Canterbury DHB

Context

Therapy Induced Menopause

In This Section

Initial Assessment

Initiating Treatment

Monitoring of Treatment

Management of Bleeding Complications

Available Preparations

Initial Assessment

Patients should be reviewed within 2 months of completing their Haematology treatment regime. If overt signs of menopause, such as flushes or sweats, have NOT occurred, assess LH and FSH.

Note: If early menopause is found then seek expert advice. A specialist oncology/hormone therapy clinic is available at CWH.

Initiating Treatment

Treatment is started with low dose estrogen and a progestogen. Low starting doses are recommended to minimise side effects, although higher than average doses may ultimately be required to fully settle symptoms of estrogen deficiency.

Start with oral estradiol 1 mg, or transdermal estradiol 25 mcg daily or Premarin® 0.3 mg. Transdermal estrogen is the preferred method of hormone delivery in young women. This minimises the impact on SHBG (sex hormone binding globulin). Oral estrogen increases SHBG and this reduces free androgen levels and leads to an impairment in libido and energy. The dose of estrogen can be increased at 2-3 weekly intervals until symptoms are controlled.

The progestogen is added for the first 10-14 days of each calendar month. This will produce regular periods in 75% of women. The timing of the bleed in relation to the course of progestogen is no longer important. The cyclical progestogen also allows early detection of pregnancy, which can occur, in 5-10% of women with premature ovarian failure. Side effects can be minimised by keeping the dose of progestogen as low as possible, e.g. norethisterone 1 mg, medroxyprogesterone acetate 5 mg, or micronised progesterone 200 mg daily. Micronised progesterone is unfunded but is the preferred progestogen due to its neutral effects on metabolic indices and breast cancer risk.

If a combination of estrogen and progestogen doses is achieved that fits a pre-packaged HRT formulation, a switch can be made to:

All these combination hormone preparations carry a part charge.

Trisequens will bring about regular withdrawal bleeds in most women. The other regimes will allow the woman to be bleed-free. Some no-bleed HRTs may cause initial breakthrough bleeding. However this usually settles within approximately 3 to 6 months.

Oral progestogen therapy is not required for patients who have had a hysterectomy or who have a Mirena IUS.

In young patients in particular consider evaluating bone density prior to starting HRT as a baseline.

It is recommended that patients receive HRT until at least age 45 years, if not until age 50 years. The Mayo Clinic database suggests higher risks of CAD, fracture, dementia, Parkinson’s disease and mental health disorders if inadequate estrogen replacement is given. Treatment beyond the normal age of menopause should be evaluated on an individual basis according to menopausal symptoms and risk factors for osteoporosis and cardiovascular disease.

Therapy should be tailed off gradually over a period of 2 to 3 months to prevent exacerbation of hot flushes and night sweats. Reduce to the lowest strength tablet for 3 to 4 weeks and then give this on alternate days for another 3 to 4 weeks and finally increase the duration between tablets to 4 to 5 days for a further 2 weeks prior to stopping. For patients using the transdermal therapy, gradually reduce the oestradiol to the lowest strength over 3 to 4 weeks. Then introduce treatment free days of 1 to 2 days per week for a couple of weeks, increasing this gradually until the patches are only worn 3 days out of every 7 to 10. Treatment can then be stopped. Advise the patient that hot flushes, night sweats and psychological problems may occur during the weaning off process and may require recommencement of therapy.

Non-hormonal options for managing menopausal symptoms include Remifemin, clonidine, SSRI or SNRI antidepressants, gabapentin, or stellate ganglion blockade. Recent evidence supports the use of hypnosis and acupuncture. CBT may be helpful for some women with vasomotor symptoms.

Monitoring of Treatment

Adequacy of treatment is determined by appropriate treatment of symptoms. If flushing, sweating and other estrogen deficiency symptoms continue to occur then the dose of oestrogen may need to be increased. It is not useful to check FSH levels as these may remain elevated despite adequate doses of estrogen. Likewise many of the forms of estrogen (e.g. Premarin) do not alter blood estradiol levels and measuring this can be misleading.

Management of Bleeding Complications

Pattern of Bleeding on Combined Sequential Treatment

Symptom

Probable Cause

Heavy bleeding

Too much oestrogen or insufficient progestogen or pathology

Spotting during cycle

Oestrogen/progestogen dose inadequate or pathology

If bleeding persists consult:

Available Preparations

Oestrogen Alone

Trade Name

Hormone

Average Dose

Doses Available

 

PREMARIN®

Conjugated Oestrogen

0.625 mg

0.3, 0.625, 1.25 mg

 

Part charge

PROGYNOVA®

Oestradiol Valerate

1-2 mg

1 mg, 2 mg (fully funded)

Body-identical. Fully funded

ESTROFEM®

Oestradiol

1-2 mg daily

 

Body-identical.

Part charge

ESTRADOT®

Transdermal Oestradiol

25-50 mcg/day

25 mcg, 50 mcg, 100 mcg

Body-identical.

Part charge

CLIMARA®

Transdermal Oestradiol

50 mcg

50 mcg, 100 mcg

Body-identical.

Part charge

SANDRENA®

Trandermal Oestradiol Gel

1 sachet

25 mcg

Body-identical.

Unfunded

Progestogen Alone

Trade Name

Hormone

Average Dose

Doses Available

PROVERA®

Medroxyprogesterone Acetate

2.5 -5 mg

2.5 mg, 5 mg, 10 mg (fully funded)

PRIMOLUT®

Norethisterone

1 mg

5 mg (fully funded)

Utrogestan

Micronised progesterone

100 mg

100-200 mg (unfunded)

NORIDAY®

Norethisterone

1 mg

0.35 mg

Mirena IUS

Levonorgestrel

20 ug

 

Oral Contraceptive Tablets Containing Progestogen Alone

Trade Name

Hormone

Dose Available

NORIDAY®

Norethisterone

0.35 mg

MICROLUT®

Levonorgestrel

0.03 mg

Combined Oestrogen/Progestogen, Cyclical Progestogen

Trade Name

Hormone

Dose Available

TRIEQUENS®

Oestradiol, Norethisterone Acetate

1 mg/2 mg varies during month (colour coded/ 1 mg)

Combination Oestrogen And Continuous Progestogen

Trade Name

Hormone

Dose Available

KLIOVANCE®

Estradiol, Norethisterone

1 mg, 0.5 mg

KLIOGEST®

Estradiol+, Norethisterone

2 mg, 1 mg

PREMIA 2.5® continuous

Conjugated Equine Estrogens, Medroxyprogesterone Acetate

0.625 mg, 2.5 mg

PREMIA 5® continuous

Conjugated Equine Estrogens, Medroxyprogesterone Acetate

0.625 mg, 5 mg

About this Canterbury DHB document (5067):

Document Owner:

Sean Macpherson (see Who's Who)

Issue Date:

January 2019

Next Review:

January 2022

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 5067