Women's Health





Managing the menopause






Management of the menopause has gone through significant and dramatic changes in the past 20 years. With the recent publication from NICE, the National Institute for Health and Care Excellence, in November 2015, ‘Menopause: diagnosis and management’, this important area has been addressed. It will hopefully allow both healthcare providers and women to have a better understanding of what options are available to manage symptoms. Malini Sharma BSc MRCOG, reports.

Menopause is defined as the time in a woman’s life when she stops menstruating, thereby reaching the end of her reproductive life. It is usually said to occur when a woman has not had menstruation for 12 consecutive months. In the Western world the typical age of menopause is between 40 and 61, with the average age being 51 years in the UK and Australia. In India and the Philippines, the median age of menopause is considerably younger at 44 years. Changes take place as a result of a cessation of ovarian activity, with decrease in production of oestrogen and progesterone.

Perimenopause, or the climacteric isthe time preceding this during which a woman may experience irregularity of her cycles, and continues until 12 months after her final period. Hormonal changes and clinical symptoms occur during this time, and physiological changes in responsiveness to gonadotrophins and their secretion occurs, with wide variations in hormone levels. Iatrogenic menopause can be as a result of bilateral oophorectomy, or as a result of chemo-radiation therapy. Premature ovarian insufficiency is menopause occurring before the age of 40, and this may be natural or medically induced.

Symptoms

Symptoms of the menopause can begin as early as 6 years before the final menstrual period and can continue for a number of years afterwards. The ovaries gradually become less responsive to gonadotrophins and eventually associated affective symptoms of menopause begin to decline. Around 80% of women will experience some symptoms, and in up to 10% of women these symptoms may persist up to 12 years.

A range of symptoms may be reported, the commonest of which is vasomotor symptoms (hot flushes and night sweats). Other symptoms include sleep disturbance, mood changes, irregular menses, memory changes, reduction in libido, and symptoms of urogenital atrophy. Prolonged lack of oestrogen affects bone and cardiovascular health, and postmenopausal women are at increased risk of osteoporosis.

Management options include hormone replacement therapy (HRT), lifestyle modifications, dietary changes and complementary therapies.

Hormone replacement therapy

HRT first became available in the 1940s, but became more widely available in the 1960s, and it revolutionized the management of the menopause. However, with the publication of two large studies from the USA, in 2002 and 2003, the Women’s Health Initiative (WHI) Study and the Million Women’s Study, concerns were raised about its safety. There were two main issues: that HRT may increase the risk of heart disease and, extended use may increase the risk of breast cancer. These findings were widely discussed in the media with resultant uncertainty and confusion amongst prescribers and users. Many women abandoned HRT immediately and there was uncertainty amongst doctors. HRT prescribing dropped by more than 60%, and remains low to this day.

With further analysis of the data from the WHI subsequently reported that the apparent increased risk for breast cancer appeared to be in the group of women who had been taking HRT before entering the study. They also reported that there was no increase in heart disease in those women starting HRT within 10 years of the menopause. The reporters retracted some of the findings originally reported, though this received less publicity.

Since then, the evidence has shifted favourably for the use of HRT in recent years. It can be prescribed to alleviate symptoms of the menopause, and should be given at the lowest effective dose. If women commence HRT around the time of menopause the risks are small, but there is limited data for continued use after the age of 60. It is not usually appropriate to commence HRT in women over the age of 60, as the risks are increased. However, this does not mean that women who started HRT earlier need to stop once they reach the age of 60.

NICE guidance on HRT

The new guideline from NICE focuses on making the diagnosis and individualizing care. It addresses the benefits and risks of treatment. The diagnosis of menopause can be made without laboratory tests in women over the age of 45 who have had not had a period for at least 12 months, and are not on any hormonal contraceptive treatment. FSH can be measured to diagnose menopause only in women who are aged 40-45 with menopausal symptoms and a change in their menstrual cycle, and in women under the age of 40 in whom menopause is suspected.

Women should be given appropriate verbal and written information about diagnosis, lifestyle changes and treatment options. Short and long-term benefits and risks of HRT must be discussed. Oestrogen-only HRT in hysterectomised women and combined oestrogen and progesterone preparations can be given to women with a uterus for the management of vasomotor symptoms. SSRIs (selective serotonin re-uptake inhibitors), SNRIs (serotonin–norepinephrine reuptake inhibitors) or clonidine are not recommended as first line options.

For psychological symptoms, HRT and cognitive behavioural therapy (CBT) are advocated. The evidence for mood stabilisers is currently unclear for these symptoms in women who have not been diagnosed with depression.

Urogenital symptoms can be treated with vaginal oestrogen, even if concurrent with systemic HRT. Symptoms can recur with discontinuation of treatment. Vaginal lubricants and moisturisers can be used alone or in conjunction with vaginal oestrogens for symptoms of vaginal dryness.

Bioidentical hormones

Women should be informed that theefficacy and safety of bioidentical hormones is not known. A lot of press has been given to bioidentical hormones which are identical to those produced by the body, and they are marketed to be safer than traditional HRT. Some types of traditional HRT actually use natural hormones such as those containing 17- beta oestradiol and micronized progesterone which are both natural human hormones. To date there is no existing safety data to support bioidentical hormones being safer than traditional HRT, and it is important to note that the production of bioidentical hormones is not monitored by government drug regulatory authorities, therefore doses may be inaccurate or inconsistent.

St Johns wort has been shown to be of benefit for vasomotor symptoms though there is no published data on appropriate doses, sustained effect or potency of various preparations. There may be potential interactions with other types of medication (such as anticoagulants and anticonvulsants)

HRT and risks

Women on HRT should be kept under regular review and adhere to regular screening programs for breast and cervical cancer. They should seek medical advice if they experience unscheduled bleeding whilst on HRT. When considering discontinuation of HRT, women can be advised they can stop immediately or with a gradual decrease in dose. The latter strategy may limit recurrence of symptoms in the short term.

Venous thromboembolism
Venous thromboembolism risk is increased in users of oral HRT compared to baseline population, though there is less risk with transdermal HRT.

Cardiovascular disease
There is no increase in the risk of cardiovascular disease in women commencing HRT before the age of 60.

Breast cancer
Fear of breast cancer stops many women from considering HRT. With the data available to date, breast cancer risk is no different to non-users in those women on oestrogen-only HRT, but there is an increased risk in those using HRT with both oestrogen and progesterone.

  • Osteoporosis
    Regarding osteoporosis, HRT-use is associated with a reduction in the risk of fragility fractures whilst on treatment, but this benefit decreases once treatment is stopped.
  • Lifestyle
    There is some evidence from randomized studies that women with a more active lifestyle suffer with less menopausal symptoms. Moreover, aerobic exercise may improve psychological health, quality of life and sleep disturbance in those with vasomotor symptoms.
  • Non-hormonal medication
    Clonidine is an alpha-2 agonist that has be used to treat vasomotor symptoms, though there is limited evidence for its efficacy. Moreover, NICE does not recommend it as a first line option for vasomotor symptoms. There is some evidence for the use of SNRI venlafaxine and its analogue desvenlafaxine, but it is limited and more studies are required to secure licensing.
  • Complementary therapies
    These tend to be perceived as being more natural and safer, although efficacy and safety data has not yet been properly evaluated. Herbal medicines may have the potential to cause unwanted side effects and have dangerous interactions with other medicines (herbal and conventional), and there is less regulation in the manufacture of these products
  • Phytoestrogens
    These are plant substances that have similar effects to oestrogen. The most important groups are lignans and isoflavones.
  • Lignans are found in flaxseed, cereal bran, whole cereals, cruciferous vegetables and fruits. Isoflavones are found in soybeans, chickpeas and red clover, as well as other legumes.
  • A number of European randomized studies are in progress, looking at the role of phytoestrogens in osteoporosis, cancer and heart disease.
  • Data is conflicting in the literature regarding the safety and efficacy of soy, red clover and black cohosh.
  • A meta-analysis of 30 studies with a total of 2,730 participants assessed efficacy and safety of foods and supplements high in phytoestrogens, and the effect on vasomotor symptoms. The review found no difference in the frequency of hot flushes between red clover and placebo. Of the other trials, two reported a reduction in hot flushes with dietary soy compared to regular diet and placebo, and five with soy extract. The remaining trials reported no difference between phytoestrogen treatment and placebo. Many studies were underpowered.
  • As phytoestrogens have oestrogenic actions there are concerns about safety in hormone-sensitive tissue such as breast and uterus. More evidence is required.
  • Despite research into alternative preparations, their efficacy remains lower than that of traditional HRT (maximally 50-60% reduction in symptoms compared to 80-90% with traditional HRT. With more robust research it is hoped that some of these alternatives may have a role in managing menopausal symptoms in women.

References
1. Menopause: Diagnosis and Management NICE Guidance November 2015 2. Lindh-Astrand L. Vasomotor symptoms and quality of life in previously sedentary postmenopausal women randomized to physical activity or estrogen therapy. Maturitas 2004;48:97-105

3. Loprinzi CL et al, Venlafaxine in management of hot flashes in survivors of breast cancer: a randomized control trial. Lancet 2000;256:2059-63

4. Alternatives to HRT for the management of symptoms of the menopause. Scientific Impact Paper No 6. Sept 2010 RCOG

The Author
Malini Sharma BSc MRCOG, is a Consultant in Obstetrics and Gynaecology at Kings College Hospital Clinics, Abu Dhabi – www.kchclinics.com


AUBMC leads in robotic surgery, a minimally invasive surgery for gynaecological disorders
and other surgical disciplines

Robotic surgery, also called robot-assisted surgery, is a form of minimally invasive surgery that allows surgeons to perform complex procedures through small keyhole incisions. It enhances precision, flexibility, and control during the operation and allows surgeons to better see the operative site, compared with traditional techniques. Using robotic surgery, surgeons can perform delicate and complex procedures that may have been difficult or impossible with other methods.

The American University of Beirut Medical Center (AUBMC) is a tertiary care centre of excellence with a longstanding tradition of providing state-ofthe- art medical care for the population of Lebanon and region. In 2013, AUBMC launched the Robotic Surgery Program which included urology, obstetrics, and gynaecology. The program is led by a multidisciplinary team of surgeons dedicated to providing patients with robotic assisted surgery. It offers patients all the benefits of minimally invasive surgical techniques while securing less postoperative pain, shorter hospital stay, faster recovery, and smaller abdominal incisions. Over 200 successful cases of robotic surgical procedures have been performed by the surgeons in the various divisions at AUBMC since the introduction of the program with excellent outcomes that compare favourably with those of the best centres in the world.

Robotic surgery at AUBMC has served various surgical disciplines. In the field of urological surgery, it has led to a tremendous increase in the rate of minimally invasive removal of the prostate gland and kidney tumours. In general surgery, robotic systems have assisted in performing a wide variety of surgical procedures including surgical removal of colorectal and gastric cancer and myotomy to treat achalasia.

Every woman is unique
As we focus our attention on women’s health in this issue of the magazine, we cannot but highlight the increasingly important role robotic surgical systems are playing in the management of gynaecologic disorders. We understand every woman is unique in her health needs. It’s one of the many reasons we work closely with each patient to understand her condition and personal wishes, especially for women of child-bearing age. Minimally invasive robotic surgery is particularly promising for women suffering from fibroids who would like to have children in the future. In addition, our expert surgeons offer a wide range of robotic surgical procedures that include hysterectomies, treatment of vaginal and uterine prolapse, ovarian surgery and surgical treatment of endometriosis. Our multidisciplinary team of highly skilled surgeons with American Board certification and advanced training are proud to offer this service to the people of Lebanon and the region.



Healthpoint Hospital offers specialised services for women

 

Healthpoint Hospital is a multi-specialty, elective hospital located in Zayed Sports City, Abu Dhabi that is helping to address some of the Emirate’s most pressing healthcare concerns by reducing local patients’ need to travel abroad for worldclass care. It is part of Mubadala’s network of world-class healthcare facilities and Regional Healthcare Partner to Manchester City Football Club.

As a community health provider, women’s health is a key area of focus for Healthpoint Hospital. The newly expanded Department of Gynaecology includes four UK and international board-certified practitioners with diverse experience in all facets of women’s health ranging from reconstructive vaginal surgeries to early detection and treatment of gynaecological cancers. Healthpoint Hospital, in collaboration with Cleveland Clinic Abu Dhabi, also part of the Mubadala Healthcare network, is also one of the region’s few providers to offer comprehensive treatment of uterine fibroids.

Gynaecology
The Head of Gynaecology at Healthpoint Hospital is Dr Osman Ortashi, a UK board-certified Consultant Gynaecologist who brings 10 years of practice in the UK to the benefit of regional patients. Dr Ortashi is accredited by the British Society of Cervical Pathology and Colposcopy (BSCCP) and is a member of the UK Royal College of Obstetricians and Gynaecologists, in addition to his roles on the Health Authority Abu Dhabi (HAAD) and UAE National Cancer Committees.

“Healthpoint Hospital’s specialised Department of Gynaecology offers a wide range of services to women in the community, scaling from routine obstetric care to highly complicated laparoscopic procedures. Under our integrated practice model – which brings physicians and surgeons across multiple disciplines together to deliver coordinated care – our Department of Gynaecology works closely with our colleagues in the Department of Urology and Department of General Surgery to deliver advanced laparoscopic treatments and other services previously unavailable in our region,” says Dr Ortashi.

Community education
Complementing Healthpoint Hospital’s medical offerings for women is its community education program, the Women’s Wellness Initiative. Led by Dr Mai Aljaber, Deputy Medical Director and Head of Public Health at Healthpoint Hospital, the Women’s Wellness Initiative promotes healthy living amongst women through an ongoing series of informational seminars and fitness-related events that emphasize the importance of both physical and mental wellness to overall health, as well as relationship- building.

Healthpoint Hospital routinely partners with the Fatima Bint Mubarak Ladies Sports Academy, the UAE’s premiere organisation for women in sports, to conduct workshops and lectures on proper training, rehabilitation and recovery for female athletes. Healthpoint physicians are also regular speakers at women’s health events at ladies-only universities and corporations looking to create awareness about topics including plastic surgery options, breast cancer prevention and the importance of the HPV vaccine and early detection of gynecological cancers.

“Women’s health is a family issue, as the health of the wife or mother impacts the whole family,” says Dr Mai Aljaber. “Healthpoint Hospital is proud to contribute to the UAE Government’s call to increase women’s participation in our nation’s advancement by playing our humble role to safeguard their health and to encourage their participation in sports and other lifestyle activities.”

Alongside gynaecology, Healthpoint Hospital offers approximately 20 outpatient clinics and inpatient services such as aesthetic and plastic surgery, bariatric surgery, cardiology, dentistry (including oral surgery, orthodontics and paediatric dentistry), dermatology, diagnostic imaging, ENT, family medicine, gastroenterology, general surgery, paediatrics, podiatry, respiratory and sleep medicine, rheumatology, urology and vascular surgery.

 Date of upload: 11th May 2016

 

                                  
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