Post menopausal patients

POST MENOPAUSAL -
Continuous combined therapies.

Continuous combined, or "period free" therapy should be offered to patients who are known to be more than 1 year post menopausal at whatever age, or who are aged >54years. The criteria should be filled in order to offer such treatments to patients who are unlikely to have continuing ovarian function, so that steady systemic levels of estrogen and progestogen can be achieved. Patients should be advised to expect some bleeding in the first few months of therapy but this should have settled by six months. Start with low dose preparations and increase if necessary for symptom control. All therapies in this group are licensed for bone protection as marked*.
See WHY AND WHEN TO OFFER CONTINUOUS COMBINED THERAPY.

b. Medium dose:

c. High dose:

d. Gonadomimetic

Because of its androgenic component, Livial can be particularly helpful for postmenopausal patients with reduced libido. Current evidence suggests that Livial does not increase mammographic breast density, as occurs with other types of HRT and long term use of Livial is thought to be associated with a similar increased risk of breast cancer to that of estrogen alone, which is less than that of estrogen plus progestogen.

TRANSDERMAL

"Tailored" continuous combined therapy allows flexibility but is less convenient than ready-made preparations. Use any continuous oral or non-oral progestogen with one of the following:

Why?

• No physiological reason for menstrual bleeds if can be avoided.
• Most women prefer a no-period option.
• Cheaper for patient - one prescription charge instead of two.
• Thought to be less risk of endometrial hyperplasia in long term compared to sequential therapy.

When?

• Patient known to be post-menopausal at whatever age, ideally by having had at least one year of amenorrhoea.
• If sequential therapy started while patient still having periods, wait until age 54. At this age, 80% women will have cessation of ovarian function.
• Change from sequential to continuous combined by advising patient to finish sequential pack and start new therapy at the end of the expected bleed.