MENOPAUSE AND PERIMENOPAUSAL SYNDROME

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GENERAL MEASURES

Counselling.

Stop smoking.

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Maintain a balanced diet.

Regular exercise

MEDICINE TREATMENT

Hormone replacement therapy (HRT)

This is not indicated in all postmenopausal women. Symptomatic menopausal women and those with osteoporosis risk factors will benefit

including the emergence of risks as therapy continues.

Note:

Contraindications to
HRT: »     breast cancer,

»     endometrial cancer,

»     women 60 years,

»     thrombo-embolism,

»     coronary heart disease,

»     active liver disease,

»     porphyria cutanea tarda, and

»     women without severe menopausal symptoms.

Intact uterus (no hysterectomy)

HRT can be offered as sequentially opposed or continuous combined preparations. Continuous combined preparations have the advantage of less breakthrough bleeding, but should only be commenced once the woman has been stable on sequentially opposed therapy for a year. Treatment should be planned for 5 years but reviewed annually.

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Sequentially opposed therapy:

  • Conjugated equine estrogens, oral, 0.3–0.625 mg daily for 21 days.
  • Add medroxyprogesterone acetate, oral, 5–10 mg daily from day 11–21.
  • Followed by no therapy from day 22–28. OR
    • Estradiol valerate, oral, 1–2 mg daily for 11 days. o Add medroxyprogesterone acetate, oral, 10 mg daily from day 11–21.
  • Followed by no therapy from day 22–28.

Equivalent doses to medroxyprogesterone acetate:

  • Norethisterone acetate, oral, 1 mg daily from day 11–21.
  • Cyproterone acetate, oral, 1 mg daily from day 11–21.

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Continuous combined therapy, e.g.:

  • Conjugated equine estrogens, oral, 0.3–0.625 mg plus medroxyprogesterone acetate, oral, 2.5– 5mg daily.

OR

  • Estradiol valerate, oral, 0.5–1 mg plus norethisterone acetate, oral, 0.5–1 mg daily.

Note:

Start at the lowest possible dose to alleviate symptoms. The need to continue HRT should be reviewed annually. A mammogram should be done once a year, and abnormal vaginal bleeding requires specialist consultation/referral

Any unexpected vaginal bleeding is an indication for excluding endometrial carcinoma as with other cases of postmenopausal bleeding. The use of transvaginal ultrasound to measure endometrial thickness plus the taking of an endometrial biopsy are recommended.

Uterus absent (post hysterectomy)

HRT is given as estrogen only. Estrogen supplementation to prevent postmenopausal osteoporosis requires long-term treatment.

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  • Estradiol valerate, oral, 1–2 mg daily.

OR

  • Conjugated equine estrogens, oral, 0.3 mg daily or 0.625 mg on alternative days up to a maximum of 1.25 mg daily.

REFERRAL

»     Premature menopause, i.e. < 40 years of age.

»     Severe complications, particularly severe osteoporosis.

<

p style="margin-left: 18pt">»     Management difficulties, e.g. where a contra-indication to oestrogen replacement therapy exists.

»     Post menopausal bleeding.

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