Download Menapouse

Natural
Surgical
premature
RETROSPECTIVE
Cessation of menstruation for 12 months
In the absence of other physiological or psychological cause
STRAW staging
SYMPTOMS
Acute
Hot flashes
Sleep Disturbance
Mood SWINGS
Joint pain
Sexual dysfunction (loss of libido.Vaginal
Dryness. Loss of elasticity)
LONG TERM
Bone loss : Osteoporosis
Needs separate lecture !
Cardiovascular:
Change in lipid profile
↑LDL 6%
No change in HDL but reduced protective
effect
DEMENTIA
There is limited epidemiologic support for the
hypothesis that estrogen preserves overall
cognitive function in non-demented women.
Preliminary data suggest that estrogen may be
important in preventing amyloid deposition, in
addition to any role it plays in cognitive
function
OTHER
SKIN: reduced cutaneous collagen
elasticity
Joints: Degenerative Osteoarthritis
Body composition :↑ fat mass >lean mass
Balance
WHI STUDY
27000 women
Age mean 63y
Placebo Vs Unopposed Estrogens and continuous combined estrogens and
progesterone
Regarding the WHI trial:
Demographics of women in trial
Relative risk of hip and total fracture with HRT
Relative risk of breast and total cancer with HRT
Relative risk of AMI and CVS problems with HRT
What is the problem with general application of these findings?
What are the risk factors for breast cancer
Demographics of women in WHI trial
16,600 women in combined HRT treatment arm
Age 50-79 (mean age 63) with intact uterus (only 33% were in 50s and 20% were > 70)
60% were overweight or obese
50% were previous or current smokers
35% were hypertensive
12% had hypercholesterolaemia
5% had previous coronary artery disease
Randomised to 0.625mg of equine oestrogen with 2.5 mg MPA or placebo
Primary outcome measures were CHD and breast cancer, and global index of risks and benefits
Relative risk of hip and total fracture with HRT
Hip fracture HR 0.66
Total fracture HR 0.76
Relative risk of breast and total cancer with HRT
Breast cancer HR 1.26 – this lead to premature
cessation of the trial
Total cancer HR 1.03 (not significant)
Note colorectal cancers HR 0.63
Relative risk of AMI and CVS problems with HRT
Coronary heart disease HR 1.29
Stroke HR 1.41
Total cardiovascular disease (including stoke & venous thromboembolism) HR 1.22
WHAT IS THE PROBLEM WITH GENERAL
APPLICATION OF THESE FINDINGS?
WHI was designed as a primary prevention RCT – not a trial of adverse outcomes of 51 yo
taking HRT for menopausal symptoms (which is the main reason women take HRT)
Wide inclusion criteria (not really healthy women) – average age 63 (only 33% were in 50s
and 20% were > 70), half were past or current smokers, 2/3 were overweight or
obese, 1/3 had HT, 12% had  chol, 7.7% had CVS disease
Counted events not people – hip #, DVT, PE could all occur in the same person and
therefore are not independent
HR for beast cancer was 1.26 but CI was 1.00 – 1.59, so result is actually not significant !
Furthermore 25% had already used HRT – there was no increase in the hormone naïve
subjects (HR 1.06)
Subgroup analysis in women < 10 yrs postmenopausal indicated no increased coronary
heart risk
Absolute risk of harm to an individual women is very small
Only one drug regime tested – cyclic progesterone may have had less adverse
outcomes and is commonly used
¼ had used HRT before
Does not address the short term risks & benefits of HRT for treatment of menopausal
symptoms
High discontinuation rate in treatment group 47% and 10% cross-over from placebo to
treatment arm
Short term follow-up – only 5.2 years – can conclusions really be made re long term
prevention