Menopausal symptoms

[TennisProJoe]

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I'm an MS3, working in Women's clinic and had some questions about what to do with women who come in with menopause symptoms, I've heard mixed things.
-Vaginal only symptoms Ive been told local vaginal estrogen
-Hot flashes/sweats Ive been told it is ok to give HRT with estrogen and prog, but in reading it says don't give this to women with a uterus because of increased risk for cancer and also increased risk for heart attack/stroke. So how do you decide? Also could you just give prog for these symptoms since I think estrogen is the main culprit leading to higher risk for heart attack, etc?
-How long is too long for HRT?
-What about in women with no uterus?

Thanks for the help
-Joe

 

[THP]

I'm an MS3, working in Women's clinic and had some questions about what to do with women who come in with menopause symptoms, I've heard mixed things.
-Vaginal only symptoms Ive been told local vaginal estrogen
-Hot flashes/sweats Ive been told it is ok to give HRT with estrogen and prog, but in reading it says don't give this to women with a uterus because of increased risk for cancer and also increased risk for heart attack/stroke. So how do you decide? Also could you just give prog for these symptoms since I think estrogen is the main culprit leading to higher risk for heart attack, etc?
-How long is too long for HRT?
-What about in women with no uterus?

Thanks for the help
-Joe

You are mostly correct. According to ACOG the only indications for HRT is vaginal dryness and vasomotor symptoms. With only vaginal symptoms, then a vaginal cream is fine. Something like premarin cream.

Whether or not the uterus is present is very important. If there is a uterus the concern is for the development of endometrial cancer secondary to unopposed estrogen. So any woman with a uterus can safely receive HRT as long as you include a progestin. This includes vaginal creams.

If the uterus is absent you can use estrogen only because there is no endometrium. That being said I have seen endometrial cancer in a post menopausal woman develop in a focus of endometriosis who was stas post hysterectomy. She had been receiving estrogen only.

In terms of length of use there is no strict cut off. The recommendation is to use the lowest effective dose for the shortest amount of time. You really have to individualize the treatment based on how severe the symptoms are. It also depends on whether they are surgically in menopause versus naturally. For those naturally going through menopause I don't have a lot of experience but 5 or 6 years seems to be the max of what I have seen. Can anyone else shed some light on this?

You can't just give progesterone alone very effectively because the cause of the symptoms is estrogen withdrawl so giving progesterone will not help. Also many women don't like the side effects of progesterone alone. Aygestin is a progestin that breaks down into a component that has some estrogenic effect so it may be a better choice if you are going that route.

The most difficult question is how do you balance the risks with the benefits. This is difficult because of lot of the data from the WHI trial was mismanaged and misinterpreted. Again, I think you have to individualize treatment but I don't think HRT is as scary a medication as it is made out to be.