Host: Welcome to today’s podcast Practicalities – How to manage the clinical follow-up: Frequency of visits and required exams. This episode is part of a podcast series supported by Abbott. The content is solely the responsibility of EMAS, the European Menopause and Andropause Society. All our episodes are available in English, Spanish, Mandarin, and Russian and you can find them on any of the most popular podcast platforms.
In today’s episode Dr. Oleksandra Gromova, Gynecologist and holder of an Advanced Doctorate in Medical Science, associate professor of the department of obstetrics, gynecology and neonatology of the Bogomolets National Medical University, Kyiv, Ukraine will help us understand how to follow up patients before and during menopausal hormone therapy.
Dr. Oleksandra Gromova: Hello, my dear colleagues. My greetings from Kyiv Ukraine. Today I would like to share our experience in follow-up women on MHT in everyday clinical practice in my country.
Our work in the field of menopausal disorders is regulated by the national clinical protocol, which was approved in June 2022. This document also regulates the list of obligatory and recommended examinations before deciding on MHT-prescription.
So, the first visit to a clinic. During this visit, the doctor clarifies the patient’s complaints in detail and discusses the goals of the treatment. Our obligatory questions at the beginning of the conversation are: What makes you feel uncomfortable? What concerns do you have about changes associated with menopause? What do you expect from the treatment?
We should set realistic goals for the treatment of menopausal symptoms and don’t promise our patients “drugs for eternal youth.”
First of all, we find out what period of the reproductive cycle a patient is in – perimenopause or post-menopause?
A detailed questioning of the personal medical and family history allows you to identify the most important benefits and risks of MHT in a particular patient. Often already during the conversation
I prefer to do a personal breast cancer risk estimation using the Breast Cancer Risk Assessment Tool from the USA National Cancer Institute. For patients with a strong family history of breast cancer, we recommend testing for BRCA gene mutations, but this is not routinely performed. This is an expensive test that is not covered by the National Health Service, so we recommend it for strong indications.
Sure, we perform a physical examination, evaluate the body mass index, measure the waist circumference, and blood pressure, perform a gynecological examination and TV-ultrasound. If more than a year has passed since the last mammogram, we definitely recommend this exam. We repeat the PAP-smear test if more than 3 years have passed since the last one.
All patients undergo a clinical blood count test, glycated hemoglobin, and general urine analysis. To clarify the cardiovascular risk, we recommend doing a lipid profile test before deciding on MHT. We obviously calculate the cardiovascular risk on the SCORE scale. If a moderate risk is identified by SCORE, we recommend an ultrasound examination of the thickness intima-media complex of the carotid and femoral arteries.
We do not routinely perform liver function lab tests or liver and gallbladder ultrasound examinations, but we recommend it for obese patients if there are relevant symptoms or a personal history of those diseases.
In our country, iodine deficiency is widespread, so we recommend all women take a TSH screening test.
For patients with a high risk of osteoporosis or for those who had 5 years after menopause, we provide X-ray densitometry. At a minimum, we assess the risk of osteoporotic fracture using FRAX.
For patients with a family history of colorectal cancer, a screening colonoscopy is recommended.
The National Health Service of Ukraine covers such exams as mammography, PAP test, pelvic ultrasound, lab tests like cholesterol and triglycerides, clinical blood count and liver function tests, blood sugar and glycated hemoglobin, and TSH.
We schedule a second visit after the patient completed all recommended tests and we have received lab test results. During the second visit, we evaluate all the results and decide on the prescribing of MHT.
Now we are often faced with situations of internal migration of our patients and their relocation to the safer regions. Sometimes it may be difficult to visit the clinic due to missile attacks. In this case, the second visit can be carried out remotely (Zoom).
We prescribe the next appointment 3 months after MHT starts. Why 3 months? Because plateaus in the treatment of vasomotor symptoms reach in 8-12 weeks, we increase estradiol dose if needed. Of course, we ask our patients about possible side effects. If a patient receives thyroxine, we control the TSH level 3 months after beginning of MHT.
The next visit is scheduled 6 months from the beginning of MHT. If the patient develops or retains unpredictable spotting during this period, we perform a pipel biopsy and transvaginal ultrasound.
We also recommend transvaginal ultrasound 6 months after starting MHT for patients with uterine fibroids.
We plan the next visit in 1 year from the beginning of MHT. Mammography and routine gynecological examination are recommended during this visit. If the patient has osteoporosis or osteopenia, we repeat osteodensitometry after a year from starting MHT. In my practice, I do a transvaginal ultrasound every year. We also monitor the level of glycated hemoglobin, cholesterol, triglycerides, TSH, and liver enzymes annually.
In the absence of complaints, the patient will be observed once a year. Every year we evaluate whether the patient has any contraindications to MHT and do the checkup I described.
After 5 years, we evaluate the need to continue MHT and, in the absence of a high risk of osteoporosis, stop therapy. We prefer a gradual dose reduction of estradiol. If vasomotor symptoms return, we consider continuing MHT in patients under 60 with a low risk of thrombosis and breast cancer. In cases of older age or increased risk, we use alternative approaches – from phytoestrogens to selective serotonin and adrenaline reuptake inhibitors or gabapentin.
After 5 years of MHT use, especially in cases of MHT discontinuation, I prefer to repeat osteodensitometry. If the patient has osteopenia or osteoporosis, we prescribe bisphosphonate therapy.
This concludes my story. I thank EMAS for the opportunity to share my experience. I thank the audience for their attention, and I will be glad to new meetings and cooperation.
Special gratitude to the Armed Forces of Ukraine for the opportunity to continue my life and my work.
Host: Today, Dr. Oleksandra Gromova discussed the basic principles of follow up patients on MHT. Thank you for listening to today’s episode. We hope it will be valuable for your clinical and research practice. Stay safe.
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