|
PAGE 29
MHT should be individualised
according to age , comorbidities
, individual needs and preferences to promote adherence . Interrupted or no oestrogen therapy is associated with bone density and muscle loss 14 and increased cardiovascular 9 and dementia 11 risk .
|
showed no additional bone density benefit compared with MHT , 18 but it may be useful in the setting of low libido . 19
Problems with psychosocial and psychosexual function are common , and women may be reluctant to disclose these . Multidisciplinary care
|
highlighted the negative impact of POI / EM on muscle mass , strength and function . 21 Although MHT improves or maintains bone density 15 , 16 and measures of muscle mass , 14 outcomes related to fracture and muscle strength or quality are lacking . 12
The cause of POI also influences
|
levonorgestrel intrauterine system in combination with exogenous oestrogen therapy , and this should be considered when individualising MHT choice .
Providing information is part of high-quality care , promotes self-management and health-re-
|
Online resources
For GPs :
• Early menopause tools , including diagnostic and management algorithms bit . ly / 45hToBS
|
|
Recent evidence indicates that higher oestrogen doses are needed to maintain bone density , including ≥2mg oral estradiol , 1.25mg oral conjugated oestrogens , 100μg transdermal oestrogen patch , or equivalent ( eg , 2-3mg estradiol gel ) or continuous use of 35μg ethinylestradiol contraceptive pill .
15 , 16
Higher progestogen doses may therefore be required to provide endometrial protection in women with an intact uterus ( see Australasian Menopause Society : online resources ).
Non-oral oestrogen is preferred in the setting of increased thromboembolic risk , liver disease , hypertriglyceridemia or malabsorption . In contrast to the usual practice of oestrogen only-therapy where an individual has had a hysterectomy , combined oestrogen + progestogen therapy is suggested following bilateral oophorectomy + hysterectomy for endometriosis treatment , to prevent endometriosis recurrence . 17 The usual contra-indications to MHT apply ( eg , oestrogen positive cancer ), and in this setting non-hormonal therapies should be considered .
A randomised controlled trial involving testosterone therapy
|
and counselling should be offered . Ask about urogenital symptoms and address appropriately . 12 Vaginal oestrogen may be required in addition
to systemic MHT to treat urogenital symptoms . A recent scoping review identified protective factors for psychological health , including support from peers , family and friends ; counselling ; compassionate clinicians with continuity and individualised care ; and time for questions . 7
Risk stratification , disease screening , healthy lifestyle behaviours and MHT are essential components for prevention and treatment of POI / EM-associated comorbidities ( see table 3 ). Osteoporosis is a known and feared consequence of POI , and knowledge gaps have been identified that negatively impact health-related behaviours . 10 , 12 , 20 Fracture risk calculators ( eg , FRAX ) are not validated in women aged under 40 years . Importantly , a recent systematic review
management . Short stature and cardiac abnormalities are associated with Turner syndrome , requiring paediatric endocrine input for
MHT should be individualised according to age , comorbidities , individual needs and preferences to promote adherence .
consideration of growth hormone therapy , echocardiography and cardiologist review . 22 Autoimmune disorders associated with POI / EM will require appropriate condition-specific treatment and follow-up .
2 , 10 , 12
Loss of fertility associated with POI / EM can cause significant distress . Counselling and support with provision of evidence-based information is important . 12 Spontaneous ovarian activity may occur , usually within the first years after spontaneous POI onset / diagnosis , with the chance of spontaneous pregnancy
2 , 10 , 12 ranging from 1.5-10 %.
Currently there are no therapies that can restore fertility in POI , and pregnancy is best achieved via the use of a donor oocyte . MHT is not contraceptive , unless using the 52mg
|
lated behaviours , and assists quality of life . A co-designed digital resource for women with POI / EM improves knowledge , health-related behaviours / literacy and illness
23 , 24 perception .
Monash ’ s Ask Early Menopause app is freely available on Apple and Google stores , and provides women ’ s stories , evidence-based information , animation , a question prompt list and personalised dashboard with symptom tracker and goal setting to promote self-management ( see figure 2 ).
Conflicts of interest Associate Professor Vincent has :
• received honorarium from Amgen , Besins , Theramex and Astellas
• been an investigator on clinical research trials for pharmaceutical companies
• provided medical education for pharmaceutical ( Amgen , Besins , Merck ) and non-pharmaceutical bodies
• received an unrestricted research grant from Amgen
• received research funding from the NHMRC and MRFF .
References on request from kate . kelso @ adg . com . au
|
• Lambrinoudaki I , Paschou SA , Lumsden MA , et al . Premature ovarian insufficiency : a toolkit for the primary care physician . Climacteric 2021 ; 24 ( 5 ): 425- 437 . Open access . bit . ly / 3LLTUB2
• International Menopause Society Position White Paper on POI bit . ly / 3F6qb23
• POI management guideline bit . ly / 46E1xBz
• Australasian Menopause Society Information sheets menopause . org . au
For patients :
• Ask Early Menopause app , freely available at Google or Apple stores askearlymenopause . org
• Healthtalk Australia : Early menopause digital resource healthtalkaustralia . org
|
|