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I know that. My thought you're still paused. Oh, no, you've got it. You've got it started now. Fantastic. Um, so let's see. So I'm going to start by asking you and you you're welcome. I know people in different situations with different ability, access to power and good Internet and stuff. So you're welcome to either, um, mutant, shout out or put in the chat. Um, what is the actual definition of menopause? When do we say that a woman has gone through her menopause? Uh, there are two ways of saying it, but they're not perfect definition. But one way of saying it is that the court alien second stops. The Lehman stump of saying is when the menstrual bleeding stops at the old age. And so Yeah, absolutely. So we talk about the menopause as being when the periods have stopped because, um, and that marks that when you're moving from your sort of your reproductive time of life to the time of life when you can't have Children. So how long do the periods have to have stopped for us to say that a woman has gone through her menopause? Anyone that can vary, I think um individual female to female. Okay, so someone's putting that. That's I mean, that's correct, that it takes a different length of time for it to stop. And someone's put in the chat one year, which is absolutely right. So we say we say that the menopause is diagnosed after 12 months without a period. Now we have more contraceptive options available to us than we did in the past. And, of course, some contraception options will stop the periods, and that does doesn't necessarily mean your menopausal. But assuming that the person is not on any contraception that interferes with the period, we say that they've been through the menopause when they are 12 months after the last period and the time leading up to that, we call the perimenopause, Um, and that is when the sort of endocrinological and biological features of the approaching menopause are coming. Um, and it's characterized often by the cycles, getting very irregular so they typically might get closer together and sometimes lighter, and then they will space out. And a woman might have several years of having um of having these irregular periods and of having perimenopausal so symptoms. Um, and it is absolutely fine during this perimenopausal time. If she's finding the symptoms, um, difficult, then it may be appropriate to treat her with HRT. So I think the first learning point is that we say someone who's menopausal after 12, 12 months of amenorrhea, but it's perfectly appropriate to treat them if necessary. Um, with HRT during the peri menopause symptoms during the perimenopause time. So, um, I think everyone here would know of hot flushes and night sweats as symptoms of menopause. But can anyone contribute any other symptoms of the menopause? Yeah, weak bones or it's to process. Um, yeah. So Osteo processes is a sort of a complication. Yeah, absolutely. Anything else? Yeah, absolutely. Mood changes in the vaginal atrophy and dryness. Yes, absolutely so a genital urinary syndrome of the menopause is really important to ask about vaginal dryness. Sometimes pain on urination. Difficulty with having sex. Women often don't volunteer this because they're a bit embarrassed. Um, but it's massively common and sometimes needs treating as well as systemic HRT. So that's really important to ask about it. So I will quickly share my screen to show you one slide. Um, so hopefully you can see this slide, which shows you all the different symptoms you can get of the menopause, because basically, we have estrogen receptors scattered all throughout the body. There in the brain, um, they're in the cartilage so you can get joint joint joint problems, soreness and stiffness. Um, and so it's not just, um it's not just night sweats and hot flushes, and there are lots of women will have those what we call vasomotor symptoms. Some won't and in particular the two presentations that always make me stop and think, Could this be? Menopause is a woman who has new depression or anxiety in her forties, never had any mental health issues before. Or a woman who has a new sort of vague joint pains, Maybe the sort of thing where you're thinking about heading to towards a diagnosis of fibromyalgia again in her forties. I would always just stop and think, Could this be the menopause? And before you sort of proceed down the line of diagnosing depression or anxiety or fibromyalgia, do you want to give her a three or six month trial of HRT and see if that makes a difference? So that's the second takeaway point is that there are a lot more symptoms more than these sort of typical ones that we that we would would necessarily think of. Okay, so let's say you've got a woman who's come to see her, who is in her late forties. She say 47. 48 her periods are getting a bit more irregular. Um, and she's having some hot flashes and night sweats and a bit of joint ache feeling a bit miserable. And you think, Yeah, you know, this This sounds like she's probably perimenopausal and her symptoms of bothering her. She would like to think about starting HRT. How are we going to diagnose the menopause in this woman? Are we going to call it a clinical diagnosis? Are we going to do a blood test? And if so, what test? What do you think? Okay, Someone said hormonal panels. Abdullah. What do you mean by hormonal panel? What boxes would you tick on the blood form oestradiol and progesterone. Okay. Anyone else have any thoughts? Okay, So, obviously, calcium levels. I think you're thinking about osteoporosis and bone risk. Um, and someone said TSH. Okay. Um, so, yes, it might be appropriate to check for thyroid if she has symptoms of hypothyroidism. So, um, lots of people in their menopausal years do gain weight. If she's maybe gaining weight, feeling cold all the time, having other symptoms of thyroid, then that might be an issue. Now I realize, obviously that guidance can vary, you know, throughout the world, and I can only really work from UK guidance. But in the UK were quite clear that the menopause over the age of 45 is a normal thing. It's the normal stage of life, the kind of the right thing happening at the right time, and therefore it's a clear clinical diagnosis. If you did want to do a blood test, then the specific one would be follicle stimulating hormone FSH because as your estrogen levels fall so menopausal symptoms are due to a fallen estrogen level, you don't get that negative feedback of estrogen onto the pituitary, which in the reproductive years keeps the FSH low and therefore the FSH levels will start to rise. So whilst levels can vary from lab to lab, generally speaking, if you have an FSH, a follicle stimulating hormone of above about 30 that is considered to be in the menopausal range, but a woman who is perimenopausal her estrogen and FSH levels will be all over the place. If you were to do them every day for a month, you'd find that they bounce up and down. Um, and so it's highly possible that you might have a woman who is clearly in the perimenopause who's symptomatic, who's having the changes to her periods that you would expect. And if you do a random FSH, it could be normal, and you run the risk then of being sort of kind of reassured that she's not menopausal wrongly reassured. So you don't treat her. You might be sent down different alleys of trying to find other things for her, for other other courses for her symptoms. So in the UK, we say that you certainly do not need to test in a woman who's over 45. It's a clinical diagnosis. You might want to consider testing under 45 but I would generally not test for a woman who's over 40 under 40 the menopause is early. We call it primary of Arian insufficiency, and I usually would test then, but in general the menopause and the perimenopause, our clinical diagnoses. And if you have access to treatment with HRT, then it is perfectly reasonable, um, to To to to just go ahead and to treat and to judge the success of the treatment on whether her symptoms have improved. Um, so we've got this woman in front of us. We think she's peri menopausal. Her symptoms match her periods are messed up. That all matches. What else in your first consultation, might you want to ask her thinking about making it a sort of holistic consultation? Um, considering all aspects, cardiovascular risk factors. Absolutely. So we're thinking about starting her on HRT. Um, and I'll talk in a bit about the cardiovascular implications of that. Yep. Anyone else? OK, Nutrition? Yeah, yeah. Nutrition. Absolutely so. General lifestyle stuff. What's her diet like? Does she smoke? Does she drink? Does she exercise? What's her job? Is she stressed? What are the impact of the symptoms on her life? Because that might balance her decision about whether or not she wants to start HRT in terms of cardiovascular risk. I'd certainly want to know her height and weight and b m i and her BP. Um, in the UK, we do offer everyone aged over 40 a what's called an NHS health check, which is a basically a cardiovascular risk screen for for things like diabetes and high cholesterol. So you might consider doing those, um, you would probably discuss with her how the diagnosis of the menopause is made and the fact that it doesn't need a blood test because people often come in thinking they need a blood test. Really importantly, thinking about the sort of principles of shared decision making, you want to find out? What does she know? And what does she think? Because sometimes, um particularly at the moment in this country, there's been a massive outpouring of publicity about the menopause. Lots of TV programs and stuff. A lot of women are coming in very well informed, actually, um, and someone will come in and they'll they'll be very well informed, and they're pretty certainly want to start HRT. Other women will come in at the other end of the scale that they're absolutely terrified of. Hormones don't really want them, and they'd like your advice on non hormonal things. Some women will come in Not really having done any reading around at all and wanting some information for you. So if you, um if you know where she is on that scale, then you are more likely to be able to have a sort of sensible consultation with her. And you won't kind of waste time going around in circles. Um, you need to find out if you need the contraception, and I'll talk about that a little bit more in a minute because, um, you can still conceive in the perimenopause. Um, and it's often a time time the life the kids have, you know, grown up, left home off university or whatever. And, you know, another baby would be a big shock. Um, you, um you might want to sign post her to information if she hasn't read around. So, whatever, you know, whatever websites or or so and you have, um, you have available to her, um, and then you're gonna want to discuss the options available. So broadly speaking, they fall into, um, do nothing. So it may be that her symptoms are quite mild, and she just wanted a bit of a reassurance that it's okay to do nothing. She might want to start HRT. She might want to start a non hormonal treatment, which you can prescribe. So we're going to those in a bit more. She might be interested in non medical management, you know, relaxation, yoga, that sort of thing. And she might be interested in alternative or complementary therapies, which she might buy from A from a health food shop or so on. And they have their pros and cons and and so on. So So there's quite a lot to discuss. And these are often not quick consultations, obviously depending what healthcare system. Urine depends how you manage it. But sometimes these are broken up into more than one consultation. Sometimes they have a phone call, then a face to face. Sometimes you might ask a woman to fill in a questionnaire with her symptoms beforehand. It sort of depends. Um, it sort of depends what is going what your system is. So let's think for a moment about HRT. Um what hormones are in H r t hormone or hormones? OK, estrogen and progesterone. Absolutely. So tib alone. Yep. So tib alone. I'll come onto and explain a bit about tib alone later. So, um the menopause. The symptoms of the menopause are due to not having enough estrogen. And so it is. Um it is the lack of estrogen that gives you the symptoms of the menopause. So all HRT has to contain an estrogen of some sort. If a woman has had a hysterectomy, then she just needs a student. That's it. You can stop there. If she has not had a hysterectomy, she still has her uterus. Then if you give her estrogen on its own, this will over time stimulate the endometrium. The lining of the uterus, um, and can cause endometrial hyperplasia and thickening, and in the end, might well lead to endometrial cancer so that women who still have their uterus also need a Progeston and which is to protect the uterus is really important that the woman understands that the estrogen is for her symptoms, and the progesterone is to protect her uterus so that she doesn't. If you're prescribing them separately, she doesn't keep taking the estrogen, But stop taking the progesterone if it makes her feel sick or gives her any other side effects. So that's an important message to get across. Um, you can prescribe HRT in two ways. Combined HRT. You can give estrogen and progesterone in together every day of the month. Or you can give estrogen every day of the month and a progestin for only two weeks of the month. That's called sequential HRT. The first regime is called continuous HRT. Does anyone know why you would do one or the other? Do you feel free anyone to either a mute or put it in? Put your answer, depending upon the response response of the A charity. So when might response better? Some might not. There are symptoms were times when you might change. But you need to make a decision at the start. Which one you're going to start her on. So I don't want to. I don't want to play. Guess what's in my head. So it depends whether she is essentially, whether she is menopausal or still having also perimenopausal. Yeah, absolutely right of dollars to do with her bleeding. Um, if the woman is less than 12 months from her last period, so she's in the perimenopause, then if you give her continuous HRT estrogen and a progestin in all the time, which means she won't have a period, then what is likely is that she will get start to get irregular bleeding, and we don't worry too much about irregular bleeding in the first 3 to 6 months after starting HRT. But if it continues for too long or it's too heavy, then we're going to get a bit freaked out because, you know, we worry about endometrial pathology with irregular bleeding in women over 40 and she might end up having unnecessary investigations scan hysteroscopy, that sort of thing. So, generally speaking, if a woman has had a period in the last year, then she should have sequential HRT, where she has estrogen all month long and a progesterone for two weeks of the month. And then she will have a bleed every time that she stops the progest a gyn um, nothing in medicine is ever set in stone. You know, if a woman's 10 months since her last period, she really doesn't want her periods back then you might give continuous combined ago, but but warning her that there is a risk that she will get irregular bleeding and that is the same no matter what the reason for her lack of periods So, for example, if she has a contraceptive implant in and she hasn't had a period for five years because she's had implants for five years and they have stopped her periods and now she's starting to get menopausal symptoms, then it's still fine to start her on a continuous combined HRT, even though the reason for her not having had a period is her implant, not the menopause. Um uh, So, yeah, so that's so that's that's how you decide if you're going to start at the beginning. A woman on a continuous combined or a sequential preparation. Um, so the other option, which sort of falls in between these continuous Bindon sequential, is to use an eye us an intrauterine system, Um, as the progest a gyn, um, And in this country, the one with the license is Marina. Um, generally speaking, you should only use a 52 mg. I us like marina or leave. Assert is the other brand name, and there's probably different brands in other countries. The lower dose ones are not sufficient. Um, but if I have a woman in her forties coming along for contraception, then I'm a big fan of the Merina because it can kind of segue nine nicely between the need for contraception and the need for HRT. And if a woman has a marina in or is happy to have one put in, then you don't need. You don't need to worry about the the sequential versus continuous thing because you just give her estrogen on top of the marina and the marina keeps her endometrium nice and thin, and after the first 3 to 6 months, she probably won't have any bleeding with it. So that's so That's great. And that's that's sort of very helpful. So let's talk a little bit about the menopause and contraception. Um, how can we advise a woman who wants to know when she can stop contraception? What might you say to her anything? There are absolutely no stupid answers, no wrong answers. Or if she gets like she develops, say her cardiovascular risks become too high. Or she developed certain symptoms like migraines and headaches and or or she starts to pick up smoking randomly for some reason or some kind of reason that would stop you recommending it. Yeah, absolutely. So all of those things that you said are Contra indications either relative or absolute to the combined contraceptive pill. But they're generally not contraindications to a progesterone only method. So that wouldn't mean that one would need to stop hormonal contraception. But she might need to move from a combined estrogen and progesterone method just to a progesterone method. But what about actually stopping? As in? I'm too old to have babies. I can have sex without contraception. Now, is there an age at which all women can stop? No. Okay, Any other office? So, um, you're right, that you can get breakthrough conceptions. I think the oldest term pregnancy I have heard of is in the late fifties, about 58. But generally speaking, we say that at the age of 55 the risk of getting pregnant is vanishingly rare, and therefore it is largely safe for women to stop contraception. Um, and the F srh, which is in the UK the faculty for sexual reproductive health, which produces all our guidelines in this area, say that this is the case. Even if the woman is having regular periods. Now, if a woman is still having regular periods at 55 she wants to carry on, then that's a perfectly reasonable thing to do. But generally speaking, women can stop at 55. Of course, some women will be able to stop earlier. Now, if you are not using a contraceptive method that affects your period, so you're either using condoms or you're using a copper coil, then it's very straightforward. You just need to look at when your period stop and then if your last period, obviously your last period is a retrospective thing. You don't know at the end of a period that that's going to be your last one. Um, but if you get to the point where you have not had a period for 12 months and you're under the age of 50 sorry and you're over the age of 50 then you can stop contraception to 12 months after the last period, over the age of 50 and 24 months, two years after the last period under the age of 50. If your periods are not affected by contraception, the reason for that longer period if the woman is slightly younger is because you can you can, uh, kind of going through the perimenopause. You can just have a spontaneous ovulation. Throw off an egg. So there is a risk of pregnancy now for women who are on a contraceptive method, which stops their periods such as, um, the, uh, progesterone only pill or the implant. Um, then they've got two options. They can either just keep going with their method until 55. But if they want to stop, then once they reach 50 you can do an FSH level. And if you do an FSH level at 50 and it's in the menopausal range, then essentially you can take that FSH level as being equivalent to the date of the last period. And then the woman can use contraception for an extra year, and then she can stop. And obviously, if you do an FSH level at 50 and it's not in the menopausal range, then the woman is not menopausal, and then she needs to either carry on till 55. Or she might want to repeat the blood test in a couple of years, Um, for women who are on the combined hormonal contraception. So that would be the combined pill or the patch or the vaginal ring. Um, they should all be stopping at 50 anyway, because it's considered that the risks outweigh the benefits at 50. But you cannot test FSH whilst on the combined pill because the pill will suppress it so you can test when someone's been off the pill for 6 to 8 weeks. Or they can just change to a combined method of progestin. And it's really important. And it's a slightly counterintuitive thing to recognize that HRT in itself is not contraceptive. So if a woman is using an intrauterine system for HRT, that's great, because that provides contraception as well. But if not, if she's having um, both estrogen and the progesterone by a patch or a tablet or whatever, and she's still fertile, then she needs an alternative method of contraception. So it's not unusual for someone to have estrogen and progesterone as their H R T, and then also to have, say, the implant or the progesterone only pill on top of that for contraception. And that's that's absolutely fine and reasonable thing to do. Um, those who are using the the contraceptive injection the depo. We tend to stop that at the age of 50 because we're just a bit concerned about the effects on their bones. Um, so most women above 50 who need contraception will use either a copper coil or hormonal coil and intrauterine system, the progesterone only pill or the subdermal implant. Those what generally use. Okay, so let's go on and think about HRT. So broadly speaking, um, we're talking at the moment about systemic HRT, not the vaginal local HRT which were coming on to later. Broadly speaking, you can use HRT in a pill or in a transdermal method, so that would be a patch or a gel or a spray. Um, if you've got a woman who's got risk factors for cardiovascular disease, either arterial or venous, would you be more happy to have her on a tablet or a transdermal method? Transdermal? Absolutely. Abdullah, that's that's absolutely correct. So, um, we know that oral HRT increases your risk of venous thromboembolism by about twice. The relative risk is about two. And so, if you are a fit, healthy, slim, nonsmoking person with normal BP, then your baseline vte risk and you've got no family history of a VT. Your baseline risk of vte a venous thromboembolism is probably quite low, and if you want to take a tablet because some people prefer them. That's absolutely fine. But if you have any risk factors for VT such as a B M I over 30 or you're a smoker, um then it would generally be sensible to start transdermal estrogen. And what has happened in the UK with obesity becoming much more of an issue and are sort of realization that transdermal estrogens are safer from a cardiovascular point of view is that almost everyone now goes onto a transdermal estrogen. And as a result of that, we're having sort of stock problems that, you know there are shortages of various preparations of transdermal estrogen so that you know that that can be an issue. Um, the nice guy that's in the UK does say that we should consider referring a woman who has a high risk of vte. So, for example, someone who's got a strong family history to a hematologist for assessment before considering HRT. Now, I think the assessment, what they're talking about is whether or not you do a thrombophilia screen. My experience is that when I refer these women to hematology, they generally don't do thrombophilia screens, and I think The reason for that is that a thrombophilia screen will pick up protein s and protein C problems and factor five Leiden. It will pick up the thrombophilia is that we know about, but it's quite real recognized that there are almost certainly a lot of thrombophilia is that we don't know about and therefore a negative thrombophilia screen in the context of, Let's say, a strong Family History of E. T. Doesn't say that you haven't got a thrombophilia. It just says you haven't got one that we've discovered yet. Um and so my approach to women who have a high background risk of thromboembolism venous thromboembolism is to have a really careful discussion and to make the point that they will always remain at a higher risk of a further VT than the population, because either they've had one themselves in the past or they have a family history. But that transdermal eight HRT does not increase the risk of blood clots. So if I give them transdermal HRT and in two months time they have a DVT or a P. That doesn't mean that the HRT has caused it. It just means that they remained at high background risk, and they have had an event. So you know, I'm comfortable to do that prescribing. Obviously, as with anything in medicine, your level of comfort in prescribing will vary depending on your seniority, depending on whether or not you have a special interest in the area. And obviously, if it's something that you don't feel comfortable with, then it's perfectly appropriate and reasonable to seek help. But probably the take home message is that transdermal estrogen does not increase your risk of vte, and therefore that is the women to the one to consider in people to to use in people who have risk factors for BT. So breast cancer, which is sort of the next thing really that people worry about. In fact, it's It's probably the first thing that people worry about. So does anyone know anything about breast cancer and h R t? Any facts, however irrelevant you think they might be? I think there's something about where you put the patch or like where you put the estrogen component that you can't put it near the breast or on the breast. Yeah, absolutely. So the advice. It depends on the on the sort of on the brand, but the advice is often to put them sort of below the waist, on the thighs or on the buttocks or something. I think most people feel the reason for that is generally just that. That's where it was done in the trials, and therefore that's what the license of the drug is. But you certainly you shouldn't put them on the breasts. If people want to put them on their back or their belly or their arms, then then it's probably not a problem. So anyone either Abdullah or someone else anyone is welcome to join in. Does H R T increase your risk of dying from breast cancer? So Claudia said it increases risk, and then so it there is a small increased risk of getting breast cancer. But does it increase your risk of dying from breast cancer? Uh, no, no, I'm just getting the risk of getting, but not from dying. Absolutely. Now this is so counterintuitive. And the first time I heard this, I was a bit like what? That you know, that just did not make sense to me. So we know that HRT is a growth factor for breast cancer. UM postmortem studies show that in their eighties, about sort of 7 to 10% of women will have a small focus of breast cancer that may not have ever done them any harm. Um, and as far as the evidence we have is that HRT is a is a sort of growth factor for breast cancer, so it makes pre existing cancers grow rather than necessarily causing them. And therefore, if a cancer grows very quickly, the woman is likely to find a lump, and she's likely to find the cancer before it spread. And obviously, if you find a cancer before it spread, treatment is likely to be much more successful. So there is very clearly no increased mortality from breast cancer. The increased risk of getting breast cancer is to do with the progest, a gyn not to do with the estrogen. So if you are using estrogen only HRT, then your risk of increased breast cancer is minimal, possibly zero. In fact, some studies have shown a slight reduction, although that's probably just a bit of, um, kind of statistical stuff going around the edge. But women who are taking estrogen only HRT because they've had a hysterectomy can be reassured that their risk of breast cancer is is absolutely tiny. Um, most of the data that we have on breast cancer is to do with all the more old fashioned progest a jin's that we don't use so much. So in the UK, we tend to use now micronized progesterone in which is a sort of bio, identical natural progesterone, um, which almost certainly carries a lower risk of breast cancer. And so I think within the next five years, we will probably have new figures that are more specific to people who use either micronized progesterones or micronized progesterone or, um, Irena for their progest a gin. And that will probably show lower data. But I'll share my screen. This is what I tend to use at the moment for the lack of anything better. Um, uh, So you can see there. This is the British menopause society, Infographic. So you can see that if you have 1000 women age 50 to 59 then over a five year period, 23 of them will get breast cancer without any H r t and for women on combined HRT. Our best evidence at the moment is that an extra four of them will get breast cancer. So per 1000 women just under one extra case per year because this is over five years. The four extra cases, Um and you can see that the BMS has gone with four fewer cancers in women on estrogen, only HRT, although probably it's it's more like no change. Um, I think it's really important in medicine. Generally, people always get sort of freaked out about what our Yeah, absolutely, Abdullah. That's absolutely correct. So, you know, this is not a big risk. So I qualified as a GP in 2004, and I prescribe quite a lot of HRT during my training. And then various papers came out various, um, American studies that, you know newspaper headlines about, you know, women dropping dead of breast cancer all over the shop. And no one wanted HRT. I think for the 1st 10 15 years of my life as g P. I never prescribed it because no one wanted it. It's really important to put in context the risks of what we do to patient's compared to the risk they take in their everyday life. So It has been said, for example, that your risk of death from taking the combined contraceptive pill for a year is approximately equal to your risk of death from spending two hours in a car on a motorway. And I guess that varies depending on how fast and how well you drive. You wouldn't think twice about spending two hours on the motorway and put people really worry about risk for medicine. So if you look down to the bottom of that graph, if you have a B M I aged over 30 that same group of 1000 women age 50 to 59/5 years they will 24 extra cases, so that hugely outweighs the risk. And in theory, if a woman's HRT since menopause symptoms are making her feel so rubbish that she's eating badly, she's drinking loads of alcohol. She's not exercising and she's gained weight. You put her on HRT and she feels better and she loses the weight. You might actually be reducing her overall risk of breast cancer because you're dropping her risk from obesity. Um, we think that if you do have a B m. I over 30 and therefore you've got this extra 24 cases risk that you've probably maxed out your risk. So for that group of women, they are at a higher risk of breast cancer. They probably don't have any increased risk from taking HRT because there is a point at which your your risk can't continue to improve. And then you can see they're also the risks from alcohol and from smoking and from the reduction in risk from having 2.5 hours of moderate exercise per week. And obviously you can flip that on its head and call it an increased risk from, um, from a sedentary lifestyle. Um, so this I mean you you will have access to this if you just put in B M s, which is British Med and poor society breast cancer infographic into Google, you can easily find this, and I find it quite useful. If I'm having a phone conversation with someone, I might text them the link to this, or if they're in in my surgery, then I might get it up on the screen. People worry less about ovarian cancer, and the risks are probably smaller, so it's probably about one extra case per 1000 women using HRT and maybe one extra death per 1700 women using HRT. I think people do worry a lot about ovarian cancer because, oh, fantastic, thank you for putting that up about a dollar. People often worry bit more about HRT about ovarian cancer because it's just so nasty or, you know it does often does often present late. So that's breast cancer and venous thromboembolism cardiovascular disease. Um, if a woman starts transdermal HRT under the age of 60 then you're not increasing her cardiovascular wrist. And it may in fact be protective because we know that women's risks of heart attacks and strokes and so on go up after the menopause. We are now certainly in the UK, with all the publicity and and so on. Around around menopause, we're seeing a cohort of women who are in their sixties, and I coming in to say, You know, I started my menopause in about the fifties. Everyone said HRT gave you breast cancer, so I didn't do anything about it. I've been struggling. I kind of feel like I'm missing out. I still feel a bit rubbish. I'd like to start HRT now now for that cohort. Um, there is a slight possible slight increased risk of cardiovascular disease because in that intervening 10 years, they may well have developed plaques in their arteries. And the HRT doesn't reverse that. Um, so there is certainly a small, increased risk of stroke when it started above the age of 60 less with transdermal HRT. But as always, you've got to balance the risks against the benefits to the woman of of her life. If she's still having significant symptoms and if they are affecting her life and her work and, you know and her relationship and so on, So those are the sort of main risks that people worry about. Anyone have any questions? They wanted to ask at this point about what we've covered so far? No, it doesn't look like it. Okay, so let's come on to the sort of nuts and bolts of what are you going to do if you want to start someone on HRT, What are you actually going to give her? So, um, you're going to make your decision about estrogen only versus estrogen and progesterone, which is largely based on the presence or absence of a uterus. There are a couple of points to finesse here, so if a woman has had a sub total hysterectomy, so they've taken the uterus. But they've left the cervix behind. There is a possibility that there is some endometrium left behind, and you don't want to therefore give estrogen only HRT and and risk stimulating that endometrium. What you can do for those women is you can give them three months of sequential HRT, where they take the estrogen all month and the progesterone for two weeks of a month. If they in that three months, they have absolutely no withdrawal bleed when they stop the progest a gyn. Then you can safely say they have no endometrium, and they can have an estrogen only preparation. The other group who you have to think carefully about is those who's had their hysterectomy due to endometriosis because they may have some patches of endometrium elsewhere in their pelvis, or even more distantly. And so a bit of communication with the gynecologist who did the hysterectomy would be sensible, because if he says, yeah, actually, there was loads of endometrium all over the pelvis. We couldn't get it out then they should probably have combined. Um, H R. T and women who have had an endometrial ablation, which is sometimes done for heavy periods who still have their uterus. They still need combined HRT like anyone else with the uterus. Because although the endometrial endometrium has been ablating, it won't have all gone. So, um, you make your decision about estrogen only versus combined sequential versus continuous, depending on whether or not it's been 12 months since the woman's last period. Topical, uh, transdermal versus oral. Um, and then how are you going to give it? So if you're going to give it orally, then, um, there are various preparations you can give. Some are sort of combined preparations which have both hormones in, um, in the same in the same tablet and some you might give the estrogen and the progesterone separately. If you want to give transdermal estrogen transdermal HRT, then you've got two choices. You can either give a combined patch, which could be either continuous or sequential. So I won't really talk about brand names because obviously there are only the ones I use only really probably relevant in the UK. But you have preparations where if you want to give the woman continuous HRT. The patch just has the same amount of estrogen and progesterone in in every patch or month. She just carries it on. Or, if you want to give her a sequential thing, the packet will come with, say, patches that have to be changed twice a week and they'll be in each month there'll be four patches, which have estrogen and four packets four patches, which have estrogen and progesterone gin and as long as she takes them in the right order. And then she gets her sequential HRT. And then the other option, which has become increasingly popular in the last few years, is to give a gel or a spray, which has the estrogen, which the woman rubs into her body into her skin. And then you give the progest a gyn separately, either as a marina intrauterine system or as a tablet, and we usually use micronized progesterone because it's it's a more natural form of progesterone, and we think it has less risk for breast cancer. Now, the advantage of the gel versus a patch is that you rub it in and it's gone. You don't have to worry about a patch falling off. So some women just find that the patches don't stick that well. A lot of them find they're absolutely fine. But this is where your lifestyle thing comes in. If a woman goes swimming every day, her patches probably more likely eventually to fall off. If she's a massive fan of hot yoga where she goes in and gets hugely sweaty, her patch is more likely to fall off. Conversely, some women don't like the gel because they say it takes ages to sink in and you're not supposed to have a shower for a couple of hours afterwards, and it just doesn't fit with their lifestyle. So it's very much about horses for courses. And unfortunately, the moment I What I also have to take into account is what can I actually get? Because there's not much point giving the woman a prescription. If she goes to the pharmacy and they say No, we haven't been able to get hold of that for months, so I will often have a quick chat with my pharmacist and they will say, Yeah, this brand is in at the moment and we can't get that brand so? So that that helps me to know. Look to what? To prescribe. Um And as I say that, you know, brands just depends where you where you are. And I think as with any, um, as with anything in medicine, it's a good idea to get used to a few brands. So I use the same kind of HRT in most people as a start. My starting thing tends to be gel and micronized progesterone, because unless the woman doesn't want it for any reason, um and then obviously if they come back with on going symptoms or problems that then I can Then I can change that. But, um, yeah, estrogen, estrogen and you to Gestion. Something like that. Um, I and then I'm comfortable that I I know how to work with those. And, um, I don't I don't think you need to be familiar with every single brand of HRT on the market because you can always expand your knowledge, you know, as and when you need to. If a woman comes back with side effects, then you need to be able to have something in your head about what side effects are estrogen related and What are progest a gyn related? So can anyone think of any side effects of HRT and whether they know if they are more likely to be due to the estrogen or the progest a gyn? Okay, well, I will, uh, progesterone headaches. Yeah, absolutely. Headaches can be due to either, actually, um, but yes. Some women are very progesterone sensitive, and they get headaches. So breast tenderness and headaches and fluid retention and bloating can be due to either. Um, nausea tends to be an estrogen side effects. So you might think about dropping the dose as the leg cramps and skin problems and mood problems tend to be more of a progest a genic side effects. So you might want to think about changing the changing the progest a gyn. We're not worried, particularly. Oh, cancer. Some of the please. I don't really get the indications for either choice of HRT regime. Okay, so just go through it again. Um, So your first decision is Does she need How many hormones does she need? So if she has a uterus, then she needs estrogen and progesterone in. And if she doesn't have a uterus, then she needs estrogen only that's your first decision. And then assuming that she needs to hormones, your next decision is, Do you give them? Do you give her both hormones all month, all the time continuously, in which case she won't get a period? Or do you give her estrogen all month with progesterone for only two weeks? And if you do that, then when she stops the progest a gyn, she'll get a withdrawal believe, like a period. And the decision on that is whether or not she's had a period in the last year. So if a woman's had a period in the last year, so she's perimenopausal, then she should have a combined a sequential preparation estrogen all the time and progesterone for two months, because if you give her a continuous preparation, estrogen and progestin all the time, she's likely to have a lot of irregular bleeding. If she's using an intrauterine system, a Mirena as her progestin, then you can sort of forget all of that because the intrauterine system will keep her endometrium nice and thin, protect it from hyperplasia, and then she can just have estrogen with it all month. So hopefully that sort of clears it up. Um, so in general, we say that we're not terribly worried about new vaginal bleeding that starts in the first 3 to 6 months of HRT. If it persists for longer than six months, then we would get a bit concerned. And we might think about Does this woman need either a scan or a hysteroscopy? But as always, you know, they, they say, don't know when you're doing MCQ us. If the multiple choice is always or never, it's probably wrong because there's no always and there's no never in medicine. Um, if a woman is having very heavy bleeding, that would worry me. Um, and if a woman has had a period of amenorrhea time of amenorrhea and then starts being, that would worry me. So if you started her on HRT and she's been a moderate for four months and suddenly she has a massively heavy period that would concern me. Whereas the sort of more common picture is that in the first 3 to 6 months of HRT, the woman gets sort of a bit of annoying light spotting, which gradually improves over time. That is quite common, and I wouldn't be worried about that and I wouldn't investigate it. Um, I'm gonna just briefly show you a slide here, which is probably too much detail for most of you at this stage. But it's just to make the point that there are lots of different progesterones in h. R. T. And so, for example, if a woman you can see here, some of these are listed as androgenic, which means they are sort of more towards the male hormone. If a woman's having a lot of acne with her HRT, then you might want to change her to a less androgenic side effects. So, you know, once you get familiar with these, then then you can play around with the different types of progest a gyn. But I think at your stage this is This is probably more than you need to know. So alternatives to HRT. So some women can't take HRT of any type and that the the biggest group of is probably women who've had breast cancer. So I think very few doctors in the UK prescribe HRT two women with breast cancer. There are a few specialists who are happy to sometimes do it in close consultation with their oncologist. But usually we do get a bit nervous even with triple negative breast cancer, which doesn't have estrogen or progesterone receptors. Um, so what can you do? So options would include, um, an antidepressant. So, um, an S S r I or an SNRI which we are not using to treat. We're not causing the we're not calling the women's menopausal related mood changes depression, treating that we are actually using it to treat the menopause. There is some evidence for it for vasomotor symptoms. Um, clonidine, which is an alpha drug often used for hypertension. Um, menopausal specialists say you are Clonidine is rubbish. It doesn't work. Um, but that's because the women for whom it doesn't work go on to see the menopause specialist, whereas the women for whom clonidine does work, stay in primary care and keep taking it. It's a bit of an all or nothing drug. Um, so I will try it for a couple of months, but I'll be very clear to the woman that if it's not working after the first month or two, it's not going to start working, and you may as well stop it. But it does have a license in the UK for vasomotor symptoms for hot flushes and gabapentin, which is a neuropathic pain drug, is also something that can be used. And if there are predominant mood symptoms, then you can use cognitive behavioral therapy. So those are really the options for a woman who can't have or doesn't want to have HRT. Then, of course, there's all the myriad of natural remedies. Um, now, the problem in general with natural remedies, is that you never quite know. Um, if you never quite know what you're getting in each packet if I buy it, if I prescribe a packet of amlodipine 5 mg, I know it's gonna have exactly the same amount of medicine in as the packet of amlodipine 5 mg that I prescribed two years ago, even if it's from a different manufacturer. Um, and you just don't know this with herbal remedies. We do in the UK now have a bit of a registration scheme for some of them, but I suspect not every country does so. It's very much sort of buyer. Beware. A woman who is who is using herbal remedies should look at some reputable advice online. Fine, but you know in the end, the bottom line is that if a remedy herbal remedy significantly improves her symptoms, then it's probably got some natural estrogen in it. And, of course, she's not getting any progesterone to protect her endometrium from that. So you've got to be sort of very cautious about that now, we've got five minutes left, and I just want to talk a bit about genital urinary syndrome of the menopause. Um, so this is, um, uh, symptoms of the genital and urinary tract, which are caused by thinning and shrink ning of the sort of thinning and shrinking of the tissues of the valve and the vagina. The urethra in the bladder due to estrogen deficiency, Always specifically asked, women often will be embarrassed, and they won't volunteer this, um, you can treat genitourinary syndrome of the menopause G S m with vaginal estrogen. Um, and there is very little absorption, so you don't need If a woman is only having vaginal estrogen, then she doesn't need, um, progestin gyn as well, even if she's got a uterus. Roughly speaking, it said that a year's worth of vaginal estrogen is equivalent to taking one tablet of systemic HRT, so it's very little. Um, some women will need two different types of vaginal estrogen. So, for example, there is a ring called Estring, and you can sometimes use that to estrogenize the top two thirds of the vagina. And then she might need a bit of cream for the valve and the lower third. And you can. And I often do combine vaginal in estrogen with systemic estrogen. So when you're following someone up after you started them on HRT, asked about gender urinary symptoms because they may say, Oh, yeah, much less anxious. My joint pains have gone. My hot flashes have gone, but it's all still a bit dry down below. And I can't have sex, and that's a bit stressful. Um, so So that is that, um, I think I'll probably end there. So the other couple of things I usually cover well, I will also a very brief word about testosterone, which in the UK um, women are very keen. There's been a lot of publicity about testosterone. Um, and women are very keen to have it. It is only licensed for low libido in women who are already on normal HRT and well estrogenized, and it is not a panacea for fatigue, depression, feeling a bit rubbish. It's going to make you younger, Um, and it's not long that we've been using it. So I think we need to be careful about prescribing it. Um, and what I'll do is I will share. So the talk that the the slides I have shown have come from I'll share that with Sharon so they can go around. And there's a little bit more about testosterone and a little bit about bio identical HRT. But I think at your stage there's a probably sort of for interest only rather than things you need to know. So with just a couple of minutes before 11 o'clock, so I will stop there? Um, no. In fact, I won't stop there. I will say a couple of words about premature a rare in insufficiency, which is menopause below the age of 40. Um, key things there. Some women will have a genetic cause. You need to think about whether you want to refer them. Um, some all women, almost all women, should use HRT. The risks that we talked about breast cancer do not apply to this cohort who go to go through the menopause early because, um, you are only replacing the huh woman's that most women would have. So they absolutely all should have HRT, with the possible exception of those who've had breast cancer. Um, and they may need higher doses, and they may need. They need contraception for longer, and you need to be very aware of the psychological implications. These are women who may not have completed their family. Their friends are not going through the menopause. It wasn't what they were expecting at all. It's an absolutely devastating diagnosis. It can be to have your menopause younger than the age of 40. So these women might need a lot of help and input from you and possibly referral, and I will now stop there. And so there's one or two minutes if anyone wants to ask any questions. Just one question for you, Doctor. Yes, sure. When we talked about the cardiovascular risks, I find it sometimes difficult. So when you have a patient who has, obviously, the cardiovascular risk is now out way in the benefit of the medication. But they, like, swear by the HRT treatment they want to continue it. Is it okay for a patient to assume the risk, Like, accept the risk and continue? Or do we have to withhold the treatment? Yeah. No, Absolutely. I mean, I I you know, I'm a big fan of the patient, sort of making their own decisions. And if she is, if her symptoms are at such a point that she's not sleeping, her relationships going down the tubes, she's about to lose her job. Then she's probably quite happy to take on a little bit of extra cardiovascular risk. Um, to have her life improved to have the symptoms resolved. So, yeah, I've got In fact, I have a woman in her nineties who's still on it. HRT because she is adamant that for her, the benefits outweigh the risk. I've heard more than one woman say, You know, they'll have to prize my HRT out of my cold, dead hands before I stop it. So it's absolutely reasonable to carry on. But we should be reviewing these women at once a year and making sure that they understand the risks of that. They're making an informed decision. Thank you, Doctor. Okay. You're welcome. Right? I will leave it there. Thanks.