HRT

Diagnosing the menopause

The menopause is often a diagnosis made retrospectively
Contraception is still needed during the peri-menopausal years
There is little place for the routine measuring of FSH, LH or oestradiol as women may suffer with vasomotor symptoms but have normal FSH, LH and oestradiol levels.
If FSH, LH and oestradiol levels are measured then blood should be taken within the first 5-7 days of the menstrual cycle.
FSH may be of some use in women: - Under 45 years with atypical symptoms - To help diagnose the menopause in those women taking COC or HRT - Who have had a hysterectomy with conservation of the ovaries.
Oestradiol levels may be useful:
- To assess the level of oestradiol absorption in patients using non-oral therapy in respect to adequate bone preservation or poor vasomotor symptom control.
- In the management of patients with oestradiol implants (preventing tachyphylaxis).

Menopause and contraception

Menopausal women over the age of 50 should use a contraceptive method for one year following their last menstrual period.
Women under 50 should use a contraceptive method for 2 years following their last menstrual period as break through ovulation can occur.

Women using the combined oral contraceptive PILL (COC)

May develop vasomotor symptoms in the pill free interval
May have a rise in FSH during the pill free interval in 30% of menopausal women
Diagnosis of the menopause may be possible by checking the FSH on day 7 of the pill free interval.
- if the FSH is 30 U/L or more it should be repeated in 3 months - if the FSH is again raised above 30 U/L it is likely that the woman is menopausal
- contraception should be continued for the next 2 years (the COC should only be used in women under 50 years old).
Alternatively, a 50 year old woman could change to using a different contraceptive method such as a POP. If no bleeding occurs in the first two months an FSH level can be measured. If the FSH level is 30 U/L or more the above procedure is followed.

Contraception in women using HRT

A number of women start HRT before the cessation of menstruation
HRT is not a contraceptive
The menopause is suggested if an FSH level taken within 7 days of the start of a withdrawal bleed is >30 U/L on two separate occasions, 1 – 3 months apart.
In women under 50, contraception should be continued for two years.
In women over 50, contraception should be continued for one year.

Indications for HRT

To treat menopause vasomotor symptoms.
To treat menopause urogenital symptoms.
To prevent and treat osteoporosis.

Possible benefits

To prevent the development of coronary heart disease and secondary prevention of CHD.
To reduce cerebrovascular accidents.
To delay the onset and retard the progression of Alzheimer's disease.
To prevent mood swings and depression at the time of the menopause.
To decrease the incidence of large bowel cancer.

Which regime?

Women who have had a hysterectomy can use unopposed oestrogen orally, by patch, gel or implant.
Women who have a uterus or who have undergone endometrial ablation need continuous oestrogen with cyclical or continuous progesterone, i.e. for 10-14 days every 28 days, for 14 days every 3 months or continuously.

Contra-indications

Active breast cancer/undiagnosed breast lump
Active thrombo-embolic disease (not phlebitis)
Undiagnosed vaginal bleeding
Uncontrolled hypertension

Extra caution is required if prescribing for women with the above conditions.

Alternative therapies for controlling menopausal symptoms

Tibolone may decrease vasomotor symptoms.
Clonidine may reduce vasomotor symptoms in 30% of women.
Norethisterone 5-15 mg and Megestrol 40 mg may reduce vasomotor symptoms in 60% of women and may offer bone protection.
Transdermal natural Primrose Oil (no scientific data).
Chinese angelica (unproven).

Alternative Therapies for the Prevention of Osteoporosis

Tibolone
Raloxi feve (selective oestrogen receptor modulator)

Menopause and contraception

Menopausal women over the age of 50 should use a contraceptive method for one year following their last menstrual period. *
Women under 50 should use a contraceptive method for two years following their last menstrual period as breakthrough ovulation can occur.

Women using the Combined Oral Contraceptive Pill

May develop vasomotor symptoms in the pill-free interval.
May have to rise in FSH during the pill-free interval.
Diagnosis of the menopause is possible by checking the FSH on day 7 of the pill-free interval. If the FSH is 30 U/L or more it should be repeated in 3 months. If the FSH again is raised above 30 U/L, then it is likely that the woman is menopausal. Contraception should however by continued for the next two years.

Contraception in Women Using HRT

A number of women are commenced on HRT before the cessation of menstruation. The menopause is suggested if an FSH level taken within 7 days of the start of the withdrawal bleed is more than 30 U/L on two separate occasions.

In women under 50, contraception should be continued for the next two years.
In women over the age of 50, contraception should be continued for one year.

Recommended products

	First choice	Alternatives	Notes
Sequential combined therapy	Prempak-C	Nuvelle Femoston 2/10 Femoston 2/20	Nuvelle is the alternative for those women objecting to conjugated oestrogens (obtained from horses). Femoston 2/10 is useful when an alternative progestogen is required and Femoston 2/20 gives a higher dose of progestogen for improved cycle control.
Continuous combined therapy	Premique		Cheaper than Kliofem and Climesse. Tibolone can be used for patients who have a family or personal history of breast cancer and post-menopausal women who are intolerant of continuous combined therapy who request a period free preparation to help prevent osteoporosis.
Combined patches/patches/tablets	Nuvelle TS (oestrogen and progestogen patches)	Evorel patch (oestrogen patches and progestogen tablets)	Tablets should be first choice therapy. The patches are inatrix-type which are preferred to reservoir type patches (Estracombi and Estrapak) as they adhere better and are better tolerated.
Oestrogen only tablets	Conjugated oestrogens (Premarin)	Oestradiol (Elleste Solo)
Oestrogen patches	Twice weekly patches - oestradiol 25, 50, 100. Once weekly patches - Progynova TS		The matrix type patches are preferred as they adhere better and cause less irritation. Initial dose is 50 micrograms but 25 mcg patches may be needed by older patients if they experience side effects.
Adjuctive Progestogens	Norethisterone 1 mg	Dydrogesterone 10 mg	For use by women with an intact uterus using oestrogen only patches or tablets.
Topical Oestrogens (for atrophic vaginitis)	Oestriol 0.01% cream (Artho-gynest)		Oestriol cream is preferred to Dienoestrol and Premanin as systemic absorption and effects on the uterus are less. Vagifem pessaries and Estring can be used by patients where there is difficulty using Oestriol cream. If long-term use is required, Estring is cheaper than Vagifem.

Non-equine alternatives

	Manufacturer	Drug	Form	Source	Vegan?
Non-equine alternatives for oestrogen replacement	Sandoz	Climaval	Tablets	Synthetic	Not known
	Shire	Hormonin	Tablets	Not known	Not known
	Schering	Progynova	Tablets	Soya	No
	Duphar	Zumenon	Tablets	Soya/other plants	No
Non-equine alternatives for oestrogen/progestogen replacement	Sandoz	Climagest	Pills	Synthetic	Not known
	Schering	Cyclo-progynova	Tablet	Plant/other	No
	Schering	Nuvelle	Tablet	Soya	No
	Roche	Menophase	Tablets	Synthetic	No

Risks of HRT

Breast cancer
HRT risks and benefits (Regional Drug and Therapeutics update 11/01)
HRT - breast cancer risk 2005

Oestrogen implants

Check the Oestradiol levels 6-monthly to make sure that the implant is needed.
The Oestradiol level should be between 300 and 600 units

Further information

HRT patient advice leaflet
HRT and breast cancer patient advice leaflet
HRT - breast cancer risk 2005
The Womens Nutritional Advisory Service offers a free menopause information package: tel 01273 487 366
The Menopause Helpline gives free advice on 0181 444 5202
Menopause Matters

Based on guidelines of the Newcastle and North Tyneside Health District Drug and Therapeutics Committee.