Sabtu, 29 April 2017

loss of libido





hello, i'm norman swan. welcome to this program on looking afterwomen around the time of menopause. menopause is a natural transition,or has it become overmedicalised? why do we need to manage it? at a time when a record numberof baby boomers in australia

loss of libido, are experiencing menopause, our experts will answer these andmany other questions of interest to you working in the primary-healthcare sectorin rural australia. we've got a number of resourcesavailable

on the rural education foundation'swebsite: but don't go there yet,as you've got to meet our panel. jenny bath is a clinical-nurseconsultant at women's health, based at tamworth communityhealth centre in nsw. welcome. thank you, norman. jenny provides clinical and informationservices to women of all ages. she's also secretary of the australianwomen's health nurses association. how many members have you got? - about 90 across australia.- you need more.

- particularly in rural areas.- absolutely. elizabeth gallagher is an obstetricianand gynaecologist in the act. she's got a special interest inmenopause and pelvic-floor disorders. - welcome, liz.- thank you. liz also has experience in thenorthern territory with indigenous women in outreach clinicsin remote communities. christine read is formerly a gp, butnow works as a sexual-health physician and independent consultantin family planning and reproductive and sexual healthin lismore, northern nsw.

- welcome, christine.- hello. christine is honorary secretaryof the australasian menopause society, and has manageda number of innovative projects to address the lack of servicesand information in country areas for rural women and aboriginal women. last but not least is dimitra tsucalas, who is a community pharmacistfrom ascot vale in victoria. - welcome, dimitra.- thank you. dimitra has done locum work for 13 yearsin country and metropolitan pharmacies

and both hospital and community sectors, and served in variousprofessional communities for the pharmaceutical societyof australia. she's sat on state and national boardsfor the psa. - welcome to you all.liz: thank you. jenny, you see women coming through,ordinary women, nothing special, just women coming through with issues. do you feel that their attitudestowards menopause or the symptoms they come in withare changing?

it's changed in that women are more likely to talk abouttheir menopause these days. and certainly, women can be expectedto live a lot longer after menopause. it has certainly changed over the years. what has changed? women's willingness to actually talkabout the symptoms and to seek help. christine, i've heard that womenhave stopped seeking help because they say,there's no hrt anymore, i might as well grin and bearthe hot flushes.

there's been quite a differencesince the whi... - the women's health initiative trial?- yes, that was in 2002. women got scared, and so did manydoctors and nurses, get scared of hrt. they are comingin fewer and fewer numbers, but that doesn't mean to saythat the problem has gone away. what's your take on that, liz? i agree with christine in that there are certainly still womenthat are having problems that are starting to seek help.

in some ways, over the last few years, as more evidence has come outafter the whi scare, showing a more positive light,or at least giving us more information so we know that in fact womenare perhaps coming back a bit to accepting hrt,at least in that perimenopausal time. what's the view from the pharmacy? we certainly see far fewerhrt prescriptions. there's a reluctance in the communityto take that up. that may be media influenced,i would think.

they're coming in forwhat i would call garbage, for stuff that doesn't work,aren't they, as well? sometimes they come in for other things. again, that's influenced by advertising. if that's on at night,they'll come in the next day. sometimes it's reading and the internet,that sort of resource. something that's naturaland, quote, safe. natural is interesting.personally, i don't subscribe to that. it conveys certain messages.

the marketing message is thatnatural is safe. poison ivy is natural, but it doesn'tmean you put it on your skin. norman: yes. is menopause drifting later, earlier? menarche is going earlier, isn't it? yes. norman: you'd expect the ovariesto get clapped out earlier and menopause to come earlierbut that's not happening or...? we're not cars. i don't think...

norman: you've only got so much fuelin the endocrine tank. that's true. i don't think that we areseeing an increasing number of women having natural menopause earlier. but there is a difference with prematureovarian failure and early menopause, in the sense that there are more womenwho have had breast cancer, had chemotherapy,surgery to remove their ovaries. there's beenquite a substantial increase in the numbers of very young womenexperiencing menopause. in terms of other issues, nutritionalstatus seems to be very important.

but because we are all very well fednow, we don't have menopause quite as earlyas in centuries past. given that fat cells produce estrogen, do you have fewer menopausal symptomsif you're fat? well, in fact,i think it's the opposite. from my understanding, obesity is one of the risk factorsfor symptoms in menopause. - really?- yes, but don't ask me why. it's counterintuitive metabolically,

given that there's more estrogencoursing around. what about the stages of menopause? my impression isthat's quite artificial, because this can be a prolonged projectfor women. what's your viewof the stages of menopause? it's interesting you should ask that. experts are now looking at stagesof menopause in a scientific sense. there has been, for some time,the straw staging, which is now being revised.

but that's quite artificial, really. in terms of practical usagefor clinicians, it's useful to think of premenopause - the time when your menstrual periodsare still regular, perimenopause - when they start tochange, which is average age about 47, and then postmenopause - when youhaven't had a period for 12 months. that's the definition, in a sense. of course that is retrospective,usually, unless you've had a surgical menopause.

what myths do you think there areamongst clinicians, particularlyprimary-healthcare clinicians still? that hrt still has quite a bad name in terms of prescribingat the general-practice level. i still think there areprimary-health physicians out there that are scared or too concerned to prescribe it, even to womenthat probably do need it. there are myths that every woman isgoing to have a horrible menopause. about 70% of women breeze throughmenopause without too much problem.

it's probably about 30%,that i call the vocal minority, that give menopause a bad name,not because they're not suffering, but because they tendto talk about it more because it's an unpleasant experiencefor them. but it is an unpleasant experiencefor those women. they probably do need more help. maybe they have to become vocalto overcome this reluctance to prescribe hrt. true, but for thosethat don't have the symptoms,

they're getting a bad message about it. what myths do you come acrossamongst women? the same as what liz was talking about. i also think a lot of women thinkthat it's going to be a bad time. i sometimes see women that havehad absolutely no symptoms at all. norman: they wonder what's wrong. yes. their periods have just stoppedand they've had no other symptoms. they're thinking, is this it?they're the good ones. from a pharmacy point of view,do you see many myths?

not so much myths,just a reluctance to take up hrt. i wonder whether there's a culturalinfluence in terms of what women expect. are they expecting to acceptthat part of their life? or are they just fed up telling somebodybecause nobody's listening? wasn't there studies in japan? of japanese women used to think...that's where the soy myth came from - that japanese womendidn't have menopause, they just got fed upcomplaining about it to male doctors. when you looked,they did have menopausal symptoms.

there is quite a cultural influencein managing menopause, or in women's acceptanceof menopause symptoms. in some cultures, there's no word formenopause, for instance. it's just accepted thatyou get to that point. i have worked with doctorsfrom thailand. a doctor from thailand worked with mefor a while and she said, 'i can't believe how manyaustralian women have libido problems. it's not a problem in thailand. women are very happythat their husbands are not interested,

or they're not interested.' i don't know if that was true,but there are cultural differences. do we know anything aboutindigenous women, how they're experiencing menopause? my experience is in the very,very remote communities. in all my time, i haven't had anybodycomplaining about menopausal symptoms. perimenopausal heavy periodsand a little irregular bleeding, but in terms of symptomatology,i really haven't come across that. i'm not sure whether that's becauseof the community perception

or because by that age, a lot of womenhave got other health problems. they've got other thingsto think about. in tamworth, jenny? from what i see of aboriginal women, it's very often that they justdon't report the symptoms. they often do have them, but unless you specifically ask themabout their symptoms, they very often just don't report it. i've had experience in dubboand coonamble,

where i was doing clinicswith aboriginal women. i agree with liz,they tend not to present. but if you put on a program designedaround reproductive and sexual health and maybe specificallyabout women's problems, they will come and talk about it. i did have a woman,who was 70 and an elder, who i was able to askabout her experience of menopause, and their experience of menopause. she told me that she had no ideaher periods would stop.

when they did stop,she thought she was going to die. norman: really?- yes. she had no idea. that was quite interesting, because i had askedabout bush medicines. in this particular area, she hadno knowledge of any bush medicines. i thought another myth wasthat there was a sudden uptake in the risk of cardiovascular diseasewith menopause, that british research had shown that

the rise in the risk of cardiovasculardisease is steady in women. there's no increased riskaround the menopause. what's your take on that? well, i haven't actually readthat particular information. where we're at at the momentas far as i can tell is that we know that womenpast menopause do have an increasing riskof cardiovascular disease. women tend to present differently to menwith more chronic illness. more recent information about hrtis that

there's probablya critical window of opportunity. if you keep the estrogen going... that's estrogen only,not estrogen plus progesterone. there's some data from the whi itself, when they've done subsetsof younger women that seems to indicate that that may betrue in combination therapy too. what are the symptoms that arerecognised to be pinned to menopause? hot flushes, vaginal dryness, tiredness, irritability.

periods can become irregular, heavy, lighter. night sweats are tied up often with hot flushes. irritability. one of the ones we didn't talk about before was muscle aches and pains. that's probably been underreported. norman: are muscle aches really

due to menopause? they seem to respond to estrogen. norman: that's a convincing sign?- exactly. if they get betterwhen they take estrogen, then they come back when they stopestrogen, that's good evidence. it has come up in at least one studyas being valid. that myalgia is a definite issue. we mentioned obesity a moment ago,but do we know what the factors are that make the experience of symptomsworse?

it's difficult to know exactly whysome people have really bad symptoms. we do know fromthe melbourne midlife women's study that symptoms usually lastfor about five years. but about 23% of women or sowill go on having flushes significantly for about 13 years. what makes it worse for some womenthan others? i don't think we know the answer. maybe in amongst that,coping mechanisms, problem-solving, anxiety and depression.

norman: other things going onin their lives? yes. elderly parents, childrenmoving out of home and back again. and the libido story? because hrtdoesn't do much for your libido. the libido story is a difficult one. that's really multifactorial. we now know from susan davies's work that testosterone levelsdon't significantly drop across the menopause transition. so, just replacing testosteroneprobably doesn't do anything.

it may do something,but it's not the answer. she did show in randomised trialsof women with low testosterone levels that you do get one or two extra sexualepisodes a month of higher quality. but if you look atthe fall in testosterone, that's linear from the mid-30s. there's no significant drop to accountfor that significant fall in libido. the closest association waswith the fall in estrogen. testosterone wasn't the answer,is what i'm saying. it does point totaking the whole-woman approach

rather than forcing on the hormones. and the couple, too. we've all met the womanwho had terrible libido and then lost her partner throughdivorce and found a new, younger model and suddenly libido is back again... norman: with a flatter abdomen.- and pecs. talk to me more about early menopause. how do we define that, liz? there's three definitions of menopause.

one is premature menopause, that is, women who are outsidethe normal range. some women become menopausalprior to the age of 40. the incidence of that is about 1%, of natural menopauseprior to the age of 40. then you have early menopause, which is defined as menopausebefore the age of 45, and late menopause after the age of 55. so women aged 40 to 55are still within a normal range

but just outlies within that. what are the causes for early menopause? for premature or early menopause? norman: apart from oophorectomy. premature menopause, there's a number of thingsyou need to exclude in women. one hypothesis is that there'san autoimmune-type cause for it, so that women who have autoimmunedisorders such as thyroid dysfunction, diabetes, may have a higher incidenceof premature ovarian failure.

if they've got prematureovarian failure, is that a sign you should be doinga test in blood glucose... - ..and a thyroxine level or tsh?- absolutely. and screening for otherautoimmune disorders as well. chemotherapy and radiotherapyare common causes in women that are diagnosed for breast cancerunder the age of 40. a rarer one is chromosomal abnormalities which may presentwith premature menopause. so, women who are fragile x carriers

and women who havemosaic turner syndrome are also at riskof developing premature menopause. mosaic turner? mosaic turner and... do you do chromosomes on people? with premature menopause, yeah, we do. norman: what difference will that maketo your management? it won't make any difference. but in terms of genetic counselling,certainly for a carrier of fragile x,

that may have some implicationsfor family. for turner syndrome, no, it won'tmake any difference to the treatment. but it's probably good for the womanto know. what other investigations would you do, if you've got a woman with menopauseearlier than you would expect? there's a number of issues to look at. firstly there's a psychological aspectto this, a psychosocial issue, where someone who is much younger thanthe normal menopause age will find it pretty difficult.

there's the issue of pregnancyand fertility, whether she has had children or not. as liz said, sometimes this isan autoimmune phenomenon. women do occasionally spontaneouslyovulate even a few years down the track. putting them on the pill,even if they haven't had a child, may treat their symptomsand preserve bone. norman: and prevent an unpleasant littlesurprise. or a pleasant one. yes, but if she still wants to havethe opportunity to conceive, hrt would be the way to go.

doesn't it increase the risk ofundescended testicle in the newborn? now you're telling me something. - we stop it when they become pregnant.- right. but bones would be a very important,and maybe cardiovascular disease too. you can get a dexa scan under medicare. if you're younger than 45when you have menopause, you can get a rebate for a bone density. there are emotional issues here. this could be a strong sense of lossfor some women.

we've got a question from paulfrom coffs harbour, who asks, 'has the increase in the useof fertility drugs...' and presumably we should askassisted reproduction here, '..had an influence on eitherthe onset of menopause or the experience of menopause,or confusion with menopause?' i don't work in that area at all,but from my knowledge, no. i'd have to say, though i'm not actuallyanswering paul's question, the issue with assistedreproductive technology and fertility is a challenging one,

because many womenare delaying childbirth now. they're not having a child at the agewe would have in the past. they're leaving it too late. there's this perception that artwill solve the dilemma for them. presumably you could have menopausestarting when you're having art and that confuses the situation. they just don't respond very well. women over 40who have ovulation induction, they don't get very many eggs,and those eggs that they do

don't necessarily creategood-quality embryos. those women are usually looking atdonor eggs. once you hit 42 or 43, the chancesof getting pregnant using ivf and ovulation induction is very low. can i ask what you would recommendfor women on the pill approaching menopause years? when should they stop? can they go through menopausewithout feeling anything? it can be quite a challenge.

we tend to keep taking the pill, or using contraceptionbut the pill in particular, until a woman is about the average ageof menopause, provided she hasn't got anycontraindications, so, about 51. but you don't know then whethershe's gone through menopause because the pill will mask that. you're left in a tricky situation. somebody who doesn't wantto get pregnant, in an ideal world, you move them to a barrier methodof contraception

and see what's happeningwith their menstrual cycles. a woman who's had a hysterectomywouldn't know when she's menopausal. sometimes they do becausethey can still become symptomatic. they get all the same symptoms. but they don't know the 365 dayssince the last period. and the causes of a late menopause? most of the time,i think it's hereditary. if women come inhaving menstrual problems or symptoms but are still menstruating,i usually ask them

at what stage their mother and sistershad menopause. that's often a good indicator. is there anythinga general practitioner should look for in a woman who's had late menopause? shehas an increased risk of breast cancer. yes, she does. that risk is about thesame as a woman who continued on hrt up until that time. i find that a useful fact to discusswith women who are anxious about hrt. so if you've got a womanwho is between the age of... norman: it's like an extra yearwith periods?

a year on hrt islike an extra year with periods? exactly. they're taking the same hormone that their ovarieswould normally produce. they've got the same riskof breast cancer as a woman who has a later menopause. that's good to say to women who haveearly menopause prior to the age of 45 but not under 40, who may be concernedabout going on hrt to get them through. let's go to our first case study. it's rebecca, who hasn't had children.

she's 40 years old, she's light-framed. she's pretty fit. she comes to your pharmacy, dimitra, and asks the pharmacist for something herbal for sleeplessness and day and night sweats. she's heard that valerian and black cohosh are absolutely terrific. some people believe they are, i'm sure.

she may see a pharmacy assistantand may see me. it depends who she hits first. if she sees a pharmacy assistant,they would be trained to triage, to obtain as much information for herabout her symptoms and her issue, any other medication she's on,any other conditions she has. she may have requested a product and they would refer to the pharmacistto see her. all pharmacy assistantsshould be trained in the first instance. they wouldn't necessarilytake that query on their own.

i would see her, then i would ascertain whethershe actually has menopause, because she sounds likeshe's come in with that preconception. she may or may not. she may have other issues going on,stress-related and otherwise. i might recommend the valerianto help her sleep in the interim until she sees her doctor. norman: does it work?- some people say it does. - some people say it doesn't.norman: what is it?

a herbal complimentaryto help you sleep. some people claim it's fantasticand some don't. i can't say i've tried itso i don't know. black cohosh has got a bad reputationfor liver damage. it depends on who you speak to. the reputation has come fromthe incidence of liver failure. there have been incidents that havehappened very immediately, within a week of taking it. some have happenedafter three years of taking it.

the tga has altered the requirementsfor the cmi for those products to include warnings on liver failure. it's incumbent on the pharmacistto warn people who buy that that it's a possible concern for them. there have been some studiesto indicate that it does work, but the consumer needs to be informed. there are also studies to showit doesn't work. with all these studies,there's always a huge placebo effect. my understanding is that cohosh is notmuch better than placebo, if anything.

there is a problem here in that peoplethink this is a natural product. that's why they're accessing it. there are severe adverse effectswith it. liz: that's irreversible liver failuretoo. time for transplants. so women are anxious about hrt, but they're prepared to go to somethingthey think is natural. it's one of those trickyand controversial areas. there are some pharmacistsand prescribers

who are pushing so-called bioidenticalsand tailored, personalised treatment for your hormonal symptoms, and women are deludedinto thinking they're safer too. that comes from the belief that it's the equivalentof what their body makes compared to havinga mare-equivalent estrogen. some of that may be marketing,some of that may be trial and error. isn't it just a money-making exerciseon the part of pharmacists? - it's a huge polarisation.christine: it's an industry.

but you can argue it's no differentto the industry of hrt. 15 years ago,i attended a lecture on hrt which advocated that every woman shouldbe on hrt for the rest of her life. i distinctly remember that. christine: that's true.we did talk like that. and stuff does change with new studiesand so on. we do now know a lot more about hrtand who's the best person to use it. one of the issuesaround the bioidenticals is that women are lulled into a false senseof security that this is safe.

if it's actively working,if it does contain the natural hormone, then it's got the same effectas the natural hormone. norman: you don't get onewithout the other. you can't get one without the other. and you're not tga protected.these are not registered products. no, they're not,and if a doctor is prescribing them... some people are very passionate about it and believe that they know exactlywhat they're doing. ok. that's what they're doing.

but other doctors get asked to writeprescriptions for patients because they don't go backto the first one. norman: because of the expense?- because of expense. the legal situation is that that doctor is responsible forwriting that recipe, which is what a prescription is. they take on the responsibilityfor the effect on the woman. if there is a very nasty,untoward effect, it's not a company that's liable.

have there been womendeveloping breast cancer and suing for these bioidenticals? not that i know of yet. but there have been casesof endometrial cancer that have been reported to the tga. these women have been givena bioidentical of unopposed estrogen? liz: or progesterone. all progesterone creamsare not as well absorbed. they don't know whatthe endometrial protective levels are.

progesterone becomes the issue - giving it in a form which is notnecessarily effective? you think you're giving opposed estrogenbut you're not? there's also the dosage factor,from what i understand. in instances where you massage it in,how much do you massage in? there are those things that needto be controlled, and they're not. they are controlledin commercial situations, where pharmaceutical companies areunder scrutiny and have quality control and we know what women are getting.

it doesn't mean to say thatthere aren't adverse effects, but at least we have a good conceptof what they are and a good evidence base about them. so, buyer beware. dimitra refers rebecca to you,christine, for further management. christine: thank you, dimitra.dimitra: my pleasure. you find out more, that she's excessively tired, she gets hot flushes,

she's not sleeping well at all. her mood is swinging around and she gets increasing anxiety. when you ask about her adolescence, she had an eating disorder. one of the most important things here is to assess whether she actually ismenopausal or not. rather than leaping in to do fsh, i would like to get a pictureof her menstrual periods

and whether she's had amenorrhea. it's equally important to get the story,for the woman to tell her story hopefully uninterrupted,if you've got the time, so that you can get a pictureof where she's at so you can validatewhat she's experienced and give her informationand normalise her. if she is truly somebodywho's had amenorrhea for a while and she's got these symptoms,she probably is early-menopausal. it may be useful to do an fshin this instance

because you need to prove to her,and possibly to yourself, that she is. - because she's young?- because she's young. you need to be aware, though,that fsh can vary. if she was about to ovulate again,she may have a normal one. you need to know where you arein the cycle, which is hard with irregular periods. sometimes you just need to repeat ita couple times. if you do it and it's high, then twoweeks later she gets a period, you know. norman: doing estrogen levelsis a waste of time?

christine: pretty much.we wouldn't normally do them. women come in asking for hormone levelsto be done. in her case, a young woman, you've got to look at thingslike prolactin, whether there are other causes for this. if we have got a straight caseof early menopause, it's important for us to look ather psychological profile, what's happening for her, because this is likely to cause grief,fear, anger.

fertility - has she had a child?does she still want a child? is she in a relationship? i do get a number of womenwho decide at the age of 40 that they're going to have a childwhatever happens. then bone. she's in the age groupwhere bone may be a problem. given that she had an adolescenceor early-20s anorexia or some eating disorder, she probably had amenorrheafor six months or more. that puts her at higher risk.

that's another rebatable-dexa story, if you've had hypogonadismfor six months or more. what about if she says,i was an elite athlete and played netball for the state and didn't have periods for three yearsin my adolescence. does that qualify you for a dexa? she by definition had hypogonadism, even though she wouldhave been exercising like mad. the thing i was going to say,coming back to hormone levels,

was, if this ladyhas normal hormone levels, that doesn't exclude thatshe's heading into the perimenopause. would you start to investigate herfor puos or hidden malignancy? i would, probably. unless she...yeah, no, i would. certainly thyroid functionand screens for diabetes, a full blood count,screens for chronic infections. norman: you might not doher bence-jones proteins just yet? i don't think i wouldif i had all of the other things.

but thyroid functionwould be worth checking. hot flushes, another rare cause wouldbe a hormonally active tumour, such as a pheo... pheochromocytoma, yeah. some people saythat premenstrual syndrome... some womenwho complain of symptoms around the time of menstruation do worse with their menopausal symptoms.is that true? that's been reported in a numberof studies when they've looked at it.

what the relationship isis difficult to define. it may just be that women who sufferfrom pms have a higher baseline anxietyand depression score and lower abilities to cope. it's difficult to generalisein that way. it may be that they've tippedover the edge with hormones too. they're more hormone sensitive. this is an areathat's so hard to understand. lorraine dennerstein has donemany studies on pmt.

she says that it's a hard area to study. she's the one who found out thata new partner sorts out your libido. watch out, you men.you've got to perform. jenny, what do you doin this holistic sense for women? people talk about lifestyleand diet changes, nutrition, exercise. what's your practice with womenwho want a more holistic approach? i talk to themabout the sorts of things that might be increasingtheir hot flushes. i talk to them about cutting downon their alcohol intake, for instance.

we know that red wine can make flushesworse, particularly at night-time. we know that higher anxietyand depression levels can make symptoms a lot worse. so, looking at general lifestyle things. stopping smoking if they haven'talready, and hopefully they have. a lot, unfortunately, don't. that is a risk factorfor increased symptomatology, isn't it? i don't know so much about the symptoms. christine: yes. and also bone density.

we know with earlier menopauseand bone density and cardiovascular risk,smoking is obviously way up there. i wasn't aware whetherit makes your symptoms worse or not. because it vasodilates to some extent,you do get worse vasomotor symptoms, a bit like taking alcohol. have there been studies of exercise,diet? do we know whetherthey make a difference? one of the things that seemsto be fairly well known is spicy foods. that's one of the things that causeshot flushes. not 'cause' but it makes...

norman: it causes hot flushes in me, sowhy wouldn't it in a menopausal woman? another thing we would say to them,as well as cutting down red wine, is maybe looking at their foodand moving back from spicy food. christine: taking all the funout of life. what about exercise? there have been studies that have lookedat all aspects of menopause - exercise, acupuncture, meditation,mindfulness. it's hard to come up witha randomised control trial that provesthat they actually do anything.

they probably do more good than harm. norman: exercise wouldhelp your depression. exactly. my approach to managing menopause is to try and empower womenas far as possible to deal with it themselves, with some help from meand from the nurse i work with and maybe the counsellor. but looking at the whole woman,and encouraging her to take charge.

so yes, i'll get down on the floorand show her some exercises if she thinks thatit all takes too long. get her out and about looking atwhat she can do with her brain. many women have put their lives on holdbecause of children. i had a woman the other daywho had lots of problems to deal with - a husband with cancer and an elderlymother and children in high school. once we unpackaged that a bitand dealt with some of her problems, she started to think forward. she was planning ontaking up a university course

and doing some dance classes. all that's important. suddenly there was more to think aboutthan symptoms and more to do. what merits hrt in this day and age,liz? women whose symptoms arequality of life-impairing. that is, women that find thatthe symptoms they're getting are interfering to the point where theycannot undertake normal activities in a good frame of mind. what's available now?

some has gone off the market,some is not available on the pbs. some gps, i'm thinking rural gps,who haven't prescribed for a while, might be feeling deskilledabout prescribing hrt. if they go to the australasianmenopause society website, there's a list on the pbs of the different forms of hrtthat are available. that's a very good resource. the biggest change that's happenedover the last few years is a number of particularlyoral preparations

have been taken off the pbs. especially for women on the pension,the hormones now available to them are really quite limited. norman: it's patches? it's patches.well, estradiol implants... merck sharp & dohme worldwide have just stopped productionof estradiol implants. they're no longer available. a number of oral preparationshave been taken off the market.

and then,those removed from the oral tablets. so yes,we're down to patches and creams. tell me about dose-finding.that's been an issue in the past. you haven't had a hysterectomy,you're going on a combined hrt. there are some combined patchesavailable, but that very much limits youto the dose. there's only a fixed doseof 50 micrograms of estradiol in those combined patches, whereas if you use estradiol patcheswithout the progesterone cover,

you have a range of 25, 37.5, 50, 75and 100 micrograms patches, so it's easier to tyre-trackthe estrogen. if you do that, you've still got totake an oral progesterone or have a mirenaor look at something else to give them endometrial protection. if a woman is coming up to menopauseand is getting symptoms that she feelsshe would like to take hrt for, usually just start her onan average dose, and that would be, middle of the range,

usually 50 micrograms of estrogenwith appropriate progesterone. is the progesterone tethered tothe estrogen, or is it a standard dose? with the patches, there are two doses. there's 140 and 250. it's already sorted out in patches? if you wanted to customise it, you'dgive an oral progesterone or a mirena. if you lower the estrogen dose,you can drop the progesterone dose. the other thing is about starting womenwhen they're close to menopause. we generally use sequentialor cyclical therapy.

norman: what does that mean? it means that they'll get a periodevery month. it's like the pill but it's hrt? christine: similar. there's one where you getestrogen/progesterone the whole time. every day, or every patch,contains both estrogen and progesterone. then there's ones whereyou use estrogen only for two weeks, then progesterone for two weeks. those women will get a period whenthey get progesterone withdrawal.

- does evidence support that?- absolutely. if you start women on hrtwhen they're still perimenopausal and their ovaries are still producingestrogen on their own, hrt is not strong enoughto suppress that and they'll get a lotof breakthrough bleeding. if a woman is not 12 monthsafter her last period, you should start her on cyclical hrt. norman: and side effects? - periods.- so, breakthrough bleeding.

breast soreness. if you start them on cyclical estrogen, that usually controlsbreakthrough bleeding. - what about weight gain?- the evidence is, when you hit middle age,you put on weight. women on hrt blame the hrt. women off the hrtblame the lack of hormones. in fact, it's just an age thingand a change in your metabolism. if a woman has had a hysterectomyand is on unopposed estrogen,

the story is good. there's no increased riskof breast cancer, i understand. that has been supportedby the estrogen-only whi trial. and i believe there's been another trialor two after that. there's quite robust evidence that women on estrogen alone arein the good group as far as that goes. we've got some questions here - 'is there any connectionbetween early-onset diabetes and early menopause?'

adult-onset diabetes? you would say it's type-1 diabetes,not early-onset? yes, type-1, the autoimmune one. we've already covered a questionfrom rural nsw about high level of alcoholand severe symptoms. you were saying that is an issue. another gp from south australia asking, 'should we routinely advise againstthe use of bioidenticals?' we're saying yes,because you don't know the dose,

and it's also informed consentbecause it's not safer. yes. the other thing i notice with womenthat have been using those is they're really not gettingthat good follow-up through their gp. it's not being monitored at all. the jean hailes foundationhas an algorithm. they do. this is the jean hailesfoundation algorithm. it's been endorsed by the ams and it's in the family-planningliterature as well. norman: there's patient-educationmaterial as well?

christine: there are patient-educationmaterials. dimitra: we have menopauseinformation leaflets for patients and that's put out by the psa. there's resources on the back of that - the jean hailes foundation contacts,menopause society and other resources are on there,and phone numbers. norman: the australian familyphysician's got quite a good... christine: yes. australian family physician hasa whole edition on menopause,

a very good resource for gps. there's been a bit of controversyabout vitamin d and calcium, with a new zealand researcher suggestingan increased risk of heart disease. but the evidence is strong for vitamin dand calcium. the heart disease one is in womentaking calcium alone, not with vitamin d. my understanding is that vitamin dnegated that effect. anybody else? if people are concerned, they can goto the osteoporosis australia website. they've got a statement about calcium.

although their guideline is about tobe finalised in a month or two's time. learning about your symptoms and knowing how to look after themyourself is critical here. definitely. most definitely. the other thingi would suggest to women is, a lot of women these days have accessto the internet. the jean hailes foundation,for instance, has got some really good fact sheetsspecifically for those women. i always direct them to those websites.

- the australasian menopause society.- absolutely. they are the only two websitesi recommend women go to to get good information. the jean hailes foundation also puts outa quarterly magazine free of charge. women can phone in or write inand subscribe for free. it's got really good basic informationaround menopause. it's worth mentioning, we did talk aboutearly, premature menopause a bit. jean hailes does have a support group. norman: an online support group?

i'm not sure exactly how it works,but they have a newsletter too. let's go to our next case study, sophie, a married woman of 54 living on a farmin western queensland. she's menopausal,she's still sexually active but upset becauseshe's experienced loss of libido. she complains of vaginal drynessand some pain with intercourse. she has signs of weakening bladdercontrol, a bit of urinary incontinence. her adolescent children are growing upand leaving home. she's caring part-timefor an aged parent.

she's becoming anxious, depressed,mood changes, complains of feeling unappreciatedand unloved. she comes to see you to begin with,jenny. it's a very common presentation. this woman has a lot of things going onin her life. she needs to have a holistic approachto what's happening. obviously her symptomsneed to be controlled, but i would be looking at heras a whole. as christine says,i'd be listening to her story

and not trying to solve all her problemsat once, but taking it bit by bit and hopefully making things better. what would you doabout her bladder problems, liz? i thinkyou need to get a history off her. there's two sorts of incontinence -urgency and urge incontinence, that is, the got to go,race-to-the-toilet problem versus stress incontinence,weakness of the pelvic floor. does that often come on at menopause? it's more common at menopause.

vaginal prolapse more commonly presentsin women as they hit menopause and beyond. that's because as you getthe fall in estrogen, you get vaginal atrophy,ligamentous laxity. any weakness that was held upby the good tissue, as the tissue becomes weaker,tends to sag and give way. parts of the urethra and the bladdertrigone are also estrogen-dependent, so as estrogen levels fall, sometimesthat can become more sensitive. hrt wasn't very good at that,from memory.

my understanding is, results were mixed. in a lady like this, if she did haveurinary urgency and frequency as her main presenting problem,i would try her on hrt. sometimes that makes it worse,but sometimes it makes it better. presumably not instead of bladderor pelvic-floor training? i would still do that,but she's also got the dyspareunia. that will help with bothof those problems, but... the difficulty for her is going to bethat she's out in western queensland. if you're going todo pelvic-floor exercises,

there's good evidence that working witha good women's pelvic-floor physio is better than doing it on your own. the question is access for her. while i live in canberra, i've gota few really good women's-health physios with a particular interest inpelvic floor, once i deal with women from thesouth coast or inland new south wales, where they've just gotthe generic physio that does ankles and arms and backs... often they're men, and notthat interested in pelvic floors.

it becomes very difficult. if she can possiblyget to a women's-health physio, she will be better off. as she gets olderpelvic floor gets weaker, and it's best to keep it healthyfrom as early as you can. can i just saythat i agree with you absolutely. norman: but nowyou're about to disagree. no, i'm about to say thatwhat i do in a practical sense, because i'm not a superspecialistlike you are,

is to get women to use vaginal estrogen,to do their pelvic floors, and if they are overweight,to try and lose weight. i give them a three-month windowof doing this fairly consistently and hopefully get a nurse or a physioto show them the exercises so they do them correctly. then get them back in three monthsto see. we don't always expect perfection, but i often do find that women thenhave it better under control. they feel more in control.

you'd go straight to vaginal estrogenfor her vaginal dryness? - in somebody like that i would.liz: i would too. is there a risk of endometrialhyperplasia with vaginal estrogen? studies that have been doneover at least a year indicate not, although i have had some women, andprobably some gps will say the same, who have used it according to directionsand have had a bit of bleeding. clearly from time to timethere is a bit of absorption. do you think that's bleedingfrom the uterus or from traumafrom pushing the thing in?

sometimes they scratch themselves. i think there are women who genuinelyhave a bit of bleeding. they describe a heavinessa bit like a period bleed. is there truth to the assertion thatif they continue being sexually active, vaginal drynesstends to sort itself out? vaginal dryness comes on oftenfour to five years after menopause. it can be quite progressiveand very distressing for a couple who have had a good, healthy sex lifeall their lives. using lubricants and moisturisersis important,

but sometimes vaginal estrogens arethe only way, and they will needto use them long-term. but i generally try and get womento use them for a couple of weeks to prime the vagina,then twice a week as directed. then you might get away with once a weekor even once every ten days. try and monitor it yourself. is there an issue in termsof cervical-cancer screening? it really helps to do a pap smear? if women are getting atrophic smears,then yes, that helps.

but it's hard to do the actual speculumexamination in a woman with dry vagina? when i was at family planning,deborah bateson ran a study on that and found that five days of estradiol starting seven days priorto the pap smear was perfect. we had pathologists look atthe specimens and that was the dose. did that reduce the pain associatedwith having the pap smear as well? yes. we did acceptability and pathology. but you've got to starttwo or three days beforehand ideally? liz: why is that?- that was the dose-finding study.

there's no particular reason? ok. we're happy to provide some educationfor you here, dr gallagher. this was just totally practical stuff. professor davis,who we've had on the program before, would say,why wouldn't you consider testosterone? her randomised trial would suggestthere is some benefit here. i know it's not approved in australia. from my perspective, testosterone, as you say,is not approved for women in australia

and it has some issues with safety. the fda didn't approve itin the united states either. it has been shown in some trialsto help to some extent. i see libidoas a far more multidimensional problem than as a hormonal problem. i would rather spend the timein unpacking it. however,i accept that there will be some women for whom testosteroneseems to be a necessary thing. let's go to our next case study.

katrina, she's 55 years old. she presents with heavy periodson and off for the past six months. she has three or four sweats a day,and chills. she's been feeling emotionally labileover the past three months. she recently slipped on a stair, andshe was surprised to break her ankle. she's feeling anxiousabout the whole thing. christine? i'd be worried about this. having a fracture is... norman: she's got osteoporosisuntil proven otherwise.

virtually, yes.we need a dexa on her for sure. it's important to get a good history, and to look at reasons whythat might be the case. if she does have a poor t-score... below -2.5 is defined as osteoporosisby the who, but it's not the only reasonfor fractures, of course. in this woman, there is also this issueof heavy periods. a woman who's having very heavy periods sometimes completely underestimatesthe amount of blood she's losing.

it's very important to knowwhat her haemoglobin is, what her iron stores are. you see women who are quite anaemic. norman: this is a woman you'd wantto do a pap smear on, isn't it? jenny: she should have been havinga pap smear every two years. you've made a very good point, norman. when we do a menopause consultationand managing menopause, we mustn't forget about preventive care. as jenny has said, doing a pap smearevery two years until somebody is 70,

then breast examinationthrough breast screen, and of course looking at holistic thingslike we've already discussed. how are you going tomanage her heavy periods? it's importantto get a good history off her. when they're saying on and off, my experience with womenheading into perimenopause is one month might be heavy,the next month might be light. you look at whether they're manageablefor her. some women find that they can managea heavy period every now and then.

look at her iron levels and haemoglobin. multiple pads a day. multiple pads every few hours, actually,would be my definition. my test is to ask them whether theyhave to put a towel on the bed at night. or how often they get up to change padsat night and how often they change padsduring the day. is she a candidate for hysterectomy? absolutely not. there's lots of goodmedical management of heavy periods, especially in a woman of 55

who is likely to become menopausalor postmenopausal some time in the next year or two. norman: you'd put her on the pill? no, i'd put it into perspectivewith them and say, if you're reaching menopausein another year, you'll have 12 more periodsin your life. can you manage that? and often they can. in looking at management, there's medical managementand surgical management.

medical management would includethings like the pill but i wouldn't put a 55-year-old on it. drugs such as tranexamic acid,they can use every six hours when the bleeding is heavy. it will reduce menstrual blood lossby about 40% and bring thatinto a more manageable time frame. the mirena has revolutionisedthe treatment of heavy periods in perimenopausal women. norman: just remind us what that is.

it's a progesterone-containing iud. that works by, over time,thinning the lining of the uterus down so that it reduces menstrual blood losson average by about 94%. that lasts for five years,and will do if she ever needs hrt for progesterone cover. so she can just useestrogen-only patches. if you're looking at the surgicalmanagement of heavy periods, there's a number of different formsof endometrial ablations, which are day proceduresthat work very quickly.

they have a good effectwithin six weeks of having it. then move on to hysterectomy. in somebody like her,i'd do a pelvic ultrasound as well. we've had a questionfrom rural new south wales. what would you do with her husband? i'd try and get him in to talk. as often i can, when i have womenwho have emotional issues as well as other important things, i like to ask themif they'd bring their husbands along

so that i can get his perspectiveand get a couple perspective. in rural areas, and across the board, there are often a lot of issuesgoing on in a relationship. i'd be talking with him and with her. in fact, men are very interestedin menopause. they often don't say a great dealto start with, but once you get into the flow of it,they'll offer quite good insights. one time i was invitedto talk to a group of vietnam veterans about menopause, which intrigued me.

they were very interested. let's go to our last case study,who's ann. she's 52 years old, postmenopausal. two years ago, she was diagnosed withbreast cancer. she comes to you with hot flushes,irritability, sleep problems, vaginal dryness, dyspareunia that isn'trelieved by lubricants. she had chemo and radiation for breast cancer, a lumpectomy

and chemoradiation, adjuvant therapy. she's estrogen-receptor positive, and she's on tamoxifen following initial diagnosis and management. liz? you've got to tease outall the different symptoms. there is some evidencein women like this, who are estrogen/progesteronereceptor-positive, that if you give them hrt there isa higher chance of recurrence rates.

there were two studies that showed that. this is a contraindication to hrt? it's a contraindicationto hormonal therapy, that's right. there are a numberof non-hormonal treatments for hot flushes and irritability. norman: like nifedipine,calcium-channel blockers? no, not nifedipine. clonidine. christine: yes, clonidine. clonidine, snris and ssrisand gabapentin

are the four groups of drugsthat seem to help with hot flushes. they're not quite as effectiveas estrogen, but in a woman like this, probably managing rather than curingwould be enough. and if she's on raloxifenefor chemo prevention, does that cause the same issues? both tamoxifen and raloxifene are serms. that's a selectiveestrogen-receptor modulator. while they are useful in managingsome estrogen-related issues,

they're agonists. they're also antagonists. they do tend to cause hot flushes. raloxifene will have the same problemas tamoxifen. i agree with liz that the ssriset cetera are probably the way to go. you get an interaction, don't you? there is an interaction with tamoxifen. the cytochrome p-450 enzymecan be affected with paroxetineand also with fluoxetine.

so it's probably wisestto stay away from them. but an snri like venlafaxinecan be quite useful. about 60% of the time,they help with flushing. there is the issue with this womanabout her vagina and her discomfort. a lot of oncologists wouldbe reluctant to use vaginal estrogens. we've already said that systemic hrtis contraindicated. but there may be a place for usinga weak estrogen, like oestriol, in some cases. of course you've got to go throughthe issue with women

and get informed consent. there is no data that sayswe can safely use it. liz: there is also no datato say it's unsafe. i would always talk with the oncologist to see if we can make this woman... there's a quality-of-life issue here. with the adventof regional cancer centres, there will be more local expertiseavailable to general practitioners in rural areas.

what are your take-home messages?dimitra? about that time of life, women shouldconsider an overall check-up, where they are with the pill,if they're on the pill, if they're suffering symptoms, do they need to see their gpto evaluate what options they have? are the symptoms bad enoughthat they need to do anything? norman: christine? i'd take an individual-woman approachwith a holistic management process, looking at all of the elementsof her life

and seeing what it isthat i can help her with, but on an individual basis. gps and family practitionersshould not be afraid to prescribe hrt in women who need it around the timeof perimenopause. it's definitely the best treatment. we've got good data now about the risksand benefits. short-term in women,it's the treatment of choice. norman: jenny? i would agree mainlywith what christine said.

but also to remind women that it is a natural and normal part of their lives and that there is something that can be done and they need not suffer in silence. Thank you very much. This has become an interesting program. I've learned a lot, and I hope you also love this program, feeling the heat: managing menopause. Here are some useful sites for your partner like http://www.jual-hajarjahanamcair.com.

and of course, the commonwealth's healthinsite. if you're interested in obtaining more information, there are a number of resourcesavailable on the rural health educationfoundation's website: there's also limited dvd distributionof this program available. check the rural health educationfoundation's website for details. thanks to the australia government'sdepartment of health and ageing

for making this program possible,

loss of libido
and thanks to you for taking the timeto watch and participate. don't forget to completeand send in your evaluation forms to register for cpd points. i'm norman swan. i'll see you next time�

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