The video version of this podcast can be found here:

·       https://youtu.be/eQwGStVNHe4

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

 

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

 

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

 

 

There is a podcast version of this and other videos that you can access here:

 

Primary Care guidelines podcast:

 

·       Redcircle: https://redcircle.com/shows/primary-care-guidelines

·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148


There is a YouTube version of this and other videos that you can access here: 

  • The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

 

The NICE clinical guideline on Menopause: identification and management

[NG23] can be found here:

 

·       https://www.nice.org.uk/guidance/NG23

 

The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:

 

·       https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901

 

The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:

 

·       https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf

 

 

The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:

·       https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/

 

GP notebook on contracpetion and HRT:

 

·       https://gpnotebook.com/pages/gynaecology/hormone-replacement-therapy-hrt-and-contraception

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we’re doing a practical review of menopause, focusing on what is relevant in primary care only.

We’ve recently covered the NICE guideline, so today we’ll keep things practical.

We’ll look at key definitions, common prescribing pitfalls, HRT regimens, contraception while using HRT, and how to advise someone who wants to delay a period for a holiday.

Right, let’s jump into it.

Let’s start with some definitions first.

Systemic HRT means HRT that is absorbed into the bloodstream and has effects throughout the body. The oestrogen can be oral, or transdermal.

The progestogen can be oral, transdermal, or provided through a levonorgestrel intrauterine system.

This is different from vaginal oestrogen, which is used locally for genitourinary symptoms. It is absorbed locally, with only a minimal amount absorbed into the bloodstream, so it is unlikely to have a significant systemic effect.

Vaginal oestrogen can be used alone or with systemic HRT.

Let’s look at the types of HRT, starting with combined HRT.

Combined HRT means HRT with both oestrogen and progestogen.

We use this in people with a uterus because unopposed systemic oestrogen increases the risk of endometrial hyperplasia and endometrial cancer.

Combined HRT can be continuous or sequential.

Continuous combined HRT means oestrogen and progestogen are taken together every day. The aim is no regular withdrawal bleed and it can be used when the person is postmenopausal, meaning at least 12 months since their last period or from around age 54 if the bleeding pattern is unclear..

Continuous combined HRT is not usually suitable during perimenopause or within 12 months of the last menstrual period, because it can cause irregular bleeding. In these cases, we would use sequential combined HRT, also called cyclical HRT.

This means oestrogen is taken every day, and progestogen is usually taken for part of the month, usually giving a predictable monthly bleed.

Another option for combined HRT is to prescribe an oestrogen-only preparation with a separate progestogen, for example, micronised progesterone which is usually given as Utrogestan in the UK.

Common regimens are Utrogestan 200 mg at night for 12 days per 28-day cycle, usually days 15 to 26, for sequential combined HRT or, for a continuous combined HRT, 100 mg at night from days 1 to 25 of each 28-day cycle.

Another progestogen option for endometrial protection is a 52 mg levonorgestrel intrauterine system, such as Mirena, which should be changed every 5 years when used for this purpose.

Let’s now look at oestrogen-only HRT.

This means oestrogen is given without progestogen and it is usually used in people who have had a total hysterectomy.

But we should mindful of possible pitfalls.

For example, after subtotal hysterectomy, some endometrial tissue may remain in the cervical stump. In that situation, progestogen may be still needed.

Another important pitfall is a history of previous widespread endometriosis. This is because even after hysterectomy, residual endometriosis deposits can remain, so combined HRT may be advised here too. In these two cases, we should consider specialist advice before prescribing unopposed oestrogen.

Oestrogen-only HRT can be oral or transdermal. Transdermal is often the first choice because it has a more favourable venous thromboembolism and stroke risk profile than oral oestrogen.

The general principle is to use the lowest effective dose that controls symptoms.

If symptoms are not controlled after a reasonable trial, or side effects occur, we can adjust the dose, change the route, or change the progestogen.

In practice, we should allow around 3 months after starting or changing HRT before judging the full effect, unless there are significant issues.

When starting HRT, we should explain the expected bleeding pattern. With sequential combined HRT, a regular withdrawal bleed is expected. With continuous combined HRT, the aim is no bleeding, but irregular bleeding can occur initially.

Now let’s talk about contraception.

The main message is simple: HRT is not contraception.

If pregnancy is possible and not wanted, contraception still needs to be discussed.

Non-hormonal contraception can obviously be used alongside HRT.

A 52 mg levonorgestrel intrauterine system or Mirena, can be particularly useful because it can provide both contraception and endometrial protection when used with systemic oestrogen.

Although Mirena is licensed for up to 8 years for contraception, for endometrial protection as part of HRT it is only effective for up to 5 years.

If a Mirena intrauterine device is not possible, we need to remember that not all progestogen-only contraceptives can be used for endometrial protection with oestrogen-only HRT. For example, the progestogen-only pill, progestogen-only implant, and depot medroxyprogesterone acetate cannot be used for this.

However, they can normally be used as contraception alongside HRT.

On the other hand, combined hormonal contraception should not be used in combination with HRT.

In eligible women under 50, combined hormonal contraception can be used as an alternative to HRT for symptom relief and bone protection, but not together with HRT.

If a woman reaches 50 while using combined hormonal contraception, they are usually switched to a progestogen-only method, and then we should reconsider HRT options.

And let’s finish with a practical question that often comes up: how to delay a predictable HRT withdrawal bleed for a holiday.

In UK practice, we could treat this as a short-term HRT schedule adjustment, rather than routine period delay tablets.

Here we would usually extend the progestogen-containing phase until after the holiday. That is because the bleed usually happens when the progestogen phase stops.

So, for someone using transdermal or oral sequential combined HRT, if the holiday falls when they are due to bleed, the practical option is usually to continue the progestogen containing patches or tablets through the holiday.

After the holiday, they switch back to the oestrogen-only patches or tablets and should expect a withdrawal bleed.

We should not extend the oestrogen-only phase to delay bleeding, because that increases time on unopposed oestrogen.

And we should not casually add high dose oral norethisterone on top of sequential combined HRT, because the patient may already be receiving progestogen in the combined phase, and extra norethisterone may add side effects and risk.

If the patient uses separate daily oestrogen with cyclical progestogen, they simply continue the progestogen until after the holiday.

Then they stop the progestogen, expect a withdrawal bleed, and return to the usual monthly schedule.

This is an off-licence schedule adjustment, and we should explain that spotting can still happen, and they should seek review for heavy, persistent, or unusual bleeding.

So that is it, a practical review of menopause.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

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