History
- To establish diagnosis
- To assess positive indications for HRT
- To determine any specific risks or contraindications for HRT
Symptoms Associated With The Menopausal Transition
These include:
- Hot flushes
- Night sweats
- Vaginal Dryness
- Menstrual irregularity
Symptoms not specific to menopause include:
- Lack of concentration
- Failing memory
- Sexual dysfunction
- Arthralgia
- Depressed mood
N.B. Exclude cyclical symptoms and PMS
Examination
Consider breast, abdominal and pelvic examinations if clinically indicated
Treatment
Non-Hormonal
- Lifestyle
- Medication
- Alternative therapies
Hormonal
- Types available
- Indications for use
- Patient preference
Advice and Information
Physiology including:
- Average age of the menopause in the U.K. is 50.7 years
- 5% of women undergo the menopause at age < 45 years
- 1% undergo the menopause at age < 40 years
- Irregular cycle common in the perimenopause
- Intermenstrual bleeding requires endometrial assessment
Benefits of HRT
- Symptom relief and urogenital atrophy
- Prevention of osteroporotic fractures
- Reduces risk of heart disease
- Delays onset of Alzheimer’s Disease
- Reduces risk of colon cancer
- Reduction of late onset diabetes
Risks of HRT
- Breast cancer
- Thromboembolic disease (with oral route)
- Side-effects
- Endometrial cancer
- Ovarian cancer
- Gall bladder disease
- Ischaemic stroke
Each of these factors will vary in importance for each woman and will need assessing individually
No Contraindication to HRT or Positively Indicated
| Asthma | HRT not contraindicated if stable. If poorly controlled, stabilise before initiating HRT. Estrogen may improve and progestogens may exacerbate the symptoms. |
| Benign Breast Disease | Proven benign breast disease is not a contraindication. |
| CIN, Abnormal Smears and Carcinoma or Cervix | Not contraindicated. |
| Contact Lens Wearers | May alter corneal curvature. Rarely a problem in practice. |
| Depression | Estrogen not contraindicated. Progestogens may exacerbate problems. |
| Diabetes | HRT – no evidence of diminished glycaemic control. Advise referral to specialist menopause clinic. |
| Endometriosis | If asymptomatic, may prescribe HRT. Rarely causes activation of disease. Consider use of continuous combined therapy to suppress endometriotic foci even after hysterectomy. |
| Hyperlipidaemia | HRT has a beneficial effect on lipid profile. May be used in conjunction with diet and other lipid lowering agents. Oral estradiol increases triglycerides and transdermal preparations decrease triglycerides. |
| Hypertension | Oral HRT rarely causes increase in BP and may cause a small fall in BP secondary to vasodilation. Regimens with drospirenome reduce BP. Long term studies tend to show a drop of about 2mm Hg with HRT. Monitor in a routine manner. |
For follow-up, visit Appendix 11
For ongoing support, visit Appendix 13