A to Z of Menopause and Medical Conditions
- Much controversy continues to surround the topic of heart disease and the use of HRT. Generally, opinion states that HRT should not be used for the treatment of coronary heart disease, though it is becoming more accepted that, when used within ten years of the menopause, or under the age of 60, HRT is likely to prevent coronary heart disease. Menopausal women with angina requiring treatment for menopausal symptoms are usually offered non-hormonal therapies initially. If these are ineffective and HRT is being considered, it should be known that there may be a small increase in risk of myocardial infarction (heart attack) in the first year of use of systemic HRT in women with coronary heart disease, but different types and routes of hormone therapy will have different effects. In women with established heart disease, taking estrogen through the skin by patch or gel (transdermal), starting with a low dose, is generally safer than tablet form. Vaginal estrogens may be used safely for treatment of vaginal and bladder symptoms.
- A history of anorexia, particularly if amenorrhoea (premenopausal absence of periods for more than 6 months at a time) occurred, increases the risk of osteoporosis. The menopause is an ideal time for assessment of risk and bone densitometry should be considered. If required for control of menopausal symptoms or prevention/treatment of osteoporosis, HRT can be used.
- There does seem to be a relationship between hormones and respiratory function, but the exact association is unclear. Some women do notice a worsening of asthma before a period and asthma may improve or worsen around the time of the menopause. The use of HRT may lead to a small increased risk of asthma but its use does not seem to worsen pre-existing disease and some studies have suggested a beneficial effect. [ref 23]
- Breast cancer
- A history of breast cancer is generally seen as a contraindication to the use of systemic HRT but vaginal estrogens may be used for treatment of vaginal and bladder symptoms. For systemic menopausal symptoms, non-HRT therapies should be offered. Occasionally, if symptoms are severe and unresponsive to other therapies, HRT may be considered under specialist supervision. A recent trial, the HABITS trial suggested that HRT may increase the risk of recurrence of breast cancer but a study in Stockholm showed no increase and further trial results are awaited. Occasionally, the breast cancer treatment causes a premature menopause and an increased risk of osteoporosis. Bone protective measures should be considered.
- Breast cysts
- HRT use may be associated with the development of breast cysts. This may deter women with a history of breast cysts from commencing HRT but this history is not a contraindication.
- Cervical cancer
- Cervical cancer treatment may cause an early menopause when bone protective measures should be considered. If menopausal symptoms occur, HRT can be used.
- Coeliac disease
- Coeliac disease is thought to cause poor absorption of calcium and hence reduced bone mineral density and an increased risk of osteoporosis. Bone protective measures should therefore be considered, particularly at the menopause. If HRT is used, the transdermal route (patch or gel) is preferred for more reliable absorption.
- Crohn's disease
- Crohn's disease may lead to an increased risk of osteoporosis due to both malabsorption and long term steroid use. Bone assessment should be considered in menopausal women and if HRT is used, the transdermal (patch or gel) route is preferred to ensure adequate absorption.
- Women with type 1 diabetes are thought to be at increased risk of osteoporosis and coronary heart disease. The association between HRT use and diabetes has caused some confusion; some studies, including the Women's Health Initiative trial, showing a reduced risk of diabetes in women taking HRT, yet fairly recently HRT advice sheets advised caution when using HRT in diabetic women. Currently, HRT may be used when indicated in women with diabetes, and it is thought that either low dose oral estrogen or transdermal (patch or gel) preparations are best. If progestogen is required, either dydrogesterone or micronised progesterone seem least likely to interfere with diabetic control, although further studies are required on ideal type and route of HRT. A recent study showed reduced fasting glucose levels in women with diabetes taking low dose tablet combined HRT. The use of sage is not advisable in presence of diabetes.
- There is a small risk of reactivation of endometriosis with HRT use and any recurrence of symptoms should be reported. If a hysterectomy has been performed for endometriosis, the choice of HRT use thereafter should be influenced by the extent of endometriosis at the time of the operation. Since hysterectomy often causes a premature menopause, it is often advised to take HRT until the average age of the menopause; 51 years. HRT after hysterectomy usually consists of estrogen only. However, in the presence of endometriosis, estrogen may cause stimulation of residual deposits and consideration should be given to using continuous combined (estrogen plus daily progestogen) therapy, or tibolone, though little research has been done on the effect of different types and duration of therapy. Medical treatment of endometriosis often involves ovarian suppression which, along with ovarian removal, may increase the risk of osteoporosis.
- Women with epilepsy may have an increased risk of osteoporosis due
to the effect of antiepileptic therapy. Firstly, antiepileptic drugs are thought
to increase the breakdown of bone which may result in lowering of bone density
in some people. Secondly, anticonvulsants are thought to interfere with the
body's use of vitamin D which is essential for calcium absorption, this interference
consequently impairing calcium absorption. The risk of osteoporosis is particularly
increased if antiepileptic therapy is used in high doses, for long term and
more than one drug is required. If HRT is indicated, some antiepileptic drugs
can increase the breakdown of hormonal therapy by stimulating liver enzymes.
Low or standard dose oral HRT may therefore be ineffective and the transdermal
(patch or gel) route may be preferred.
Sage use is not advisable and St. John's Wort should be used with caution since drug interactions may occur.
- Fibroids are benign smooth muscle tumours of the uterine (womb) wall and are dependant on estrogen. They tend to shrink after the menopause but shrinkage may not occur, or they may even increase in size with HRT use. Increase is thought to occur in 25% of HRT users and mainly occurs in the first six months of therapy. There is some evidence that transdermal (patch or gel) but not tablet HRT nor tibolone may promote fibroid growth. [ref 24] Fibroid size can be monitored by regular examinations and sometimes by ultrasound scans. There is some evidence that the use of the progestogen releasing intra-uterine system, Mirena may cause fibroids to reduce in size. Mirena is often used in the perimenopause by women who have heavy periods and/or require contraception and can provide the progestogen part of their HRT.
- Gall Bladder disease
- HRT has been shown to increase the risk of gall bladder disease, particularly gall stones, thought to be due to an effect on bile composition. Transdermal (patch or gel)HRT is usually recommended with a history of gall bladder disease.
- Hyperlipidaemia (high blood fats) is not a contraindication to using HRT. Care should be taken to decide on the best type and route of HRT since the type and route determine the effect on certain lipids. For example, oral estrogen generally increases triglyceride levels so that the transdermal route is preferred in the presence of high triglyceride levels.
- Blood pressure should be measured and, if high, should be controlled prior
to starting HRT. Blood pressure measurement should be repeated 3 months after
starting HRT and is then usually checked at annual review.
There is a very small risk of conjugated equine estrogens causing a rise
in blood pressure which resolves on cessation of treatment. In the presence
of controlled hypertension, HRT is unlikely to worsen control; some recommend
using transdermal (patch or gel) HRT.
Sage should be used with caution if hypertensive and St.John's Wort should be used with caution if taking antihypertensive therapy.
- Jaundice-see liver disease
- Kidney failure/transplant-see Renal failure/transplant
- Liver disease
- A history of liver disease with liver function having returned to normal would not be a contraindication to HRT use, though non-oral route would usually be advised. Active liver disease with abnormal liver function tests is seen as a contraindication to HRT use.
- Migraine is often triggered by hormonal fluctuations and therefore may occur around the time of a period. Such migraine may improve at the time of the menopause. Some women find that migraine may be triggered by the daily hormone fluctuations which can occur with oral (tablet) HRT so the transdermal (patch or gel) route is usually preferred with a history of migraine.
- For many years, a history of malignant melanoma was considered a contraindication to the use of HRT but this is now controversial and association between development and progression is thought to be unlikely.
- Multiple Sclerosis
- Menopausal women with multiple sclerosis have additional risk factors for osteoporosis and fracture, namely reduced mobility and weight bearing exercise, low levels of vitamin D and sometimes previous steroid treatment and an associated increased risk of falling. Bone protective measures in the form of general advice and specific treatments should be considered. Multiple sclerosis is not a contraindication for HRT use when indicated.
- This inherited condition causing progressive deafness has been shown to worsen with pregnancy and, very rarely, with the contraceptive pill but there is no evidence that HRT has such an association.
- Ovarian cancer
- A history of ovarian cancer is not a contraindication to HRT.
- Parkinson's disease
- Some studies have suggested that use of estrogen after the menopause may reduce the risk of Parkinson's disease and there is certainly no evidence of a worsening effect associated with HRT use.
- Post transplant
- Patients who have had organ or marrow transplant have an increased risk of osteopenia or osteoporosis, thought to be as high as 80%, with osteoporosis related fracture expected to affect up to 65% of transplant patients [ref 25]. Post-transplant steroid and other immunosuppressive therapy is thought to play a part in the bone loss, as well as the illness leading to the transplant, and its treatment, often causing an early menopause. For such patients, HRT and other bone protective treatments should therefore be considered.
- Renal failure
- Renal failure increases the risk of early menopause, and osteoporosis. HRT and other bone protective treatments should therefore be considered but little information exists about benefits and risks in such patients.
- Renal transplant - See post transplant
- Rheumatoid arthritis
- Rheumatoid arthritis confers an increased risk of osteoporosis, thought to be related to use of steroids, increased bone resorption and reduced weight bearing exercise due to the disease. Use of HRT or other bone protective measures should therefore be considered. The use of HRT does not appear to affect disease progress.
- The incidence of stroke increases in women after the menopause and an association between a protective effect of ovarian hormones estrogen and progesterone has been suggested. Similarly, it was thought that the use of HRT reduced the risk of stroke. Although some studies have shown a protective effect, others, including the Women’s Health Initiative trial, have shown a small increase in risk of stroke in those women taking HRT. It has been concluded that HRT should not be used for either primary or secondary prevention of stroke. If a woman has had a stroke and is considering treatment for menopausal symptoms, non-hormonal options should be tried first and HRT should only be considered after full discussion with a specialist.
- Systemic Lupus Erythematosus
- Systemic lupus erythematosus (SLE) is a multi-system disease which can manifest as rashes, seizures, kidney problems, blood disorders, fever, pericarditis and arthritis. Women with SLE are at increased risk of osteoporosis due to steroid use. Although SLE is thought to have hormonal associations and indeed often worsens during pregnancy, there is no evidence of a worsening effect of HRT. However, SLE may be associated with venous thrombosis (blood clot in a vein) in which case HRT should be used cautiously.
- Since HRT is associated with a small increased risk of venous thrombosis, care must be taken when considering HRT use in women with a past or family history of thrombosis. Depending on the indication for HRT and on the cause of the thrombosis, risks and benefits should be assessed. If HRT is to be used, preference would usually be given to the transdermal route (patch or gel) [ref 22]. Specialist advice should be requested. Vaginal estrogen may be used for treatment of vaginal and bladder symptoms.
- Thyroid disease
- Hyperthyroidism, due to either overactive thyroid gland or over-replacement of thyroxine in under active thyroid disease, leads to an increased risk of osteoporosis due to excess bone loss. Consideration should therefore be given to screening for osteoporosis in postmenopausal women who have a history of hyperthyroidism and offering bone protective measures. HRT does not worsen thyroid disease and in fact may be particularly helpful because of the bone protective effect. However, patients taking thyroxine should be monitored by having thyroid function rechecked 3 months after starting HRT since the thyroxine dose may need to be adjusted. Similarly, thyroxine requirements may alter if HRT is stopped and thyroid function should be rechecked 3 months after stopping HRT [ref 26].
- Uterine cancer
- A past history of uterine (womb) cancer would usually be considered a contraindication to HRT. However, if the cancer was of very early stage and there was a very strong indication for HRT, its use may be considered after a specialist opinion. Progestogens or other non-HRT therapies may be used as an alternative to HRT for menopausal symptoms.
- Varicose veins
- The risk, if any from HRT use with varicose veins is a blood clot (deep vein thrombosis) in the leg. The risk of a deep vein thrombosis on HRT is an extra 2 women per 10,000 women years of use. There is conflicting evidence as to whether or not HRT use in someone with varicose veins increases the risk further. However superficial thrombophlebitis (pain in the superficial veins of the leg due to inflammation in the blood vessel) is probably a risk factor. To put it in perspective, being overweight is more of a risk factor than varicose veins alone.