Climacteric + Menopause Flashcards
The menopause is the end of the female reproductive life. It is a physiological process which begins as perimenopause (climacteric) at around the age of 45 and progresses until the final menarche and the end of fertility (UK average age is 51).
What is the recommendation for how long to be using effective contraception in menopausal women?
- 12 months after the last period in women > 50 years
- 24 months after last period in women < 50 years
What hormonal changes occur during menopause?
- reduction in circulating oestrogen
- due to reduced sensitivity of ovary to FSH + LH
- due to reduction of follicles
- increase in anovulatory cycles
- increased LH + FSH
- perimenopausal women: hot flushes, urinary incontinence, inc UTIs, irregular vaginal bleeding
- oestrogen breakthrough bleeding due to lack of progresterone → not maintaining endometrial lining so it breaks down
- as levels of oestrogen reduces, bleeding gradually ceases
What vasomotor changes occur during menopause?
- 75% experience hot flushes
- occur with a red flush starting on face + spread down neck + chest
- associated w/ peripheral vasodilatation + transient rise in body temp
- due to pulsatile LH release influencing central temp control
What urogenital changes occur during menopause?
- uterus + vagina are both maintained by circulating oestrogen
- after menopause, marked atrophy of vagina + thinning of myometrium
- also thinning of vaginal wall and dryness
- results in dyspareunia
- bladder + urethra atropy → urinary incontinence + UTIs
What happens to bone density during menopause?
- oestrogen protects bone mass + density through reducing activity of osteoclasts
- with drop in oestrogen → inc bone reabsorption → acceleration of age-related loss of bone density
- increased frequency in fractures esp wrist and hip
What is the link between ischaemic heart disease and menopause?
- oestrogen offers protection against heart disease
- oestrogen reduces levels of LDL cholesterol whilst raising HDL cholesterol
- after menopause women exp same freq of CV disease as men
Summarise the clinical features of the menopause
- change in length of menstrual cycles
- dysfunctional uterine bleeding
- hot flushes
- night sweats
- vaginal dryness + atrophy
- urinary frequency
- anxiety + depression
- short-term memory impairment
- osteoporosis
- inc risk of IHD
How is menopause diagnosed?
- when woman has had amenorrhoea for 12 months
- if menopause occurs between 40-45 → ‘early menopause’
- measure blood FSH → >40 iu/L indicative of menopause
What are the 3 categories of managing menopause?
- Lifestyle modifications
- Hormone replacement therapy
- Non-hormone replacement therapy
What is the management with lifestyle modifications?
- Hot flushes → regular exercise, weight loss + reduce stress
- Sleep disturbance → avoid late evening exercises + maintaining good sleep hygeine
- Mood → sleep, regular exercise, relaxation
- Cognitive → regular exercise + good sleep hygeine
What are the main indications (menopausal symptoms) for hormone replacement therapy?
- vaginal atrophy
- vasomotor symptoms
- early natural or surgical menopause (<45yrs)
- postmenopausal osteoporosis (but other drugs preferred)
What are the different types of HRT?
- Oestrogen → for women without uterus / post-hysterectomy
-
Oestrogen + progestogen (for women w/ uterus intact)
- cyclical HRT → for perimenopausal women + within 1yr of cessation of period
- continuous
- Oestrogen + progestogen + androgen preparation (AKA Tibolone) - continuous
What are the different forms of HRT?
- oral: tablets daily
- implants: twice yearly on abdomen subcut
- transdermal: patch (1-2x/week) OR gel (daily)
- topical: vaginal cream / pessary
What are absolute contraindications to HRT?
- existing cardiac disease
- pregnancy
- active liver disease
- breast cancer (prev/current)
- endometrial cancer (prev/current)
- undiagnosed vaginal bleeding or breast lump
- prev personal/FHx of VTE/stroke
What are side-effects of HRT?
- nausea + vomiting
- abdominal cramps
- bloating
- weight changes
- breast enlargement + tenderness
- premenstrual like symptoms
- sodium + fluid retention
Women should be advised that the symptoms of menopause typically last for 2-5 years and that treatment with HRT brings certain risks, such as what?
- BREAST CANCER → increased risk w/ all combined HRT although risk from dying from breast cancer not raised; greater risk from moderate alcohol use and smoking; risk returns to normal 5yrs after stopping
- VTE → slight inc in risk with all forms of oral HRT; no inc risk w/ transdermal HRT
- CHD → combined HRT may be associated w/ slight increased risk
- OVARIAN CANCER → v small inc risk w/ all HRT
- ENDOMETRIAL CANCER → oestrogen-only HRT can inc risk; combined lower risk
