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Laura MRCOG Part 2 > 13) Gynaecological problems - Menopause > Flashcards

13) Gynaecological problems - Menopause Flashcards

1
Q

Definition of menopause

A

Permanent state of amenorrhoea due to reduced ovarian follicular activity diagnosed retrospectively 12 months after the LMP.

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2
Q

Mean age of menopause in UK

A

51

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3
Q

Aetiology of menopause

A
  • 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
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4
Q

What percentage of people experience vasomotor symptoms, what percentage are severe and what is the median duration of those symptoms?

A

75% experience vasomotor symptoms, 25% are severe.

Median duration of symptoms 7 years.

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5
Q

What percentage of postmenopausal women experience osteoporosis and what percentage of fractures in postmenopausal women is this responsible for?

A

1/3 of postmenopausal women have osteoporosis.

This is responsible for 50% of fractures in PM women.

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6
Q

How is menopause diagnosed?

A
  • If age > 45 years, diagnosis can be made on clinical grounds.
  • If age < 45 years, test FSH (but not if on COCP)
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7
Q

Management options for vasomotor symptoms (NICE guideline)

A

(1) HRT
(2) SSRI/SNRI/Clonidine/Gabapentin
(3) Alternative therapies

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8
Q

Management options for psychological symptoms (NICE guideline)

A

(1) HRT
(2) CBT
(No evidence for antidepressants in this group unless diagnosed with depression)

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9
Q

Management options for urogenital atrophy (NICE guideline) and those with evidence from TOG article

A

(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
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10
Q

Management options for sexual dysfunction (NICE guideline)

A

Consider testosterone in addition to HRT

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11
Q

Benefits of HRT

A
  • 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
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12
Q

Risks of VTE with HRT

A
  • 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)

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13
Q

Risks of coronary heart disease/stroke with HRT

A
  • 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
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14
Q

Risk of breast cancer with HRT

A
  • 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.

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15
Q

How and when to stop HRT?

A
  • 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.

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16
Q

Contraindications to HRT

A

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
17
Q

Which progestogens are less androgenic?

A

Medroxyprogesterone
Dydrogesterone
Drospirenone

18
Q

Which progestogen has aldosterone antagonist properties?

A

Drospirenone

19
Q

What are alternative “combined” preparations?

A
  • Tibolone

- Oestrogen/bazedoxifene (Duavive)

20
Q

Different HRT regimens

A
  • 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)
21
Q

Percentage of women with vaginal oestrogen deficiency experiencing dryness, dyspareunia and recurrent UTI

A

75% Dryness
40% Dyspareunia
20% Recurrent UTI

22
Q

Percentage of women on cyclical HRT who experience unscheduled bleeding.

Percentage of women on continuous HRT who experience unscheduled bleeding.

A

(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.

23
Q

How to investigate unscheduled bleeding?

A

–> 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

24
Q

What percentage of pregnancies in women age > 40 end in abortion?

A

30%

25
Q

What is the increase in maternal mortality in women aged >40?

A

3 x higher than women aged 20-24 years.

26
Q

What percentage of women aged 45-55 and 55-65 have at least one new sexual partner in the previous year?

A

45-55: 9%

55-65: 4.5%

27
Q

How long can copper IUD be used for?

A

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).

28
Q

How long can mirena IUS be used for?

A

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.

29
Q

Advice re: progestogen contraception in women > 40 years

A

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.

30
Q

Advice re: CHC in women > 40 years

A
  • 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.
31
Q

When to stop contraception?

A
  • 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.

32
Q

What proportion of women does sequential HRT suppress ovulation in?

A

Only 40% (so need contraception!!)

33
Q

Which SSRI has the best evidence for use in menopausal symptoms?

A

Venlafaxine 37.5mg BD

Laura MRCOG Part 2 (56 decks)

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