Menopause and HRT

Menopause

Some definitions

There is a difference between the colloquial terms surrounding the menopause and the medical ones can be very different. Hence, this section:

• The menopause is the last period a woman has.
• She has to be period-free for a year in order for it to be considered her last.
• Evidently, this is a retrospective diagnosis as women generally don't know their last period is their last until they've had it.

The climacteric is the preceding time where a woman moves from a reproductive state to a non-reproductive state. Postmenopausal bleeding is where bleeding restarts after 12 months since the menopause.

Physiology

There are a limited number of follicles in the ovary and when the numbers start to dwindle, ovulation and thus menstruation begin to become erratic as oestrogen levels start to fall. Some of the initial symptoms of menopause may start to show through. Eventually, oestrogen levels fall because there are no follicles to produce it, stopping the negative feedback which keeps FSH and LH levels down. Thus their levels go up.

Symptoms

Short-term

• Vasomotor symptoms - (hot flushes) (70%) are one of the earliest symptoms of the menopause. Women feel intensely hot, sweat a lot and blush.
• Psychological symptoms are common - anxiety, lethargy, insomnia, reduced libido and poor concentration.
• Sexual dysfunction can also occur - decresed desire and arousal, dyspareunia and anorgasmia.

Medium-term

These are basically:

• Atrophy of the skin - it loses loses collagen, so dries and becomes wrinkled and can result in hair loss. It also affects the breast as fatty tissue is replace and they shrink.
• Atrophy genital tract - the vagina becomes drier and its walls, thinner. The pH rises making it more prone to infection and laxity in the pelvic floor can result in vaginal prolapse which is not very fun.
• Atrophy of the urinary tract - symptoms in the urinary tract include urgency, frequency and the inability of complete bladder filling. The latter happens due to bladder atrophy. Atrophy of the urinary tract commonly causes incontinence.

Long-term

These symptoms of the menopause are more serious. The first is the effect on bone density. Oestrogen deficiency causes calcium loss (though I'm unsure of the mechanism - please fill it if you know). This calcium loss can reduce bone density by a third over 20 years i.e. it results in osteoporosis - a reduction in bone density. This affects 1 in 3 women and increases risks of fracture (particularly Colles fracture and fractured neck of femur) and height loss (reduction in the bone density of vertebrae).

There is also an increased risk of vascular problems, particularly cardiac and cerebrovascular disease. After menopause, the risk of a stroke or MI increases to the equivalent level for a man. They are uncommon in premenopausal women.

Investigations

LH and FSH levels are unreliable as they fluctuate in the climacteric. Mammography is advised 3-yearly after menopause. and bone density assessment is required in women at-risk of osteoporosis which involves a variety of imaging.

Hormone Replacement Therapy

This shouldn't be given out to everybody. Essentially, it's risk vs. benefits including how the women feels. If she's not being affected by the menopause and she isn't at particularly high-risk of anything, HRT is unnecessary. And the same applies the other way. Of women prescribed HRT, <50% continue after a year.

Preparations

This is the timeline for oral preparations of HRT.

HRT consists of a combination of oestrogen and progestogens. Oestrogen is the main hormone you're trying to replace but "unopposed oestrogen" increases risk of endometrial carcinoma. Hence, progestogens are also given as part of the preparation unless the woman has had a hysterectomy.

Oral preparations involve taking 28 days of oestrogen and 12 days of progestogens. A withdrawal bleed will occur at 12 days after stopping the progestogens. This 28-day cycle is repeated until HRT is stopped.

Implants can be inserted subcutaneously into the abdominal wall under local anasthetic. This will last up to a year but the patient still needs progestogens if she still has her uterus. Testosterone can be given via implant to improve libido.

Other alternatives are: transdermal patches containing oestrogen; daily gel which is rubbed into the skin; and finally nasal sprays and vaginal rings. Progestogens (needed in an intact uterus) can be given by patches as well.