Professional Documents
Culture Documents
Climacteric
The phase in the aging process of women marking the transition from the reproductive stage of life to the nonreproductive stage
Menopause
The final menstrual period and occurs during the climacteric. The average age of menopause is 51.
Menopause
Premature menopause Surgical menopause Natural menopause
Diseases (late)
Menopausal symptoms
Vasomotor symptoms: hot flushes, night
sweats and palpitation
Osteoporosis
Oestrogen deficiency Peak bone mass at 30-35 years old Bone loss at a rate of 0.5-1% per year afterward Bone loss at a rate of 2-3% per year for 10 years after menopause Osteoporosis is associated with fracture ( femoral neck, vertebral body and distal radius)
Family history Ethnicity Early menopause Hypoestrogenism (excessive exercise, anorexia, bulimia) Hyperthyroidism, excessive thyroxine therapy Cigarette smoking Caffeine High alcohol intake
Cardiovascular disease
Rapid increase in mortality and morbidity from cardiovascular disease after menopause Epidemiological evidence suggests that HRT is associated with 50% reduction in cardiovascular risk in menopausal women There is no prospective randomised data to show that HRT is effective in the primary prevention of cardiovascular disease.
Management of menopause
Advise on a healthy life style
Psychological support Hormone replacement therapy
Understand menopause Strengthening of self-image Avoid spicy food, alcohol, strong tea and coffee. Healthy life style Hormone Replacement Therapy
Prevention of osteoporosis
Change lifestyle risk factors Exercise Adequate calcium / vitamin D intake Hormone Replacement Therapy Alendronate Raloxifene
Prescribing HRT
Absolute contraindications
Absolute contraindications
Existing breast cancer
Existing endometrial cancer Venous thrombo-embolism Acute liver disease
Oral therapy
Natural occurring oestrogens: includes
premarin and various oestradiol preparations. These oestrogens are metabolised in the liver to the weaker metabolite oestrone and then converted to oestradiol in the peripheral circulation and in the target tissue.
Transdermal therapy
Patches (oestrogen only or combined preparation) or oestrogen gels Womens preference Skin irritation may be a problem but new matrix patches and the gels are usually well tolerated Route of choice for women with risk factors for venous thrombo-embolism, liver disease or gastro-intestinal problems
Oestrogen implants
Now less widely used Implants should be given no more than every 6 months Not commonly used in HK
HRT regimens
Women who have had a hysterectomy only need to take oestrogen Women with an intact uterus must take progestogen for endometrial protection to prevent endometrial cancer or hyperplasia
Regular surveillance of endometrium is required for women (extreme intolerance of progestogen) on unopposed oestrogen
Commence HRT
Previous hysterecomy Unopposed oestrogen therapy Intact uterus + amenorrhoea < 2 yrs Cyclical / sequential HRT Intact uterus + amenorrhoea > 2 yrs Continuous combined HRT
HRT regimens
Sequential preparation: progestogen added
for 12-14 days each month. Some women will not bleed on sequential preparations and this is not a cause for concern provided that the progestogen is taken correctly.
Progestogen
Oral or transdermal form
Levo-norgestrel releasing intra-uterine system
Oral progestogens
C21 progesterone derivatives : dydrogesterone or medroxyprogesterone acetate
C19 nor-testosterone derivatives: norethisterone acetate or levonorgestrel
Risk of HRT
Breast cancer
Thrombo-embolism
1.023 (1.011-1.036)
1.35 (1.210-1.400)
For women aged 50-70 years not using HRT, about 45 in every 1000 will have breast cancer diagnosed over the next 20 years.
Extra breast cancers in HRT users, above the 45 occurring in Non-users, over 20 years 2 per 1000 6 per 1000 12 per 1000
The extra risk of developing breast cancer on HRT does not persist beyond about 5 years after stopping treatment.
Women taking HRT diagnosed with breast cancer are less likely to have tumours with metastatic spread and therefore have an improved prognosis. Regular mammography is indicated for women on HRT after 50 years old. There is no indication to arrange mammography routinely for women commencing HRT under the age of 50 years.
Duration of treatment
Indication of HRT
Menopausal symptoms
Duration of treatment will depend upon the womens preference and the presence of risk factors
In the absence of risk factors, HRT can be stopped after 2 years
Prevention of Osteoporosis
10 years after HRT has been stopped, bone density and fracture risk are similar in women who had used HRT and those have not
Long term treatment (>10-15 years) is required to prevent osteoporosis Constant reassessment (general health, risk factors and life expectancy) is required.
At each visit
Every 2 years
As indicated
Bleeding pattern
Tibolone
Steriod hormone The parent compound and its metabolites can all bind to steroid receptos Oestrogenic, progestogenic and androgenic properties Different hormonal effects predominate in different tissues. Oestrogenic: climacteric symptoms, bone and lipid Progestogenic: endometrium Androgenic: libido Breast: less breast pain and no change in breast density on mammography
Bisphosphates
Etidronate and Alendronate Inhibitors of bone turnover and slow down or prevent bone loss Both need to be taken on an empty stomach Non-hormonal agents Treatment of choice for older women and those with contra-indications to HRT
Raloxifene
Selective oestrogen receptor modulators (SERMs) Agonist and antagonist properties Bone protective and reduce cholesterol No effect on the endometrium Evidence to suggest that it is protective against breast cancer Does not help menopausal symptoms and may worsen them
Summary
Menopause provides an excellent opportunity for the woman to see a doctor and discuss about her own health Health education Promotion of healthy life style Update on the various options for long term health benefit