MEDICAL ADVICE
Seeking
good medical advice at menopause is important so that you can make the most of
this remaining post menopausal time of your life happy and healthy. Many women
will benefit from hormone replacement therapy (HRT), depending on various risk
factors and the presence of any chronically debilitating ailments. To get the
most benefit it is wise to seek your doctor’s advice as early as possible.
Women in their 40s will benefit from a routine medical consultation and
examination which can detect any serious problems such as high blood pressure,
diabetes and breast cancer. Advice on HRT, cancer diagnosis, life style factors,
can be provided at this time. The menopausal time frame is divided into three
periods; (1) premenopausal:- that is just before menopausal years and
menopausal symptoms that have not yet started to bother you.(2) The perimenopause;- This can last for many years,
women may start to have many symptoms at this time, for example, infrequent or
frequent periods, heavy or scanty periods and many general problems which can be seen in the chapter on symptoms of menopause. They are hot flushes,
cold sweats, dry vagina and many any others. (3) The final period is called
postmenopausal after a woman has not had a period for 12 months.
HRT
represents the greatest breakthrough in the health care of women during menopause.
When this treatment is combined with changes in lifestyle, a healthy diet,
adequate exercise and good medical advice, women can look forward to many
fulfilling and happy years.
HRT (now
called MHT) is a way of replacing your lost or deficient hormones after the
natural decline of ovarian hormones or surgical removal of the ovaries. HRT
consists of varying amounts and forms of oestrogen, progesterone, and sometimes
testosterone. The main component of HRT is oestrogen. Progesterone’s main role
in the treatment is to counterbalance the risk of endometrial cancer caused
from unopposed oestrogen (oestrogen used alone). Of much lesser importance in
the trinity of HRT is testosterone which mainly improves sexual function. Your
doctor can start treating you with HRT to relieve your symptoms, most commonly
hot flushes, mood swings or a dry vagina as well as preventing long-term
adverse effects of menopause such as heart (cardio vascular) disease,
osteoporosis and genital atrophy (shrinkage of the vulva and vagina). Although
HRT has been around, in various forms for about 80 years, it has only gained
popularity in the last ten years because of improved understanding of its
appropriate use and the recent emphasis on women’s health. In 1821 a male
French physician gave the name La Menopausia, or the Greeks called it the end
of periods (Meno , Pause). Before this it was often called hysteria and
horrible , disgusting treatments were offered. Women were given opium, cannabis,
belladonna, terrible vaginal and vulval injections and hideous concoctions to
drink. Women became hysterical and the disease was named Hysteria.
HISTORY OF HRT
When
it was learned that it was the lack of oestrogens, which caused the problems
with menopause, as a result of this, in
1941 hormones prepared from the pregnant mares urine called Premarin where released
for human use. In 1966, one physician wrote a book called FEMININE FOR EVER.
Then there was no end to the use of oestrogens. The women and their partners
were very happy, but then in 1970 endometrial cancer raised its ugly head. In
1970 The International Menopause Society was established. The first
international congress on menopause was held in PARIS. In 1977 many books were
published called “Women and Crisis in hormone health”by different auothers. This controversy continued for a long time. Since then many studies
have been done to assess the benefits of HRT on women’s health, particularly
about Cardiovascular Disease, Cancer, Osteoporosis and Quality of Life. But
constantly there was concern about benefit/risk ratio running in parallel. In
many of these studies the selection of women was not so good, women of all ages
were included (50-79) mainly in the biggest study THE WOMENS HEALTH INITIATIVE
which started in 2001 and is still continuing. However I am very pleased that
HRT is now received very favorably around the world in most countries, many
risk factors have been resolved.
Your
initial medical consultation for advice
When
and why to go to your doctor
On the
initial visit, your doctor will take your medical history, perform an
examination and relevant tests and provide counseling about whether to start
HRT. Even if you have never had a medical check-up and are, in your 60s, you
should still seek advice from a doctor at this period of your life, although it
is best to seek advice around 40.
This
consultation will help the doctor to assess if you’re an appropriate candidate
for HRT. Your doctor will discuss with you the benefits and any possible
side-effects to enable you to decide whether or not you should consider HRT. An
examination will help rule out any cancer (especially breast cancer), diabetes,
high blood pressure and any number of Gynecologic conditions. Cancers which
need to be ruled out include breast cancer, as well as ovarian, uterine and
cervical cancers. The most common non-cancerous gynecological conditions in
women of this age group are prolapse of the pelvic organs, urinary difficulties
and fibroids of the uterus. Disorders of the thyroid gland (usually under
activity)] are also common at the time of menopause.
It is
important to choose a general practitioner who is well informed about this area
of medicine. Referral to a specialist may be necessary for dealing with more
complex or difficult problems. You can also attend a menopause clinic.
The
treatment of menopause starts with a thorough medical history and clinical
examination. A few blood and radiological investigations can provide additional
useful information. Your doctor will take a family history which should focus
on heart disease, stroke, cancer, osteoporosis, deep venous thrombosis, and
diabetes. The clinical examination should include checks for height and weight,
blood pressure as well as a breast and heart examination. A pelvic examination
including a smear test is done. Smear test, in recent years in younger women is not
always required, if they have had, the vaccination for the Human Papilloma Virus
(HPV) which is now available in many countries as a protection against cervical
cancer. Breast cancer must also be excluded by clinical examination; a
mammogram should be performed if thought reasonable. It is also good practice
to have a rectal examination, and also to get your stools examined for blood,
as bowel cancer is common in this age group.
A
consistently high level of follicle stimulating hormone (FSH) will confirm
menopausal status although treatment can be started on the basis of a woman’s
symptoms if the woman is younger than 40. FSH or a pregnancy test is required.
Assessment of bone density is not routinely ordered; however, the present view
is that they should be done at the initial medical assessment. The need for
repeat testing will vary from woman to woman. A low bone density with the
associated higher fracture risk will often lead women to choose HRT for this
reason alone.
An ultrasound of the pelvis is particularly useful if
you are overweight, or if a normal pelvic examination is difficult or if a
pelvic disease is suspected on clinical examination. Ultrasound can confirm or
detect uterine polyps, fibroids or ovarian cysts. In addition, some institutions
use ultrasound to assist in the screening of ovarian cancer
In situations of irregular bleeding, especially in women
over 60 years, it is useful to assess the thickness of the endometrial cavity
and check for uterine polyps. This investigation can be done by transvaginal
ultrasound and may prevent the need for more invasive diagnostic surgical
procedures (such as curettage)
After
examination and investigations, women are generally counseled about their
various medical options and the achievable goals for a healthy lifestyle. Your
doctor will caution you about possible side-effects of HRT before you make a
decision.
Generally, your doctor will want to see you again within
two months, after the initial consultation, in order to tailor the HRT dose and
to manage any side effects such as uterine bleeding or tender breasts. If you have any
side-effects, consult your doctor, but do not stop treatment. Up to twelve
months may be necessary to establish a satisfactory HRT dose combination.
Who
should take HRT?
The
decision to take HRT is an individual one. In general all women who are suffering
from oestrogen deficiency symptoms, who are at risk of heart disease or
osteoporosis, or who already have osteoporosis, will benefit from HRT. Women
who have had premature ovarian failure, surgical menopause, or long periods of amenorrhea
will especially benefit from HRT as the period of oestrogen deficiency begins
earlier for them.
After
discussing treatment options with your doctor and making an informed decision
about whether to start hormone replacement therapy, you will be prescribed HRT
according to your health profile. You wil1 usually start with average doses
which are then tailored to your needs depending on your response.
In
three to seven days the symptoms of hot flushes and mood changes will improve.
Generally, within three to six months your doctor will achieve a happy balance
between symptom relief and side-effects by choosing the appropriate therapy
combination.
What
combination of HRT is most suitable for you depends on your age, your
predominant symptoms, your desire to continue with regular periods, the
presence of any risk factors, and if you have had a hysterectomy, with or
without the removal of your ovaries, and the reason for the hysterectomy.
Follow-up
visits to your doctor
After
starting HRT, it is recommended that you see your doctor every two months until
you are satisfied that the therapy is keeping you free of: symptoms and side
effects. It is then sufficient to have yearly checkups, involving a breast,
blood pressure and pelvic examination. A cervical smear test is recommended
every two years for postmenopausal women. After the initial scan to study your
bones for osteoporosis, another is recommended every two to five years
depending on your bone health.
Presently, a mammogram is recommended every two years for
women 50 to 70 years old for the detection of breast cancer. This does not replace
breast self-examination or a clinical one by your doctor. You should continue
to practice this preventative monthly check.
Some
authorities recommend an annual endometrial biopsy for women on long-term HRT. A
transvaginal ultrasound can also solve this problem by measuring the
endometrial thickness, this test and or biopsy, are especially important if
there is continuous or irregular bleeding, or for women with an intact uterus
on continuous unopposed oestrogen therapy and also if a woman has risk factors
for endometrial cancer. These are obesity, fibroids, diabetes, high blood
pressure and never having had a pregnancy
In summary the
management of menopause requires
•
General examination
•
Pelvic examination
•
Investigations (where
appropriate)
o
blood examination
o
cholesterol and triglycerides
o
liver function test
o
follicle stimulating hormone
o
oestradiol
o
cervical cytology
o
thyroid function test
o
stool examination for blood
•
Special investigations
(sometimes advisable)
o
mammogram
o
bone density study
o
endometrial sample
o
bleeding and clotting profile
o
ultrasound (pelvis; right upper
quadrant for gallstone and liver)
o
cardiac assessment if needed
•
Psychologist advice if needed
•
Discussion
•
Treatment
•
Follow-up
o
2 to 3 months
o
6 month
o
1 year; then yearly unless
there are any special problems
BENEFITS OF HRT
1) Improved quality of life
The symptoms such as hot flushes,
mood swings, poor memory, irritability, lack of sleep, urinary problems, loss
of libido and a dry vagina; are greatly alleviated with appropriate HRT. A
recent study showed that women over 60 years, who had no earlier symptoms, feel
an elevation of mood while on HRT. In a separate study, it was shown that there
is increased production of chemicals in the brain called endorphins while on
HRT which may be responsible for the mood elevation.
While on HRT, sleep improves partly
because of a decrease in night sweats and hot flushes and partly because of a
direct effect of the quality of sleep.
Sexual
enjoyment improves due to increased vaginal lubrication and enhanced libido.
Some clinicians recommend the routine use of testosterone implants along with
oestrogen when loss of libido is a problem. This is easily done if HRT is given
as an implant.
Tissues rich in collagen such as
skin, muscles, joints and ligament benefit from HRT with relief of symptoms
affecting them (backache, muscle and joint pains). Skin texture and thickness
improves. The nails and hair improve in quality. Urinary symptoms such as
frequency and pain also improve. Stress incontinence improves after several
months of oestrogen usage.
2) Prevention of Osteoporosis
Prevention from Osteoporosis
reduces the fracture risk by50 %
3) Reduces the risk of heart disease and possibly
stroke
This is important when HRT is started
before 60years of age and within 6-10 years of menopause, as normally incidence
of stroke increases any way with increasing age. Remarkably, HRT also reduces
heart disease; the number one killer of women in affluent societies of older
age by half. In addition, the incidence of stroke appears to be reduced,
although further studies are required to confirm the degree.
4) Slowing of ageing process
Although HRT is not a panacea for youthful
appearance, it certainly helps with excessive loss of skin tone and thinning
and shrinking of vulval and vaginal areas to prevent urogenital problems. To be able to notice these changes you have to
take HRT for many months.
Normally
when HRT (MHT) is taken orally it is absorbed by the intestines, then it is
carried to the liver from there it is passes to the target organs, heart, bones,
skin and genital organs via the blood stream. While in the liver MHT changes
certain enzymes, which can adversely affect the cholesterol metabolism,
clotting mechanism, and cardiovascular system. To prevent these problems it is
now often given as, Transdermal (via the skin) as patches, implants, gel, and
creams and even by injection. From here MHT directly goes into the blood stream
and from there to the target organs. This saves the changes in the cholesterol
level, thrombosis, liver and gall bladder. This information has already been previously
mentioned; hence it is very important to give MHT by a correct route.
Personal History
Emotions
relieved by HRT
Claire, a school teacher, expressed
her unhappiness about her changed behavior. Over the past 12 months she had arguments with
her family and friends over trivial matters. In addition, she had persistent
hot flushes, night sweats, backache and sleepless nights. In the past, she had
a benign brain tumor, and more recently gallstones. Her last period was 18
months ago.
She started continuous oral
oestrogen and progesterone within one week, she felt better, and within three
months she was back to her normal self. She had a recurrence of gall bladder
colic, which was possibly precipitated by the use of oral oestrogen. She
decided to have her gall bladder removed as she believed it was important to
remain on HRT. In recent times she could have been offered Transdermal MHT. It
was not so easily available in the1990’s when this story happened.
Risks of Taking
HRT
HRT
should not be used when a woman is suffering from cancer or has had a cancer
which was Oestrogen dependent; such as breast or uterine (endometrial) cancers.
The risk of endometrial cancer increases when Oestrogen is used alone for women
with a uterus. This risk has now been almost eliminated with the addition of
progestogen to oestrogen therapy.
HRT’s
effect on breast cancer is a contentious issue because of contradictory
conclusions reached by different research papers. WHI in 2001 said that
Oestrogen (CEE) and medroxprogesterone (MPA) increased the risk; by 26% when
this was published all women suddenly gave up there HRT. However proper analysis
of the paper showed that this risk was only, 8 out of 10,000 per year, (1 extra
case in 1000 per year when compared to women who had never taken HRT.
They did
not mention anywhere, the fact that 8 extra cancers where saved, 2 uterine and
6 bowel cancers. A study in the USA showed that if oestrogen was taken alone in
women who have had hysterectomies, there was no breast cancer in 15 years.
If you have or have had the
following conditions, you should not take Oestrogens.
1. Oestrogen-Dependent Breast Cancer
2. Undiagnosed Abnormal Vaginal Bleeding
3. Active Acute Liver Disease
4. Gall Bladder Disease
5. Chronic Liver Disease with Impaired Function
6. Uterine Cancer
7. Deep Venous Thrombosis, however this needs further study in the
current climate, as now we have transdermal treatments which are safer.
8. Sickle Cell Anaemia
Very rare disorder;
where the haemoglobin molecule is like a sickle shape.
9. Coronary Artery Disease
10. Porphyria Rare genetic
disorder of haemoglobin metabolism.
11. Systemic Lupus Erythromatosis, rare auto immune disease where immune
system attacks its own normal organs such as skin, kidney and brain.
12. Pregnancy, make sure you are not
pregnant by chance
If you have
or have had the following illnesses, you can take oestrogens, but must have a
regular check up.
1.
High Blood Pressure
2.
Endometriosis .(Women need to
take progesterone with oestrogens, if women have suffered with Endometriosis ,
otherwise oestrogens may reactivate endometriosis
3.
Smoking.
4.
Family History of Breast Cancer.
5. Deafness
6.
Benign Breast Disease
7.
Fibroids of the Uterus
8.
Migraine Headaches
9.
Any Irregular Bleeding or
Pelvic Pathology
Personal Story
HRT following a History of
Deep Vein Thrombosis and Pulmonary Embolism during Pregnancy
Nazia, a doctor, 53, consulted her
doctor for severe hot flushes. Low bone density was detected on a routine scan.
She was concerned about taking HRT because of a past history of deep venous
thrombosis and pulmonary embolism (clot in the lungs) after the birth of her
child, 18 years ago.
After discussion, she realized that
HRT, in the form of oestrogen skin patches, would not change her blood clotting
mechanism because the oestrogen did not bypass the liver. She was also given
progesterone as a Micronized Progesterone Vaginally because she still had an
intact uterus. As a precaution, she has an annual blood coagulation profile.
In women with irregular bleeding,
serious uterine disease must be excluded by ultrasound, hysteroscopy or
curettage before starting HRT. It is uncommon to have a pregnancy in the
menopausal age group; however it is a good idea to exclude pregnancy. This can
almost always be done by clinical history and examination or pregnancy test. Special care is needed with women who have had
their menopause I year ago however it is reasonably safe if it was two years
ago.
SIDE EFFECTS OF HRT
Oestrogen and progesterone can cause
some side effects for some women. In most cases, these effects diminish within
two or three months; for some women, changing the form of therapy and the
dosage is necessary.
Some women experience side-effects
of nausea, headaches or abdominal pain and leg
cramps. In the initial therapy, the main side-effects are tender breasts
(mastalgia), increased vaginal discharge, fungus, vaginal infections, irregular
bleeding and heavy withdrawal bleeding. All of these side-effects can be
corrected by your doctor by adjusting the dose. For example, the oestrogen dose
is reduced if you have breast tenderness or heavy bleeding, and the progesterone
dose is increased if you have irregular bleeding during the cycle. If irregular
bleeding persists after adjusting the dosage, further investigations are
necessary, such as an Ultrasound.
After menopause and the end of the
menstrual cycle, some women are loath to begin medication that will continue
their monthly periods. To overcome this problem, continuous oestrogen and
progesterone is now being used very effectively to prevent the recurrence of
monthly bleeds. Another psychological side-effect of HRT is having to adjust to
the routine of taking medication daily. You should try to organize a routine
which prompts you to take your tablets regularly; smart phones are great for
this.
About 15% of women suffer
side-effects such as depression and a bloated feeling similar to pre-menstrual
problems from progesterone and find it intolerable to use it. In this situation,
the frequency of cyclical progesterone is reduced by giving it in every third
cycle .Your doctor can reduce the dose further in continuous therapy. Now for
the last 20 years, micronised progesterone is available, which is well
tolerated. This is available both as oral and vaginal preparations
A gentle piece of advice and warning,
never accept HRT tablets or skin patches from your friends. Remember that each
prescription has been carefully formulated for each individual’s specific
needs. Your doctor will determine your
own requirements over a period of time by trial and error.
Personal story.
Despite heavy smoking,
having a family history of Breast Cancer and Heart Disease, HRT can be
prescribed.
Paula, 39 years old, a solicitor,
was a smoker and suffered from Endometriosis. After discussion with her doctor,
she had her uterus and both of her ovaries removed. Paula’s father, also a
heavy smoker, died of a heart attack and her mother suffered breast cancer at
the age of 53. Paula required HRT after
her operation for relief of menopausal symptoms and long-term risk of heart
disease following surgical menopause.
She was given an Oestrogen and Testosterone
Implant and together with Oral Progesterone daily, due to her history of
Endometriosis. Oestrogen alone could reactivate any residual Endometriosis. It
was stressed to her that she needed to have an annual clinical breast
examination and regular mammograms, once every two years until she was 50 years
of age and then once a year thereafter. She was strongly advised to give up
smoking.
Hormone Replacement and
Other Diseases
Varicose Veins
There is
an erroneous belief that HRT will increase the risk of deep vein thrombosis if
given to women with varicose veins. There is no proof of this and women should
not be denied HRT if the need is there.
Thromboembolic disease
There is
no proof to show that oestrogen in normal physiological dose and with regular
check-ups by a doctor causes deep venous thrombosis (DVT) or embolism. If there
is a history of having had DVT following child birth or an operation, you can
still take HRT (with Trans Dermal Oestrogens) with regular supervision by your
doctor.
In some
special situations where there is a family history of DVT or if you have DVT
for no obvious reason, then special blood tests such as Antithrombin III and
Protein C and S, should be done before you have HRT to exclude that you have
any thromboembolic disease.
Blood Pressure, Heart Disease and Stroke
HRT can
be given to women suffering from high blood pressure. It is generally preferred
to have the blood pressure under control before HRT is started. Best time to
start HRT is a time called the “Window of Opportunity”, that is within 6-10
years after menopause and at an age which is always under 60, so that there is
no time for body tissue damage due to aging. MHT or HRT is not suitable for
secondary heart disease.
Aching Legs
The cause
of aching legs is poorly understood. There is no obvious reason why HRT cannot
be given to you if you have this condition. If aching is only in one leg, then
DVT should be excluded before starting HRT. This investigation can be done by a
Doppler Ultrasound which shows the blood flow in the veins.
Oral
oestrogens can cause changes in the bile, which can cause gallstones or
precipitate an attack of gall bladder colic. It can also increase triglycerides
which adversely affects the pancreas. For these conditions, it may be better to
use a non oral form of oestrogen.
Migraine
The exact
understanding of the mechanism by which oestrogens and progesterones cause
headache is lacking. It is believed that a migraine occurs during the menstrual
period (called menstrual migraine) and is due to a lack of oestrogen. If it is
so, peri menopausal women who are experiencing migraines for the first time
should benefit from oestrogen. On the other hand, progesterone may cause
headaches. It is better to try HRT and see how you react. It is advised to
start soon after menopause, also under the age of 60.
Menopause
HRT (MHT)
HRT uses
2 main hormones mainly Oestrogens and Progestogen. In addition another hormone
often required is called Testosterone. There is another group of hormones which
are often used and these are called Selective Estrogen Receptor Modulators (SERMs).
These have a different action with different oestrogen receptors. Some block
the action of oestrogens in some areas (say in breast tissue) and enhances in another
area say bones.
What form does HRT take?
OESTROGEN
Oestradiol is by far the most common form of
HRT. It comes as oral, transdermal, gel, implants, parentral and vaginal. For
completion of HRT, it is combined with another hormone called progesterone.
This protects the side effect of oestrogen on the uterine lining. Oral
oestrogen is by far the most common form of HRT because it is inexpensive and
convenient. These oral oestrogen preparations are available in various chemical
formulations and strengths almost all over the world. There are two types of oral oestrogen preparation:
synthetic and natural formulations. Natural oestrogens, when metabolised in the
body, mimic the body’s oestrogens. Generally, only natural oestrogens are used
for HRT because they are much gentler and safer, although they are more expensive
than synthetic ones. There are many different oestrogen preparations that are
now marketed both synthetic and natural, the most commomly used are conjugated
oestrogens,and oestradiol preparations.
Oestrogens alone only, can be used in women who do not have a uterus.
IMPLANTS
(oestradiol)
In
this form, oestrogen is given as a pellet deposited under the skin by a special
applicator by your doctor. The technique requires a small incision, either in
the hip or abdomen to insert the implant which is about the size and appearance
of a grain of sago. These oestrogen implants come in three strengths: 20, 50,
and l00mg oestradiol. Generally, one 50 mg implant is inserted every six to
eight months. The pellet releases oestrogen slowly. An oestrogen implant can be
used after a hysterectomy when progestogen
is no longer needed to protect the endometrial lining of the uterus. It is
often used in combination with a testosterone implant, if your ovaries have
also been removed at the time of the hysterectomy or if you have a severe loss
of sex drive.
If there is an intact uterus and require this form of
treatment because of conditions such as liver disease, women will need to take
progestogen tablets orally or vaginally.
Disadvantages of implants are that the dose cannot be
tailored if there are any resulting side effects, and occasionally, there is a
sharp surge in the oestrogen level after the initial implant. Often with
implants there is an earlier return of symptoms, despite higher blood levels of
oestrogens (tachyphylaxis). If this is happening, this form of oestrogen must
be changed. The side effects are less pronounced if 20 mg and 50 mg
Implants are used instead of 100 mg.
Skin patches are gaining popularity
as a convenient form of HRT because of the small doses required with fewer side
effects. Patches are useful for women with lipid problems and liver or heart
disease and the risk of DVT, because the hormones go directly into the
bloodstream bypassing the liver. Importantly unlike the tablets they do not
increase the risk of blood clots thus preventing strokes and heart attacks. Many
companies make these patches. There are patches as Oestrogen alone, Oestrogen with
Cyclic Progesterone or with continuous Progesterone for different groups of
women who do and do not want to have periods. Oestrogen alone should only be
given to women who do not have a uterus; otherwise it runs the risk of causing
endometrial thickening or cancer as previously mentioned. Women who have had Endometriosis
should also be given progesterone as it can reactivate endometriosis. I have in
fact seen an unfortunate case of endometrial cancer where the woman was given
an oestrogen implant without progesterone after she had a hysterectomy and
removal of both her ovaries for endometriosis. As with implants, skin patches
are also available in different strengths.
They look like a small piece of kitchen
wrap plastic which adheres to the skin and can be applied to legs, buttocks or
abdomen.
Your doctor will determine which of the
available strengths and type is best suited to you, depending on your reaction
to the initial dose.
There are some possible disadvantages of
skin patches; local skin irritation including occasional blistering which
occurs in about 20% of women and this can be very distressing.
Again if a woman still has a uterus she
must take progesterone. Micronized Progesterone is best and you should follow
the instructions as per the manufacturer or your medical practitioner’s advice.
OESTROGEN GEL
These are the latest preparations
of oestrogens which are becoming popular although they are expensive. These are also a transdermal
preparation, as they go directly into the blood stream when applied to the skin.
They come as gel, cream, mist pump and spray.
Currently there are several
other preparations, of Oestradiol Valerate.
They come in different intramuscular strengths. The injection can last
from 2-6 weeks depending on the severity of oestrogen deficiency symptoms. It
is very useful in postoperative days after the removal of both ovaries. It is
also used when oral oestrogen should not be given. Recently it has been
successfully used in some cases of premenstrual tension and postnatal
depression.
The other injectable preparation is Conjugated
Oestrogens; this is often used when there is intractable bleeding. Sometimes combined
oestrogen and testosterone injections can be used in some circumstances especially
if menopausal symptoms are difficult or if there is a marked loss of libido.
VAGINAL
OESTROGEN AND OTHER PREPARATIONS
Oestrogens are available as
vaginal tablets and creams; and vaginal rings. Vaginal oestrogens are
particularly useful if side effects are a problem with other forms of therapy
or if only local treatment is necessary to improve the condition of the vagina
and vulva. Local Oestradiol inserts of
10 mcg produces effective relief of local atrophic vaginitis, dryness and
burning without any significant side effects. The effect of vaginal cream is
short-lived and is mainly local. A once daily dose does not affect the lining
of the uterus and can be prescribed without progestogen. Other local vaginal
oestrogens, are available in different parts of the world under different brand
names.
The other vaginal preparations are: Oestradiol vaginal ring which delivers 7.5mcg
per 24 hours. It does not help with V.M .symptoms (like hot flush). Vaginal
rings prepared from Oestradiol acetate are useful for women who do not have a
uterus. It releases 50 -100mcg per 24 hours. It takes care of VM symptoms and
Vaginal and Vulval health, for up to 3 months when a new ring is inserted. At
present, vaginal rings, tablets and micronized vaginal progesterone if indicated is the treatment of choice from
risk benefit point of view.
PROGESTROGENS
This is the other female hormone which is important to be used with
oestrogens when we use HRT. Unfortunately many different names are used for it interchangeably without
attention which creates confusion for simplicity please remember progesterones are natural hormones and
progestins are all synthetic. For simplicity just remember Progestogens. They
have different brand names in different parts of the world. Progesterones are
now available in many forms, oral, injectable, vaginal rings, combined with oestrogens.
The best form of progesterone used now today is called Micronised Progesterone.
It comes as oral and vaginal, under different names. This was first made in 1980.
It is very well tolerated especially if used vaginally. Do not use it if you are allergic to peanuts.
The normal precautions to its use are such as DVT, liver problems. It does not
interfere with the protective effect of Oestrogens on the heart. Progesterone Intrauterine
devices (IUD) are also available which use another preparation of progesterone.
If women having Oestrogens, or having too much bleeding, cannot tolerate
progesterone, can have this IUD. This is also a contraceptive.
Medroxyprogesteronacetate (MPA) is the most recommended and popular
form of progestogen. Research shows that it does not adversely affect blood
lipids (cholesterol and triglycerides). It is available in 2.5 mg, 5 mg and
10mg tablets. Norethisterone is a progestin (a synthetic preparation) also
commonly used. Now most commonly used preparation is Micronized Progesterone.
COMBINED OESTROGEN AND PROGESTERONE
These are made by
different preparations. They are normally used in contraceptive pills. These
are also used in peri menopause to correct the early bleeding patterns and are
also contraceptive. One such pill is a combination of oestradiol and a new
progesterone called Dinogest which is very useful in peri menopause and
bleeding problems and contraception is desired.
It is very useful when
ovaries have been surgically removed; it helps with sex drive and fatigue. It is available as implants,
creams, patches or gel.
TIBILONE
Tibilone is a synthetic,
steroid pill combining the actions of oestrogen, progesterone and testosterone
in small doses with the advantage of not causing uterine bleeding if given to
women whose menstrual period was over 12 months ago. It is used for HRT and
Osteoporosis. It should not be used in women who have had breast cancer or
stroke. It increases the risk of stroke. It benefits vagina, brain, bones, hot
flashes, and endometriosis. It also protects the uterus, breast and liver from
side effects. Even if you have a uterus you do not require progesterone because
of its progestogenic action. Besides this it helps to have freer testosterone which
improves sexual function. Side effects of Tibilone can be vaginal spotting,
discharge, irritation, abdominal or breast pain and some unnatural facial hair.
Generally it is a well tolerated HRT.
Personal story
Alcoholism and HRT
Joan, 46 years, was
suffering severely from menopausal symptoms, mainly hot flushes and irregular
bleeding. She asked for help to cope with her personal, family and marital
problems and her heavy drinking. Alcoholism had caused liver damage which meant
she could not take oral oestrogens. Skin patches (75 g) were prescribed twice a
week (75mcg/24 hours), plus 5 mg of progestogen daily, as continuous therapy.
Joan was happy with
this therapy which was tailored to her requirements after a few trials over
four months. A balance was eventually reached between complete relief of her
symptoms and the irregular uterine bleed. She then felt physically well and
emotionally strong enough to cope with the family stress and her failing
marriage.
Contraception and
Menopause
HRT is not a
contraceptive pill. The best option is to continue your current method of
contraception for the one or two initial years after menopause. If you are
already on a contraceptive pill and a non-smoker you can continue. If you have
an intrauterine contraceptive device, you may leave it in. Some women may
already have had a (laparoscopic) sterlisation: the clipping of your tubes (in
previous techniques, referred to as having your tubes tied). Currently there
are newer Hormone progesterone intra uterine devices women can use with oral or
transdermal oestrogens, which are very useful in some situations for menopausal
symptoms, for double purpose of HRT, contraception and, in cases with excessive
bleeding .You should discuss these variations with your doctor.
SERMS
The other group of
drugs as already mentioned used for management of menopause are called,
Selective Oestrogen Receptor Modulators. These have different oestrogen like
actions on different organs, like oestrogens on one organ and anti oestrogens
on another. There are three such drugs commonly used. (1) Raloxifene, this is
not an oestrogen however it acts like oestrogens, prevents and cures osteoporosis.
It has an anti oestrogenic effect on breast cancer and uterus hence protects
these organs. It does not help with V.M. symptoms; in fact it can make them
worse.
(2) The other is a combination drug called Bazidoxifene, it is Bazedoxifene
combined with conjugated equine Oestrogens. It protects the uterus and breasts when
women take oestrogens for severe vasomotor problems. They then do not have to
take progesterone saving its side effects.
(3) Ospemifene is another SERM, which is very favorable to the
vagina. It is used as a daily single tablet for painful sexual activity. Main
side effect is hot flushes and muscle spasms
Whenever a woman starts to take any treatment always read the
enclosed information on the drug, the contraindications and side effects, if
need be discuss it with your care giver.
Stopping HRT
If for some reason,
you have to stop taking HRT, it is better to do so gradually. While not
addictive in any way, HRT is a very attractive addition to your body’s
chemistry because it replaces your depleted naturally occurring hormones. If
HRT treatment is stopped suddenly, then there may be some bleeding and a
resurgence of the symptoms of menopause. It is the sudden drop in oestrogen
levels which causes symptoms, rather than the actual oestrogen level.
Few years ago it was believed that HRT should be given in the smallest
dosage for the shortest possible time, however this view is now superseded by
saying it should be given in adequate dosage for adequate time. These of course are individualized. If a
woman is over 60 this should be carefully supervised. Generally this should be
discontinued after 3-5 years, over age 60, any suggestion of DVT or STROKE, any
signs of Heart disease or any other problems.
Alternative
therapy for hot flushes
Sedatives, tranquillizers
and drugs used for treating migraine can offer some relief if you feel your
menopausal symptoms are making your life intolerable and you are in the rare
situation where HRT cannot be prescribed you may take these drugs.
The drugs used for treating migraine may sound unlikely but they
some times
seem to work by stopping severe vasodilatation (widening of the
arteries) which accompanies a hot flush. The basic change both in migraines and
hot flushes is vasodilatation, followed by vasoconstrictions.
A woman can help herself by changing her life style factors: exercise
regularly, keep cool, yoga, stop smoking, eat properly, and do all the life
style things, everybody keeps talking about. The most common alternative
treatments offered for menopausal symptoms are evening primrose oil, ginseng, royal
jelly, black cohosh, angelica St John’s Wort and vitamin E.
The main constituents
of evening primrose oil are the essential fatty acids, linolenic and
gammalinolenic acids. Literature on evening primrose oil states that linolenic acid
has an oestrogen like action. The truth remains that there is no well defined
and constant formulation of evening primrose oil, ginseng or royal jelly. Their
value is claimed for the treatment of premenstrual tension, atopic eczema, and
diabetes and menopause symptoms. Hundreds of women claim benefit from these
remedies and it is quite possible that they do receive some benefit. The
difficulty is that preparations are not subject to the same regulatory
requirements which control pharmaceutical drugs. St John’s Wort is known to
cause side effects if used with others drugs. I have personally had a case
where it caused oozing problem following a caesarean section, where the woman
did not inform me that she was taking it during pregnancy.
BIOIDENTICAL OR NATURAL HORMONES
These are prepared
from plant sources and are supposed to be identical with human hormones, hence
called natural. They are regulated by
the levels in the saliva; there is no proof to say that these are related. They
have not been studied and the clinicians do not know if they are effective and
free of side effects hence they are not advised. The other thing is that these
are being balanced by the hormone levels in a woman’s saliva, but we do not
know how they are related to the symptoms. There is also no solid evidence to suggest
about their safety and effectiveness. Because of these reasons they are not recommended
but still used all over the world.
ANTIDEPRESSANTS AND OTHER
MEASURES
These are not licensed
for treatment of menopausal symptoms, however most experts believe these are
very useful when treatment for menopausal symptoms is required after breast cancer,
when normal HRT cannot be used. There are two main types of these, called
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Noradrenaline
Reuptake Inhibitors (SNIRs). There are many such compounds, let us just call
them SSRIs and SNIRSs. They are very helpful. They also have side effects such as
anxiety and dizziness but settle down over time. Your care giver can discuss all this with you.
Other Treatments used for hot flush’s is an anti seizure drug called
Gabapentin. It improves the quality of sleep but also causes sleepiness and
fatigue. Clonidine is another mild drug women can take for hot flushes if she
cannot take oestrogens. This is normally used to lower blood pressure. Stellate
Ganglion Block (nerves in the neck) in some special clinics is given by
specialists to help with hot flushes.There are many new drugs which are being
used for management of Osteoporosis and Genitourinary Syndrome of menopause.
SPECIAL CASES AND MANAGEMENT OF MENOPAUSE
BREAST CANCER
If it happens in
younger women hot flushes are very bothersome. The drugs used for these cases
are Antidepressants, SSRI, SNRI, Clonidine and Gabapentin and Stellate Ganglion
Block. Women will need to improve their
life style factors and diet to have more help with hot flashes. There is no conclusive
evidence on benign breast disease or uterine fibroids.
ENDOMETRIAL CANCER
It is highly unlikely
to recur after 2 years, so HRT can be used after that time predominantly
progesterone only drug. It helps with hot flushes and bone loss.
HRT has a protective
effect and can be used in some forms of ovarian cancer as well. Consult your
oncologist for all of these. Alzheimer is less frequent in women who are on HRT.
In older women it is useful for Osteoporosis and Genito Urinary Syndrome of
Menopause.
PREMATURE OVARIAN INSUFFICIENCY
When a woman’s ovaries
cease to function before the age of 40, it is referred as premature ovarian
insufficiency. Generally if it occurs near the age of 40, it is often referred
as premature menopause, however if it happens in a teen ager it can be very traumatic.
It used to be called as ovarian failure; however the term insufficiency is preferred
as it tends to have intermittent remissions. With reference to Menopause it is
simple expect in some situations when a women has not yet achieved her child
bearing. If she had normal periods until now it only means that is run out of
her eggs. If she has finished her child
bearing, she can be advised and treated like any menopausal woman after
confirming the diagnosis, advice about cardiovascular disease, osteoporosis and
contraception. If there is desire to try for a child she can be referred to, have
help from specialist on reproductive technologies, which are very skilled now.
Recently they are even trying to use Stem cell techniques to produce new eggs,
which we always thought could never happen.
A NEW DRUG
This drug called MLE
4901 is currently being studied in London for Vasomotor Symptoms of Menopause, by blocking a receptor
in the brain called NKB, it is linked to hot flushes, lack of concentration,
sleeping problems, weight gain and many other targets and works within 3 days.
It is still being studied.
Key points
1.
Women should be as
informed as much as possible about menopause and its symptoms. Long term problems
such as, Osteoporosis, Cardiovascular Diseases and Gentourinary Syndrome these
benefit with proper treatment. This is provided in full agreement to women. HRT
or MRT is the best treatment. The
benefits are enormous as long as it is started soon after menopause or even in
peri menopause if you have symptoms.
2.
It should be started
soon after menopause within 6-10 years and under the age of 60.
3.
The side effects during
HRT can also be due to aging rather than HRT alone.
4.
The studies that were
conducted by WHI giving serious results due to HRT were due to a poor selection
of women and their age group rather than HRT. They themselves have tried to
revise their results. They reported the
risk of breast cancer as 25% how ever there is only 1 extra woman who gets
breast cancer out of 1000, in one year.
Similarly if you take HRT in early years 50% less women die of heart
attack in their older years and have fewer deaths due to osteoporotic
fractures.
5.
Recently many safer
HRT’S and their relative drugs have been discovered which are safer, have less side
effects, protective against breast cancer, stroke, heart attacks, osteoporotic
fractures and genitor urinary syndrome of menopause.
6.
There are many
different routes by which HRT can be delivered; better quality of oestrogens
can be delivered as transdermal, gel, patches, implants, and injections. They
protect the liver and are effective against the thromboembolic disorders.
7.
There are new antidepressants
that can be used for treatment of vasomotor symptoms in women after breast
cancer that cannot use HRT.
8.
There is another group
of drugs called SERMS which are useful for treatment of osteoporosis and
genitourinary syndrome of menopause. Laser treatment is also being tried with caution
for this.
9.
Side effects can be
eliminated by adjusting the drugs, dose, and route of delivery.
10.
Although not addictive,
HRT does cause withdrawal symptoms, mainly hot flushes. HRT should be stopped
gradually to avoid these unpleasant symptoms.
11.
Life style factors are
important and should be taken care of, to make menopause happy and healthy.
New drugs and research
is continuing to make this long period of women’s life happy, healthy and fulfilling.
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