Abstract
Having notched up over 30 years in a menopause clinic, I thought I had heard all the variations on the theme. That this was not the case became apparent when Wendy, a 67-year-old lady, came to see me. For some reason, she had refused to provide any GP information.
When collected from the waiting room, Wendy was clearly cheerful, of average build with neat grey hair and trotted down the corridor with her husband in pursuit.
‘Please’ she said, ‘I need your help to stay this well’. Not the usual opening gambit.
Her tale was that in about 2004, at typical menopausal age, she had gone along to her GP to discuss when she should stop the combined ‘pill’ and change to HRT.
She was told that HRT was dangerous and the GP in question was not prepared to prescribe it.
I am not completely clear about what was said about combined contraception but gather that the same GP continued to prescribe it for the next two or three years. Once she reached her mid-50s, she was told to stop. With the full knowledge and collusion of her husband, she then bought it from an online pharmacy – lying about her age by taking 10 years off. The pharmacy were now querying it at an apparent age of 57.
Wendy liked the 20 µg ethinylestradiol/150 µg desogestrel combination which she had been taking continuously. She felt well, had no symptoms of menopause or anything else. She was not functionally limited in any way. She has not seen any bleeding for years. She did not want to lose her wellbeing, which was above many of her friends. She realised that change was overdue but was very hesitant.
So, what is the problem?
The issue is in regard of thrombotic risk. FSRH guidance ‘Contraception for women over 40’ 2017 recommends a change from combined hormonal methods at age 50 to an option with less impact on venous thromboembolism (VTE). This is 17 years later.
Very approximately, there is an inherent doubling between the age of 50 and 60 in VTE risk, with increase by a similar number again by age 70 (to three times the risk at 50).
A 2015 study using the UK primary care database 1 suggests that desogestrel containing CHC will increase VTE risk over fourfold as compared to controls matched for variables including age. We understand that this would multiply the effect of age.
We know that estradiol used in HRT will reduce both coronary artery atheroma and risk of heart attack if started up to 10 years after menopause. This applies to both oral and transdermal delivery. Does it apply to ethinyl estradiol? We have no idea and she may have missed out on this benefit.
Empirically, we might have expected bone protection to have been achieved, but there are no data regarding the use of ethinylestradiol in this age group.
We have no data, but having extrapolated what we know about perimenopausal women we would not expect breast risk to be higher with this combination than if she had had conventional HRT. Endometrial and ovarian risks would be expected to be well below baseline.
Wendy wanted to change as little as possible, so the negotiated and agreed solution was to continue to use the same progestogen (taking two desogestrel 75 µg tablets together) and change the ethinylestradiol to estradiol delivered transdermally. There is now very good evidence 2 that avoiding first-pass metabolism of estradiol avoids additional increase in VTE risk. There does not appear to be a marked dose effect, and Wendy was insistent that she should maintain wellbeing.
Without an evidence base, I empirically gave her a supply of 75 µg twice weekly patches. This was derived from the assumption that if 50 µg is the typical requirement at age 50, I would add 50% on the basis that she had continued to be exposed to more potent exogenous hormones. Typically, my patients at this age who are using patches feel well at 25 µg. Her retired academic scientist husband was completely in agreement with the principles applied. He urged her to try and asked for enough to get them back from a long-haul trip to their son in Australia.
This clearly was the trigger for presentation … a 67-year-old taking the ‘pill’ on a long-haul flight would not make good publicity in the event of something untoward happening. They agreed to abide by the usual advice for fluid, flight socks, exercises and aspirin prophylaxis and understand that there is still a risk.
Four months later, I am waiting to see her again but am very confident that there would have been an email had there been a problem.
My plan now is to attempt titration to the lowest dose of patches that keeps her well. We know that desogestrel 150 µg provides endometrial protection in the ‘pill’, but can we use something more conventional at 67? This regimen took some explaining to the pharmacy. There are few progestin options to prescribe separately, but I will try to persuade her to change to micronised progesterone at bedtime and see if it is tolerated.
I will keep an open mind … you never know what is coming in next.