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HRT: helping women through the menopause

Victoria Bates
RGN RM FPCert
Nurse Manager
Female Health
Wyeth Laboratories Maidenhead

The menopause is defined as "the cessation of menstruation in the human female" and usually occurs around the age of 50 years.(1) During a woman's fertile years, two main groups of hormones, oestrogens and progestogens, regulate the menstrual cycle and evoke a number of physiological effects.(2) These include:

  • Maturation.
  • Maintenance of skin and blood vessels.
  • Blood coagulation.
  • Control of libido.
  • Water retention.
  • Control of smooth ­muscle function.
  • Control of lipid and ­carbohydrate ­metabolism.
  • Control of body ­temperature.

At the onset of the menopause, levels of these hormones are reduced, commonly ­resulting in health problems such as:(3)

  • Hot flushes.
  • Night sweats.
  • Palpitations.
  • Vaginal dryness.
  • Headache.
  • Anxiety.
  • Poor memory.
  • Depression.
  • Loss of self-confidence and libido.
  • Frequent or painful urination.

The menopause is also associated with potentially fatal conditions like coronary heart disease and stroke,(4) but it is the increased risk of osteoporosis that causes major health problems in postmenopausal women.
Osteoporosis is a progressive, systemic, skeletal disease characterised by a reduction in bone mass and a deterioration of bone tissue. The disorder is therefore associated with an increase in bone fragility. Osteoporosis is vastly undertreated and is responsible for 200,000 fractures in the UK every year.(5) Around one-third of adult women will suffer one or more ­osteoporotic fractures during their lifetime, and hip ­fractures alone account for more than 20% of UK orthopaedic bed occupancies.(6) In total, osteoporosis costs the NHS over £5 million per day.(7)
Normally, bone mass accumulates during childhood and reaches a peak by the age of 25.(8) Bone mass is then maintained for ten years, but after the age of 35 years, both men and women ­annually lose up to 0.5% as part of the normal ageing process.(9) 
In women, however, accelerated bone loss occurs after the menopause,(10) owing to the reduction in levels of ­circulating oestrogens and progestogens.(4)
Patients with osteoporosis are usually asymptomatic until the onset of bone fracture. Vertebral compression fractures often cause the patient to become shorter and/or hunchbacked,(11) while hip fractures usually occur as a result of a trivial fall. Fractures can be extremely painful and can result in patients requiring long-term nursing-home care.

Menopausal ­management
Because of the normally asymptomatic nature of osteoporosis, and the preventive nature of health strategies that combat heart disease and stroke, postmenopausal management is ­centred on ­identifying the patients who are most at risk, and preventing disease progression using lifestyle changes or medication.

Useful lifestyle changes include:(4)

  • Stopping smoking.
  • Reducing alcohol intake.
  • Regular physical ­exercise.
  • Calcium and/or vitamin D ­supplementation.

Hormone replacement therapy
The gold-standard preventive ­medication for postmenopausal osteoporosis is hormone replacement therapy (HRT).(6) This consists of either an oestrogen hormone alone, or an oestrogen in combination with a progestogen.(12)
In 1999, in a report ­entitled Osteoporosis - clinical guidelines for prevention and treatment, the Royal College of Physicians (RCP) ­highlighted HRT as a logical and appropriate first-line intervention for the prevention of osteoporosis, and stated that HRT both prevents bone loss in ­osteoporotic women and decreases fracture risk.(6) It also cited HRT as the preferred treatment for the management of menopausal symptoms. 
Although some patients have expressed concerns about a ­possible link to breast cancer, the RCP report suggests that administration of HRT for periods of up to ten years yields significant benefits and minimal risks. 
The report does recommend that accurate, up-to-date information about the effects of HRT should be made widely available to postmenopausal women and their professional ­advisers, so that each woman can make an informed decision about taking HRT.
HRT is also very effective in relieving short-term menopausal symptoms such as hot flushes. These usually disappear within a few weeks of treatment.(3)

HRT can be prescribed in several different ways:(12)

  • Orally (tablets).
  • Across the skin ­(patches, gels).
  • Under the skin (implants).
  • Vaginally (pessaries, creams, vaginal rings).

The need for education
The RCP recommendations were especially timely, as recent clinical research ­illustrates. Hope et al. measured the proportion of postmenopausal women who had successfully taken HRT, and found that only 17% of women aged between 40 and 65 years had been offered the treatment.(13) 
In addition, research conducted for Wyeth Laboratories found that less than half of these women continued with their treatment for more than a year, principally because:

  • They were not aware of HRT treatment options.
  • They did not ­understand the risks of osteoporotic fracture.
  • They mistakenly believed that HRT causes weight gain.
  • There was a lack of guidance and ­educational resources for nurses and GPs.
  • Other women's health conditions had become more of a priority (for ­example, breast and ­ovarian cancer, or tumour-induced ­hypercalcaemia).

Further independent research has found that there are also ethnic differences in HRT uptake. UK-based women from ethnic minorities, particularly those from south Asia, were less likely to use HRT than white women; not surprisingly, these women have high rates of ­osteoporosis and heart disease.(14)

The menopause nurse team
In August 2000, the existing situation prompted Wyeth Laboratories to launch the "menopause nurse team", a non-promotional initiative designed to assist health professionals in improving the management of the menopause.
The menopause nurse team liaises with primary care organisations, health authorities and/or individual GPs and practices nurses, and is already involved in over 1,000 menopause-related projects around the country. The team members are all registered nurses with specific expertise in women's health. To date the team has helped to deliver a wide range of educational services for healthcare professionals and patients, including:

  • Nurse/GP education - structured programmes run at surgeries, either as a course of sessions or as afternoon/evening events.
  • Preparation of menopause guidelines and ­formularies - including assistance with guideline development, and clinician training to help ensure effective multidisciplinary implementation.
  • Individual discussions with specialist/adviser ­nurses - one-to-one meetings between nurse ­specialists and practice nurses/GPs to cover any concerns or to identify how to best improve the existing service.
  • Menopause groups - assistance with the initial design and implementation of educational patient groups.
  • Menopause clinics - training of the surgery team, assistance with guidelines, protocol and practice formularies, and empowerment of the practice to run independent clinic sessions.
  • Public awareness events - recruitment of extended community team (for example, National Osteoporosis Society representatives, breast screening counsellors, women's groups) to help run public awareness events on osteoporosis and other menopausal complications.

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References

  1. Dorlands Illustrated Medical Dictionary. Philadelphia, PA: Saunders WG; 2000.
  2. Goldfien A. The gonadal hormones and inhibitors. In: Katzung BG, editor. Basic and clinical pharmacology. 7th edn. Connecticut: Appleton & Lange; 1998; p. 653-83.
  3. Wyeth Laboratories. Living with the menopause. Maidenhead: Wyeth Laboratories; 1997.
  4. Bates V. Preventing osteoporosis: the practice nurse's role. Practice Nursing 2001;12(3):102-5.
  5. Royal College of Physicians. Osteoporosis - clinical guidelines for prevention and treatment: update on ­pharmacological interventions and an algorithm for management. London: RCP; 2000.
  6. Royal College of Physicians. Osteoporosis - clinical guidelines for prevention and treatment. London: RCP; 1999.
  7. Togerson D, Iglesias CP, Reid DM. The economics of fracture prevention. In: Effective management of ­osteoporosis. London: Aesculapius Medical Press; 2001 (in press).
  8. Kenny AM, Prestwood KM. Osteoporosis. Pathogenesis, diagnosis, and treatment in older adults. Rheum Dis Clin North Am 2000;26(3):S69-91.
  9. Stoppard M. Menopause. The complete practical guide to managing your life and maintaining physical and emotional well-being. London: Dorling Kindersley; 1994; p. 66.
  10. Lane JM, Russell L, Khan SN. Osteoporosis. Clin Orthop 2000;372:139-50.
  11. Whitehead M, Godfree V. Hormone replacement therapy. Edinburgh: Churchill Livingstone; 1992: p. 32, 87.
  12. Monthly Index of Medical Specialities (MIMS). Menopausal ­disorders. In: MIMS. London: Haymarket Medical Ltd; April 2000; p. 340-51.
  13. Hope S, Wager E, Rees M. Survey of British women's views on the menopause and HRT. J Br Menopause Soc 1998;March:33-6.
  14. Harris TJ, Cook DG, Wicks PD, Cappuccio FP. Ethnic differences in use of hormone replacement therapy: community based survey. BMJ 1999;319:610-1.

Contact/Resources
Wyeth Menopause Nurse Specialist Team:
Victoria Bates
Nurse Manager
Female Health
Wyeth Laboratories Huntercombe Lane South, Taplow, Maidenhead
SL6 0PH
T:01628 604 377
British Menopause Society
W:www.the-bms.org

Further reading
Abernathy K. The Menopause and HRT. Kent: Ballière Tindall; 1997.
Hope S, Rees M, Brockie J. Hormone ­replacement ­therapy. Oxford:Oxford Medical Publications; 1999.
Whitehead M, Godfree V. HRT: your questions answered. Edinburgh: Churchill Livingstone; 1992.
Woolf A, Dixon A. Osteoporosis - a clinical guide. London: Martin Dunitz; 1998