users. The risk of breast cancer is directly related to the duration of of use. Long term use (5 years or greater) was associated with a 35% increased risk of breast cancer (meta-analysis of 51 case-controled and cohort studies). Unfortunately unlike in endometrial cancer combined estrogen-progestin regimens increase breast cancer risk more than estrogen alone.

References:

Symptoms and Signs of Menopause

Dr Shihaan — Fri, 16 Jan 2009 10:49:52 +0000

Summary of the Physical symptoms of menopause

-Tiredness

-Hot flushes

-Night sweats

-Insomnia

-Vaginal dryness

-Urinary frequency

Summary of the Psychological symptoms of menopause

-Mood swings

-Anxiety

-Loss of short-term memory

-Lack of concentration

-Loss of self-confidence

-Depression

i) Hot flushes:

This is the second most common symptom of menopause (after irregular menses and cessation of menses). It occurs in 80% of women.

Hot flushes presents as feelings of intense heat over the trunk and face. This is associated with flushing of the skin and sweating. Hot flushes may occur prior to the cessation of the menses.

Women who have surgical menopause may have very severe hot flushes.

Hot flushes are more severe during hot weather and more pronounced in the latter part of the day.They are also more severe after eating hot foods and drinks and periods of tension. Hot flushing frequently occur at night causing sweating and insomnia.

Hot flushes are attributed to an increase in pulsatile release of GnRH (Gonadotrophic releasing hormone) from the hypothalamus. This is beleived to affect adjacent temperature regulating areas of the brain.

ii) Cessation of menstruation:

As menopause approaches menstrual cycles become irregular. The cycles are often anovular (like during menarche) .The length of the cycle may also be irregular. There might be menorrhagia occasionally.

Due to the decreased secretion of oestrogen, the menstrual flow usually decreases in amount. The low oestrogen level causes a decrease in the size of the endometrium.

Before menses finally cease the cycles become longer, with missed periods or episodes of spotting.

Menopausal transition is said to have occurred if there has been no bleeding for 1 year.

Any bleeding that occurs after a period of one year (post-menopausal bleeding) warrants thorough investigation to rule out endometrial cancer.

iii) Osteoporosis:

A late sequel of menopause in some women is osteoporosis.

iv) Vaginal Atrophy:

The vaginal walls become thinner after menopause due to low levels of oestrogen. Thinning of vaginal mucosa and decreased vaginal lubrication may also lead to dyspareunia (painful coitus). There is also decrease in diameter of the introitus.

Pelvic examination will reveal a small cervix and uterus. The vagina will be pale and the ovaries are usually not palpable after menopause.

Management is by continued sexual activity which will help prevent tissue shrinkage. In severe cases oestrogen cream may be helpful

v)Urinary symptoms:

Frequency dysurea and urgency are frequent symptoms experienced by menopausal women. Although these symptoms suggest urinary tract infection (UTI) ,they are not associated with a positive urine culture.

There are oestrogen receptors in the trigone of the bladder and the proximal urethra. These may explain the symptoms, but in all cases a urine culture must be done before attributing it to menopause.

Stress incontinence is also frequent in menopausal women,but interovaginal prolapse must always be excluded.

It is important to note that the symptoms of menopause are highly variable . It can vary from absent, fleeting and mild to very severe. In some women the symptoms may continue for many years.

References:

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Menopause- Introduction

Dr Shihaan — Fri, 16 Jan 2009 02:52:16 +0000

What is menopause?

Menopause is the final cessation of menstruation.It can be either a normal part of ageing or as a result of surgical removal of both ovaries.

Menopause is derived from two ancient greek words menos (month) and pausos (ending). That is the end of the menstrual cycle which occurs monthly.

Menopause does not occur suddenly. It takes place gradually over a 1 to 3 year period during which there is diminishing and then absent menstrual blood flow.Some of the common physiological processes that occur during menopause include hot flushes, vaginal dryness and night sweats.

What is the average age of menopause?

The average age of menopause in developed countries is 51 years.

It is important to note that today with increasing life expectancy a woman in a developed country will be expected to live about 30 years (approximately 40% of her life) after menopause.

What is climacteric?

This is a term used to refer to the whole range of anatomical, physiological and psychological events that occurs during menopause.

Climacteric is derived from the Greek word klimakter which means rung of a ladder. That is a major movement of life’s ladder.It is the transition from fertility to infertility. It usually takes place from the age of 45 to 55 years of age.

What is premature menopause?

Ovarian failure and cessation of menstruation before the age of 40 years is known as premature menopause.

Premature menopause usually has a genetic or autoimmune basis.

What is surgical menopause?

This is menopause due to surgical removal of both ovaries (bilateral oophorectomy). This can cause severe symptoms as the withdrawal of sex hormones is of sudden onset.

Why does menopause cause psychological,personalty, emotional and even psychiatric changes?

Although mood changes such as depression and anxiety occur at the time of menopause, there is no objective evidence that this is related to oestrogen withdrawal.

The time period during which menopause occurs coincides with other major changes in life such as departure of children from home, midlife identity crisis,divorce, and loss of youthfulness.This can add to the symptoms of menopause.

Symptoms,treatment/management , hormonal therapy etc will be covered in extensive detail in subsequent posts.

References:

Pages 225 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.