7.6 - Menopause

Question 1

Define the Climacteric phase explaining its physiology.
When does this typically occur?
Explain the consequences of these changes

Answer 1

It is the Perimenopausal phase in the reproductive life where there is a gradual decline in ovarian function resulting in decreased sex steroid production and its sequelae

Typically occurs 3-5 years before complete loss of menses (menopause)

Due to the reduced sex steroid production, there is reduced negative feedback leading to unopposed oestrogen production leading to Anovulatory cycles.

Question 2

What are the consequences of anovulatory cycles?

Answer 2

Infertility/sub fertility, Irregular menstrual cycle, heavy menses, and endometrial hyperplasia.

Question 3

Define Menopause
Define Early menopause
Define Premature menopause

Answer 3

12 months of amenorrhoea at the appropriate age (50-55, median 52)
Early: <45 yo
Premature: <40 yo

Question 4

What are the causes of early/premature menopause?

Answer 4

Radiation therapy, surgery (TAH/BSO)
Chromosomal abnormalities e.g. Turner’s
Crohn’s/celiac disease
Ovulation induction
Gnrh

Question 5

What estrogen is dominant in the post-menopausal period?

Answer 5

Estrone (E1)

Question 6

What are hot flushes?
What are the associated symptoms?

Answer 6

Sudden intense hot sensation over face and chest that last a few seconds to minutes with multiple episodes per day.
It is associated with palpitations, sweatingm nausea, dizziness, anxiety, headaches

Question 7

A 55 year old woman presents to the OPD complaining of night sweats and disturbed sleep. She does not have any psychiatric conditions/mood disorders, and has no fever or weight loss. Why is this ocurring?

Answer 7

Hot flushes may occur at night causing night sweats and hence disturbed sleep, depression, fatigue.

Question 8

What are the 5 main groups of complications of Menopause?

Answer 8

1) Vasomotor instability
2) Urogenital symptoms
3) Osteoporosis
4) Heart disease
5) Psychiatric

Question 9

What are the vasomotor instability symptoms of menopause

Answer 9

Hot flushes (palpitations, sweating, nausea, lightheadedness, anxiety), may occur at night (fatigue, depression, lethargy)

Question 10

What are the urogenital symptoms of menopause?

Answer 10

Vulval and vaginal dryness (estrogen in charge of secretions) => Dyspareunia and increased risk of bacterial vaginosis

Urethral + Bladder tissue atrophy => readuced elasticity => Increased frequency, dysuria (pain on urination), Nocturia = Incontinence

Question 11

What is the significance of the dryness brought about by menopause?
How would you directly treat vulval/vaginal dryness?

Answer 11

Dyspareunia
Bacterial vaginosis (reduced sectretions include reduced glycostores of the vagina => reduced native lactobacilli => increase pH (no longer acidic) => Bacterial vaginosis

Question 12

Define Osteoporosis
Why is it more common in menopause?

Answer 12

Low bone mass on DXA scan <2.5
mass or fragility fracture.

Reduced estrogen in menopause leads to increased osteoclast activity => net loss of bone mass => fragility fractures

Question 13

What does the DEXA score represent?

Answer 13

It can be represented as T score for adults (and Z score for adolescents and children).
It compares the mean peak bone mass of normal adults aged 20-40 with that of the patient

Question 14

What is the most common site of a fragility fracture?

Answer 14

T10-L2
More specifically T12-L1 (esp because of the transition between thoracic and lumbar)

Question 15

Give RFs, for Osteoporosis

Answer 15

Menopause, reduced BMI, smoking, sedentary lifestyle, !!Corticosteroid use.

Question 16

How would the physiotherapist help a patient with osteoporosis?

Answer 16

Weight bearing exercises

Question 17

How would you manage a patient with a fragility fracture

Answer 17

DEXA scan

Conservative: reduce RF => Stop smoking, dietitian referral (Vit D, calcium, nutrition) physiotherapy referral (Weight bearing exercises)

Medical:
First line: Bisphosphonates (ibandronate)
2nd Line: Tamoxifen - ERM (selective estrogen receptor modulator)
!!+ Vit.D and Calcium supplementation

Question 18

A 54 year old patient presents with a fragility fracture in T12 on MRI. You decide to perform a DEXA scan which reveals her score to be <2.5. You ask the patient if shes been on bisphosphonates before and she tells you her previous doctor told her she cant take it. What does the patient likely have (2)?

What drug is she likely on now?
Give 1 contraindication and 1 disease that this drug increases the risk for.

Answer 18

Bisphosphonates are contraindicated in oesophageal disease or CKD (renaly excreted)

She is likely on the second-like drug Tamoxifen. It is contraindicated in pregnancy and severely increases the risk of endometrial cancer

Question 19

Menopause leads hypo-oestrogenism. What are the signs and symptoms associated with menopasue/hypoestrogenism?

Answer 19

1) Vasomotor instability: Hot flushes, (=> night sweats, palpitations, sweating, nausea)

2) Urogenital symptoms:
Vulval and vaginal dryness (estrogen in charge of secretions) => Dyspareunia and increased risk of bacterial vaginosis,

Urethral + Bladder tissue atrophy => readuced elasticity => Increased frequency, dysuria (pain on urination), Nocturia = Incontinence.

3) Osteoporosis

DXA <-2.5 or Fragility fracture

4) Heart Disease: RF for CVD

5) Psychological: Mood Lability

Question 20

How long should hormonal therapy be prescribed to a women in menopause?

Answer 20

As long as the patient wishes but she should be counselled about the risks especially that of heart disease and VTE.

Question 21

What questions should you be asking the patient when determining the ideal treatment therapy for HRT?

Answer 21

Does the patient have a uterus (previous hysterectomy) or not?

Is the patient pre or post-menopausal?

Is the patient’s family complete or not?

Question 22

When would you give sequential HR therapy? What is it?

Answer 22

You would give it to pre-menopausal woman (with a uterus). It involves giving continuous oestrogen (patch/spray/gel/oral) while giving cyclical progestogen (allowing for monthly withdrawal bleed)

Question 23

When would you give continuous HR therapy? What is it?

Answer 23

You would give it to post-menopausal women (they dont need monthly bleeds), with a uterus => Both oestrogen and progestofen are given continuously. This can be given as a combined oral/patch or Mirena + oestrogen gel/patch

Question 24

Explain your management approach to a 52 patient presenting with amenorrhoea for the past 14 months.

Answer 24

If the patient does not wish for hormonal therapy, Natural Phytoestrogens (diet) will help.

In terms of hormonal replacement therapy, this depends on whether the patient has a uterus or not. If there is no uterus, Oestrogen-only therapy would be used.

If the patient does have a uterus then the next thing to look at is whether they are pre- or post-menopausal. If the patient is pre-menopausal, then we would have a Sequential approach whereby the patient will have continuous oestrogen + Cyclical progesterone to ensure monthly withdrawal bleed. If the patient is Post-menopausal, then a Continuous approach is used whereby both oestrogen and progesterone are continuous.

Question 25

For what duration should HRT be offered?

Answer 25

It is patient’s choice but it is important to always balance out risks and benefits

Question 26

What is the effect of HRT on the endometrium?

Answer 26

Thins endometrial wall

Question 27

Why is it important to determine if the patient has a uterus

Answer 27

If the patient does have a uterus, progestogen needs to also be included in the hormonal therapy as it protects the uterus to prevent unopposed oestrogen activity and hence reducing the risk of endometrial hyperplasia and endometrial malignancies.

Question 28

What are the advantages of transdermal preparations as opposed to oral preparations?

Answer 28

Transdermal preparations bypass first-pass metabolism => reduced hepatic side effects of lipid coagulation (atherosclerosis/thrombosis)
It also has a lower risk of thrombosis

Question 29

What are the main complications of HRT?

Answer 29

1) Most common: Breast tenderness
2) Endometrial + Breast cancer
3) CVD unless started before the age of 60
4) Increased VTE risk in first 6 months of use (esp in oral preparations)

Question 30

Give 5 contraindications to HRT

Answer 30

Hx of/current breast or endometrial cancer
Unknown/irregular vaginal bleed
Active Liver disease
Porphyria Cutanea Tarda (mcq shit)
VTE/Stroke/TIA (not in oxford)
Pregnancy (not in oxford)

Question 31

You have just prescribed the appropriate post-menopausal medications. Now, the patient is asking you for the plan following this. What is the typical plan for post-menopausal care?

Answer 31

1) 6-monthly GP visit (BP, lipid profile checks)
2) Lifestyle advice -> relaxation, exercise, weight-loss, healthy eating, smoking cessation
3) Cervical smears every 5 years
4) Mammogram every 3 years
5) DEXA scan every 3 years
6) Watch for any irregular vaginal bleeding. All must be investigated

Question 32

Where are Bartholin glands with respect to the vaginal opening?
Give 2 common pathologies associated with them.

Answer 32

5 and 7 o clock from the vaginal opening
Abscess and cyst

Question 33

What is the significance of GnRH usage?

Answer 33

Premature ovarian insufficiency/failure (remember it is used for heavy menstrual bleeding and induction?)

Question 34

a 51 year old patient is presenting to your outpatient clinic. She is presenting with hot flashes. Take a focused history stating the most important information you would like to elicit.

Answer 34

LMP
Symptoms: Hot flashes, night sweats, dyspareunia, vulval irritation, jointy pain (Vasomotor, urogenital, osteoporosis)
+ CNS (irritability, forgetfulness, inability to focus)
HRT to date
Personal, family hx of breast carcinoma, or VTE risk. (imp_
Hx of osteoporosis, DEXA scan liz mcnicholl. 22222

Question 35

If a patient is diagnosed with premature ovarian insufficiency, can they have children?

Answer 35

Unlikely to occur without treatment. But if a donor egg is offered, then yes via IVF or ICSI

Question 36

Does HRT increase the risk of CVD?
Does HRT increase the risk of VTE?
Does HRT increase the risk of CHD (Coronary heart disease)?

Answer 36

For CVD and VTE, HRT does not increase the risk if given before the age of 60. The oral form specifically when COCP may increase the risk of VTE, stroke, MI.
There is no association of increased risk of coronary heart disease

Question 37

What is the impact of HRT on a patient with osteopenia.

Answer 37

Osteopenia is DEXA<-1.5 compared to osteoporosis which is <-2.5.
It is not licensed for it but its good

Question 38

A patient is asking about wright gain and mood changes with HRT. What will you tell her?

Answer 38

There is no evidence of either

Question 39

What risks are associated with HRT?

Answer 39

If given after age 60 or Oral COCP, VTE risk, CVD risk
!Breast cancer!! (contraindication if family hx or personal hx of breast cancer)
Slight increase in ovarian cancer
If taking oestrogen only and has a uterus => endometrial (also much higher risk of breast cancer)