Updates in menopause diagnosis and care
Even with women’s health finally getting the consideration it deserves in undergrad and post-grad medical training, there’s still a lot of uncertainty around the diagnosis and treatment of menopause.
In a recent webinar with Dr Schachinger, a GP with an extended role in gynaecology, we explored what GPs should know when working with menopausal patients.
This article summarises the key points Dr Schachinger shared.
While menopause typically lasts 4 to 7 years, symptoms can persist up to 12 years. The normal age of menopause is 45 to 55 years, but 42% of women still have symptoms at age 60 to 65, and 75% have vasomotor symptoms like hot flashes and night sweats.
Early menopause occurs in patients aged 40 to 45. POI can be diagnosed if the patient is under 40 with 2 FSH levels six weeks apart, although FSH levels are unreliable in patients on combined contraceptives – you have to stop contraceptives and then test.
In order to effectively diagnose menopause patients from a long list of symptoms, give them an in-person survey or send it via email. Take time to listen to what the patient wants, and explain potential treatments and alternate options. Menopause symptoms include:
- Menstrual change
- Poor sleep
- Low mood, anxiety
- Brain fog, cognitive function
- Skin, hair and joint issues
- Vaginal dryness
- Low libido
Treatment optionsThere are several alternative treatments for menopause that, while more effective than placebos, are not recommended due to safety concerns:
- Isoflavones and soya products: Most studies are of poor quality and their safety for breast cancer patients is inconsistent
- Black Cohosh: While some studies show effectiveness in hot flush reduction, it interferes with Tamoxifen activity
- St John’s Wort: Has the potential for serious drug interactions because of uncertainty around proper doses
If patients don’t want or can’t have hormone replacement therapy (HRT), other options for treatment include:
- CBT for mood disorders like anxiety and depression
- Sleep hygiene, exercise, relaxation techniques
- Clonidine, gabapentin, pregabalin, SSRI, SNRI, paroxetine, etc
- Referral to menopause specialist services
HRT is most effective for symptomatic women in peri or post-menopause. It’s recommended for POI patients at least until age 50 and can help prevent or treat osteoporosis.
Risks of HRT
While HRT can be an effective treatment for menopause systems, it does come with risks.
Combined HRT has a small increased risk of breast cancer, and the risk is slightly higher in continuous HRT compared to sequential HRT. Oestrogen only carries an increased risk of breast cancer, but vaginal HRT only does not. The risk is duration dependant and less than other postmenopausal lifestyle factors like a BMI over 30. For most of the population, the benefits of HRT for up to five years will exceed the potential harm. For POI patients, HRT is only a risk for those over 50.
Oral HRT increases the risk of venous thromboembolism (VTE). However, the risks associated with transdermal HRT given at standard therapeutic doses are no greater than the baseline population risk. You should refer patients at high risk of VTE to a haematologist for assessment before considering HRT.
HRT does not increase the risk of heart disease when started in women under the age of 60. Oestrogen is associated with no or reduced risk of cardiovascular disease (CVD).
Perimenopausal women with no history of migraine aura may benefit from continuous combined hormonal contraception until age 50. Migraine aura does not contraindicate HRT. When prescribing HRT, use the lowest oestrogen dose that effectively controls vasomotor symptoms. Where progesterone is required, continuous delivery is recommended.
While there have been HRT shortages in the last few years, the British Menopause Society gives regular updates on HRT supply, and pharmacists should know what’s available.
It’s important to remember that HRT is not a contraceptive. Contraception needs to be offered in addition to HRT.
Prescribing vaginal oestrogen
Vaginal oestrogen is something to consider for every patient. It can be used as an adjustive to systemic HRT or alongside it, and it’s equivalent to one HRT tablet a year. It’s very safe to continue as long as needed, but breast cancer patients should consult their oncology team.
- Vagifem (Vaginal tablet)
- Ovestin (Cream)
- Blissel (Gel)
- Estring (Change every three months, good for nursing home residents)
Testosterone Px in women
Currently, testosterone is a red drug scheduled to come off the list soon. Once it’s off the list, there will be prescribing guidelines available.
In combination with HRT, testosterone can help women with low libido. Before prescribing, step back and make sure the HRT preparation is actually working. Do bloods to find the free androgen index (FAI), which is (testosterone/SHBG x 100). Female FAI should be under 5. If the patient is symptomatic and the FAI is low, it’s very reasonable to try testosterone.
Most testosterone products are for men only, and women need much lower doses. After prescribing, you should re-check FAI after three months and then every year. Because testosterone prescription is off-licence, you should never go above the limit.
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