Menopause - Listen to Your Patients
Menopause Advice and Consultation
I have been at the Society for Endocrinology, British Endocrine Societies Meeting in Glasgow this week.
Once again we have had a selection of great talks on the menopause, natural or premature and what it might mean for women. These are the padded out notes from a key session from Nick Panay (Chelsea & Westminster, London) about HRT: Efficacy and Safety.
The Women's Health Initiative may have set back the use of HRT for many women, and perhaps unfairly, due to high doses in a relatively elderly population, and that data was applied to younger patients, without considering changes in dosage and formulations of HRT.
The most salient piece of advice from the talk and from my own practice is - Listen to Your Patients. Do not make decisions for them. Our job is to give the best information to the patient, based on our assessment of their health, to allow them to make the most informed decision. Occasionally we need to strongly advise patients on a course of action, but the patient should have the same information as us or as close as is practical.
HRT protects against cardiovascular disease, cognitive decline and Parkinson’s disease, and averts the symptoms of the menopause and its transition.
The transition to the menopause starts, in some women, seven years before their last period. During this time one may get symptoms of oestrogen deficiency, flushes, poor sleep, reduced libido and loss of sense of well being and these can be treated with HRT. The cardiovascular benefits of HRT might be larger the earlier it starts, and this might assuage some of the anxiety about using it during the menopause transition if it is right for the patient. We are rarely prescribing HRT as a permanent solution at first, it is often a trial, to see how the patient is, so they can be more informed about continuing or not.
Younger women tend to need higher, more physiological, doses of oestrogen. And we believe modern HRT is safe until the 50 years of age (the age half of women will have had their menopause by), and generally safe for five years beyond, with due consideration of the pros and cons. The decision to stay on or stop should be assessed yearly and of course yearly beyond 55 years.
Do not forget that local symptoms of oestrogen deficiency, such as vaginal dryness and/ or atrophy may respond very well to local oestrogen and this can be continued indefinitely.
Women with a uterus need a progesterone and the choice of progesterone is important for how the HRT performs and its safety. In the WHI many of the patients were on medroxyprogesterone acetate and this might have contributed to the risks of HRT in that study. Dydrogesterone or micronised progesterone
The combined hormonal contraceptive pill used to the menopause is an option, but it has not been studied in comparison to standard dose HRT - obviously there is a contraceptive benefit, but the doses of hormones are much higher, probably with a higher risk of venous clots. In the
Transdermal oestradiol does not increase the risk of venous thromboembolism. The choice of progestagen is very important; MPA was a troublesome drug in the Women’s Health Initiative! For women who might want an oral preparation dydrogesterone or micronised progesterone is felt to be safer (and the latter is what many of my patients now take, via capsule).
Listen to your patients - libido and sexual function are important, the ovaries make testosterone as well as oestrogen and they might benefit from testosterone therapy. Get the standard HRT right and then consider testosterone for interest/ function/ well-being. And try it for 6 months at least.
A GP might be able to advise you on the correct thing to do, but if you need to see a specialist, make an appointment at LondonSwissMedical for a consultation.
Dr Philip Kelly is an specialist endocrinologist who diagnoses and treats the menopause, as well as considering if the symptoms might be from another problem. If you would like an appointment please visit the website, click on the button below or call 020 3299 3848
There are other doctors in London who manage the menopause and my obstetric and gynaecology colleagues here in The Guthrie Clinic are also happy to see patients. So do not hesitate to ask for advice about who to see.