Health Menopause professional tool Assessment & management Phases of female Routine screening reproductive cycle Menopausal women are at increased risk of: • Regular cycles heart disease, osteoporosis, central adiposity, mood disorders. • ‘premenopause’ Exclude – thyroid, diabetes, iron deficiency, drug side effects • Change in cycle frequency • Bleeding changes – recent changes in bleeding pattern including heavy bleeding ‘early perimenopause’ Investigate for iron deficiency and gynaecological pathology • Cycles up to 3-12 months apart • Check last cervical screening test and mammogram • ‘late perimenopause’ Metabolic syndrome – monitor BP, cholesterol, blood glucose, abdominal girth and weight • Final menstrual period – discuss with patient the need to increase activity and monitor caloric intake • ‘menopause’ (average age 51 years) Bone density – see bone health section • No menstrual cycles >12 months • Smoking – discuss with patient the need to cease smoking ‘postmenopause’ Based on symptom report only. Hormonal Key messages screening unreliable due to unpredictable • Hot flushes – dress in layers, natural fibres, reduce weight, reduce alcohol, increase activity, fluctuations. FSH levels may be helpful in reduce caffeine, healthy diet young women. • Dry vagina – local treatments: vaginal oestrogen cream, pessaries and tablets. Encourage patients to select vaginal lubricants and moisturisers most similar (in pH and osmolality) Commonly reported to natural vaginal secretions, as this may make them less likely to cause irritation menopausal symptoms { There are many vaginal lubricants (for use during intercourse) for urogenital symptoms include: and vaginal dryness. Those listed in pink meet the suggested pH and osmolality composition: Astroglide®, KY® Jelly, pjur® and Yes ®. It is also possible to use natural oils • Hot flushes • Fatigue eg olive, sweet almond oil • Night sweats • Crawling ® ® { Vaginal moisturisers (for regular, twice weekly use): Replens , Yes • Muscle/joint pains sensations • Emotional health – ask initial screening questions (back page) • Anxiety on skin • Stress management – discuss with patient the need to actively manage stress and mood • Irritability • Overall eg activity, mindfulness, social connectedness • Sleep disturbance diminished • Diet – phytoestrogen diet may assist in symptom reduction • Lessened wellbeing concentration • Low libido Use of natural supplementation • Vaginal dryness There is some evidence of effectiveness for the following supplements: • Painful intercourse Black cohosh (Remifemin® and Femular®) – decrease hot flushes. Monitor for signs of liver toxicity. HRT/MHT* candidates • Women experiencing menopausal Contraindications for HRT/MHT Alternatives to HRT/MHT symptoms (peri or postmenopause) (consider referral to menopause specialist) Pharmaceutical Dose • Women with early or premature menopause • • (bone sparing and reduces CVD risk) Breast cancer (hormonally sensitive) Escitalopram 10-20mgs daily • • Women with osteoporosis <60 years Thrombophilia/past venous • Venlafaxine 37.5-75mgs daily thrombo-embolic event (VTE) • Women within 5-10 years of last period • Desvenlafaxine 50-100mgs daily • Undiagnosed vaginal bleeding for vasomotor symptoms • • Active liver disease Paroxetine** 7.5-10mgs daily In general use: lowest effective HRT/MHT dose • Uncontrolled hypertension • Gabapentin 300-900mgs daily for the short-term relief of menopausal symptoms, • except for early/premature menopause – higher CVD risk or disease • Clonidine 50-150mcg daily dose and long-term therapy. Effectiveness monitored by self-reported symptom control. ** (not to be used with Tamoxifen) Women with a uterus: important to note that HRT/MHT is not a contraceptive Early (<45 years)/ Menopausal transition Postmenopause premature (<40 years) menopause Dosage: lowest effective dose monitored Dosage: lowest effective dose monitored Continue HRT/MHT until 50 years unless by self-reported symptom control by self-reported symptom control contraindicated. Higher doses usually Options: Options: required. 1. Low dose combined contraceptive 1. Continuous oestrogen Options: (if low CVD risk & <50 years) + continuous progestogen 1. Continuous oestrogen 2. Continuous oestrogen (if menopause >1-2 years ago) 2. Continuous oestrogen (high dose oestrogen due to age) + cyclical progestogen 10-14 days each month + cyclical progestogen + cyclical or continuous progestogen + contraception (including barrier, sterilisation) (if menopause <1 year ago) 2. Combined contraceptive 3. Continuous oestrogen or levonorgestrel IUD 3. Tibolone + levonorgestrel IUD for progestogen and 3. Tibolone (if menopause is >1-2 years ago) contraception 4. Tissue-selective oestrogen complex (TSEC) Review: initially 2-6 months then assess benefits/side effects, address concerns, titrate regimen to suit the individual woman – assess need, new development/options, CVD and breast cancer risk. Then annual review. Special considerations After hysterectomy increase in size – less likely with tibolone or If atrophic endometrium (<4mms on US), Continuous oestrogen or tibolone. transdermal oestrogen and progestogen. reduce progestin/increase oestrogen. Otherwise, increase progestin dose/ Androgen deficiency Hirsutism length/type; levonorgestrel IUD. Not OCP or oral oestrogen; Oral oestrogen to increase SHBG: Testosterone therapy use transdermal oestrogen to lower SHBG; cyproterone, dydrogesterone, drospirenone consider testosterone if low calculated free or oral progesterone as progestogen. Testosterone 1% cream (for women) is testosterone, or tibolone. Can also use spironolactone. TGA approved for clinically diagnosed hypoactive sexual desire disorder (HSDD) Liver disease, gallstones Breast cancer or low sexual desire with distress, when all Refer to HRT/MHT contraindications. Vaginal Transdermal. other causes are excluded. Free oestriol for vaginal and urinary symptoms. Mastalgia testosterone is measured to exclude a high level. Cardiovascular disease (hypertension, Lower dose, transdermal oestrogen, tibolone, diabetes, hypercholesterolemia) testosterone, evening primrose oil caps. Urogenital symptoms alone Use transdermal if menopausal symptoms Migraine Vaginal oestradiol/oestriol – regular use 2-3 times weekly. bothersome. Transdermal oestrogen and progestogen, Compounded hormones lower dose, avoid oral progestogens; Varicose veins Advise against compounded bioidentical continuous therapy, not cyclic. Transdermal or tibolone preferred routes hormone therapy as not TGA approved. Obesity/morbid obesity of administration. Endometrial cancer Transdermal. VTE/thrombophilia Tibolone or HRT/MHT (refer to menopause Ovarian cancer Assess baseline risk; high risk if VTE recurrent, spontaneous, with pregnancy/ expert/liaise with oncologist/gynaecologist), No special regimen. Liaise with oncologist/ OCP, family history, smokers; screen for usually only stage 1. gynaecologist, as some cancers are inherited thrombophilia. If normal and Endometriosis hormonally sensitive. low risk, use transdermal or tibolone. OCP, levonorgestrel IUD + oestrogen, Progestogen side effect If high risk or inherited thrombophilia, tibolone, continuous combined HRT/MHT; Change progestogen, tibolone. avoid HRT/MHT unless anticoagulated; with post-surgical menopause need to PV bleeding seek specialist haematological advice consider added progestogen/tibolone. Investigate to determine cause and exclude re use of transdermal HRT/MHT. Fibroids pathology prior to treatment – transvaginal Weight increase No special regimen; theoretically may ultrasound +/– hysteroscopy. Not related to HRT/MHT. Bone health Indications for bone density assessment: • Some chronic diseases eg rheumatoid arthritis, • Family history of osteoporosis chronic liver or kidney disease • Overactive thyroid or parathyroid • Corticosteroid use or exposure • Malabsorption eg coeliac disease, inflammatory • Some medicines for breast cancer and epilepsy bowel disease and some antidepressants Osteoporosis Osteopenia Normal T-score below -2.5 T-score between -1.0 to -2.5 T-score above -1.0 Rx aim: prevent further bone loss and fracture Rx aim: prevent further bone loss Rx aim: prevent further bone loss and fracture Plain X-ray thoracic lumbar spine to exclude Plain X-ray thoracic-lumbar spine to exclude Regular weight bearing exercise, optimise compression fracture compression fracture calcium intake + vit D levels Exclude other causes: Regular weight bearing exercise, optimise Monitor bone density at 70 years or earlier • Calcium, phosphate, vit D, PTH, TFT, LFT, calcium intake + vit D levels if requested ESR, serum/urine protein electrophoresis, coeliac antibodies Monitor bone density DXA 2-5 yearly. • Use FRAX risk calculator Use FRAX risk calculator Regular weight bearing exercise, optimise If T-score between -2.0 to -2.5 calcium intake + vit D levels: and they are high fracture risk • HRT/MHT <60 years Refer to specialist for consideration: • Tibolone <60 years • HRT/MHT <60 years • Bisphosphonates • Tibolone <60 years • Raloxifene • Bisphosphonates • Denosumab • Raloxifene • Monitor bone density, DXA 2 yearly • Denosumab and bone markers • Monitor bone density, DXA 2 yearly and bone markers Assessment of emotional wellbeing in menopausal women Women experiencing premature or early menopause are at increased risk of depression and anxiety. Routine screening is recommended for this patient group. Initial screening questions Screening tools for To order copies: 1. During the past month have you often depression and