Climacteric and Menopause Flashcards
Definition of menopause
Absence of period for 12 months
Permanent end to menstruation
Define “postmenopause”
The period from 12 months after the final menstrual period onwards
Define “perimenopause”
The time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods
Includes the time leading up to the last menstrual period, and the 12 months afterwards
Define premature menopause
Menopause before the age of 40
A result of premature ovarian insufficiency
What causes menopause?
Lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
Menopause symptoms
due to lack of oestrogen
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
Risks in menopause
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
How long do women need to use contraception for after menopause?
Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50
Management of perimenopausal symptoms
No treatment
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Cognitive behavioural therapy (CBT)
SSRI antidepressants, such as fluoxetine or citalopram
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
Vaginal moisturisers, such as Sylk, Replens and YES
What is HRT?
Exogenous oestrogen
Used in perimenopausal and postmenopausal women wot alleviate symptoms associated with menopause
Why does progesterone need to be given in addition to oestrogen in women with a uterus?
To prevent endometrial hyperplasia and endometrial cancer secondary to unopposed oestrogen
Which type of HRT should be given to a woman still having periods?
Cyclical progesterone
Regular breakthrough bleeds
What type of HRT should be given to postmenopausal women with a uterus and more than 12 months without periods?
Continuous combined HRT
Outline the non-hormonal management for menopausal symptoms
Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
CBT
Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors
SSRI antidepressants (e.g. fluoxetine)
Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI)
Gabapentin
What is clonidine?
How does it work?
Agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain
Alternative to HRT
Lowers BP and HR
Can be helpful for vasomotor symptoms and hot flushes
Side effects of clonidine
Dry mouth, headaches, dizziness and fatigue
Sudden withdrawal can result in rapid increases in BP and agitation
Indications for HRT
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
Benefits of HRT
Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
Improved quality of life
Reduced risk of osteoporosis and fractures
Risks of HRT
Generally more significant in women >60
Increased risk of breast cancer (particularly combined HRT - oestrogen-only HRT has a lower risk)
Increased risk of endometrial cancer
Increased risk of VTE (2-3 times the background risk)
Increased risk of stroke and coronary artery disease with long term use in older women
How can we reduce the risks associated with HRT?
Risk of endometrial cancer greatly reduced by adding progesterone in women with a uterus
Risk of VTE reduced by using patches rather than pills
Contraindications to HRT
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy
Steps to choosing the correct HRT formula
Step 1: Do they have local or systemic symptoms?
Local: topical treatments such as topical oestrogen cream or tablets
Systemic: use systemic treatment - go to step 2
Step 2: Does the woman have a uterus?
No uterus: use continuous oestrogen-only HRT
Has uterus: add progesterone (combined HRT) - go to step 3
Step 3: Have they had a period in the past 12 months?
Perimenopausal: cyclical combined HRT
Postmenopausal (more than 12 months since last period): continuous combined HRT
What are the options for delivering oestrogen?
Oral (tablets)
Transdermal (patches or gels)
Which is the preferred method for delivering oestrogen?
Patches due to reduced risk of VTE, cardiovascular disease and headaches
What are the options for delivering progesterone?
Oral (tablets)
Transdermal (patches)
Intrauterine system (e.g. Mirena coil)
What are the regimes for delivering progesterone?
Cyclical (10-14 days per month) - women that have had a period within the past 12 months, allows for monthly breakthrough bleed
Continuous - woman has not had a period in the past 24 months if under 50 or 12 months if over 50
What are the different types of progesterone?
Progestogens - any chemicals that target and stimulate progesterone receptors
Progesterone - hormone produced naturally in the body
Progestins - synthetic progestogens
What is the preferred method for delivering progesterone?
IUS
Added benefit of contraception and treating menorrhagia
No progestognenic side effects
Oestrogen side effects
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
Progestogenic side effects
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
Stopping HRT
No specific regime
Can be stopped gradually or abruptly
Gradually may be preferable to reduce risk of symptoms recurring suddenly
