13) Gynaecological problems - Menopause Flashcards
Definition of menopause
Permanent state of amenorrhoea due to reduced ovarian follicular activity diagnosed retrospectively 12 months after the LMP.
Mean age of menopause in UK
51
Aetiology of menopause
- Finite number of oocytes at birth (highest 20-28w gestation) and decline with each menstrual cycle
- Ovarian follicular activity declines
- Reducing oestrogen and inhibit levels
- Increasing FSH levels
What percentage of people experience vasomotor symptoms, what percentage are severe and what is the median duration of those symptoms?
75% experience vasomotor symptoms, 25% are severe.
Median duration of symptoms 7 years.
What percentage of postmenopausal women experience osteoporosis and what percentage of fractures in postmenopausal women is this responsible for?
1/3 of postmenopausal women have osteoporosis.
This is responsible for 50% of fractures in PM women.
How is menopause diagnosed?
- If age > 45 years, diagnosis can be made on clinical grounds.
- If age < 45 years, test FSH (but not if on COCP)
Management options for vasomotor symptoms (NICE guideline)
(1) HRT
(2) SSRI/SNRI/Clonidine/Gabapentin
(3) Alternative therapies
Management options for psychological symptoms (NICE guideline)
(1) HRT
(2) CBT
(No evidence for antidepressants in this group unless diagnosed with depression)
Management options for urogenital atrophy (NICE guideline) and those with evidence from TOG article
(1) Vaginal oestrogen
(2) Moisturisers/lubricants
- Intravaginal phytoestrogens may be of some benefit
- Vaginal laser treatment (awaiting RCTs)
- SERMs - Lasofoxifene or Bazedoxifene
- Vaginal testosterone, vaginal/oral DHEA also effective
Management options for sexual dysfunction (NICE guideline)
Consider testosterone in addition to HRT
Benefits of HRT
- Symptomatic treatment of menopause
- Reduced risk of fragility fractures (for duration of treatment)
- May improve muscle mass and strength
- Reduces risk of colorectal cancer
- For women with premature menopause HRT until natural age of menopause reduces risk cardiovascular disease and osteoporosis
Risks of VTE with HRT
- Oral HRT carries increased risk of VTE
- Transdermal HRT risk same as baseline (therefore consider for women at increased risk of VTE including BMI >30)
Risks of coronary heart disease/stroke with HRT
- HRT does not increase risk of CVD when started in women < 60 years
- HRT does not increase the risk of dying from CVD
- Oestrogen-only HRT is associated with no, or reduced, risk of coronary heart disease
- Combined HRT is associated with little or no increase in risk of coronary heart disease
- Oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke
Risk of breast cancer with HRT
- Oestrogen-only HRT has little, or no, effect on breast cancer
- Combined HRT associated with increased risk of breast cancer
Age 50-59 overall risk of breast cancer in next 5 years 23/1000; combined HRT increases this risk a further 4 women. For context, BMI > 30 increased this risk a further 24 women, smoking a further 3 women and >2 units alcohol per day a further 5 women.
How and when to stop HRT?
- No arbitrary time period to stop.
- Vasomotor symptoms usually require 2-5 years of HRT.
- Topical oestrogen may be required long term.
Can either gradually reduce or immediately stop HRT.
Contraindications to HRT
Cancer related:
- Current, past or suspected breast cancer
- Known or suspected oestrogen sensitive cancer
- Unexplained vaginal bleeding
- Untreated endometrial hyperplasia
VTE/Cardiovascular related:
- Previous idiopathic or current VTE (unless already anti coagulated)
- Active or recent arterial thromboembolic disease
- Untreated hypertension
Other:
- Pregnancy!
- Active liver disease with abnormal LFTs
- Dublin-Johnson/Rotor syndromes
- Porphyria
Which progestogens are less androgenic?
Medroxyprogesterone
Dydrogesterone
Drospirenone
Which progestogen has aldosterone antagonist properties?
Drospirenone
What are alternative “combined” preparations?
- Tibolone
- Oestrogen/bazedoxifene (Duavive)
Different HRT regimens
- Oestrogen only (continuous)
- Combined cyclical HRT (perimenopausal) - oestrogen daily with progesterone for last 10-14d of cycle
- 3 monthly cyclical HRT - oestrogen daily for 12 weeks with progesterone for 14 days every 13 weeks
- Continuous combined (postmenopausal)
Percentage of women with vaginal oestrogen deficiency experiencing dryness, dyspareunia and recurrent UTI
75% Dryness
40% Dyspareunia
20% Recurrent UTI
Percentage of women on cyclical HRT who experience unscheduled bleeding.
Percentage of women on continuous HRT who experience unscheduled bleeding.
(1) 8-40%
(<10% have recurrent breakthrough bleeding)
(2) 80% will have in first 6 months, oral 10% at 9 months, transdermal 10-20% at 12 months.
How to investigate unscheduled bleeding?
–> Cyclical HRT –> > 2 cycles –> TVS - if ET>7mm then biopsy, if < 7mm then observe.
–> Continuous HRT –> >6 months –> TVS - if ET >5mm then biopsy, if <5mm atrophic endometrium
What percentage of pregnancies in women age > 40 end in abortion?
30%
What is the increase in maternal mortality in women aged >40?
3 x higher than women aged 20-24 years.
What percentage of women aged 45-55 and 55-65 have at least one new sexual partner in the previous year?
45-55: 9%
55-65: 4.5%
How long can copper IUD be used for?
Copper IUD - if inserted > 40 years, can be continued 1 year after LMP (if LMP age > 50 years) or 2 years after LMP (if LMP age < 50 years).
How long can mirena IUS be used for?
Mirena IUS - if used for HRT must be changed every 5 years. If used only for contraception and inserted >45 years can stay in until postmenopausal. If inserted < 45 years, immediate replacement at 5-7 years if UPT negative.
Advice re: progestogen contraception in women > 40 years
Progestogen implant/POP - no associated increased risks of VTE/stroke/MI/BMD loss.
Depo - loss of BMD (but not repeated when menopausal). Review regularly if age >40 and counsel re: alternatives if >50.
Advice re: CHC in women > 40 years
- Preparations with LNG/NET preferred as reduced VTE risk
- Preparations with ethinylestradiol doses < 30microgram preferred due to reduced CVD/VTE/stroke risk
- Stop using at age 50 (or age 35 if smoker)
- Reduces risk of ovarian and endometrial cancer. Increases risk breast cancer.
When to stop contraception?
- Age 55
- Non-hormonal methods: Age 40-50 can stop after 2 years amenorrhoea, age > 50 can stop after 1 year amenorrhoea
- CHC: Stop age 50 and swap to alternative method
- Progestogens can continue to age 55 (counsel from 50 re: depo).
If woman > 50 on progestogen contraception wishes to stop before age 55, can check FSH. If >30 can discontinue after 1 year.
What proportion of women does sequential HRT suppress ovulation in?
Only 40% (so need contraception!!)
Which SSRI has the best evidence for use in menopausal symptoms?
Venlafaxine 37.5mg BD
