Gynae - Menopause Flashcards
define perimenopause
the years surroundinig the cessation of menstraution
it begins with the onset of vasomotro symptoms and irregular bleeding
define premature menopause
cessation of menstruation before age 40
affects 1% of women
define postmenopausal bleeding
bleeding occurring at least 12 months after the last menstrual period
list the causes of postmenopausal bleeding?
Endometrial carcinoma - 1st thing we want to exclude
Endometrial hyperplasia ± atypia and polyps
Cervical carcinoma
Atrophic vaginitis
Cervicitis
Ovarian carcinoma
Cervical polyps
how would you investigate postmenopausal bleeding?
Bimanual exam
Speculum (+ smear if not already done)
TVUS:
o check Endometrial thickness
o 4mm or less = normal
o Multiple bleeds or thickened endometrium:
Endometrial biopsy + hysteroscopy
(bcos tvus will not give histological diagnosis)
what are the symptoms & Consequences of the Menopause?
- Cardiovascular disease - as increased riisk of atherosclerosis
- Vasomotor Symptoms
Hot flushes, Night sweats
Usually present for less than 5 years - Urogenital Problems
Oestrogen deficiency (Vaginal atrophy)
Itching, Burning, Dryness
Urinary symptoms (FUN I) - Sexual Problems - 50%
- lose interest, lose arousal, issues orgasm
- Dyspareunia
what is the BMD and T score for osteopeania?
BMD: −1 to −2.5 SD
T Score: -1 to -2.5
what is the BMD and T score for osteoporosis?
BMD: less than 2.5
T score : less than 2.5
name the most common sites of osteoporotic fractures?
Wrist or Colles’ fracture
Hip (30% mortality within 1 year of fracture)
Spine
what tests are done to Investigate menopause ?
FSH - high when oocytes are low
AMH - low levels = ovarian failure
Others for specific disease: TFTs: Catecholamines LH, oestradiol and progesterone Low P4: anovulation
how can a woman achieve a ‘no bleed’ HRT regimen in perimenopause? - something useful for mennorhagia
Mirena IUS - progesterone
+
Oestrogen only HRT - patch or oral
this also provides contraception
which estrogens cannot be used in perimenoapuse? why?
synthetic - due to increeased cvd risk
which hrt is best in postmenoausal women?
Use continuous combined regimens
continuous - taken everyday: so no time for withdrawal bleeds
combined - estrogen + progesterone
which hrt is best in perimenopausal women?
Can give cyclic or sequential therapy
OR
Mirena + estrogen - if HMB + want contraception
how can combined regimen be given?
Monthly: oestrogen every day of the month + progesterone for the last 14 days of the month
Three Monthly: oestrogen every day for 3 months + progesterone for
the last 14 days
- Withdrawal bleed occurs when on progesterone
- Suitable for peri-menopause
Continuous: always on oestrogen and progesterone
• Suitable if definitely post-menopausal
how long is hrt taken for?
up to 5 years of onset of menopause sx
and then stopped to evaluate if symptoms recur severely enough to warrant continuation
what are the risks of HRT?
Combined HRT increases risk Breast Ca , if used for 5 years+ (combined therpay with progesterone not estrogen only)
Oral HRT increases risk of VTE 2-fold
Oral HRT increases gallbladder disease
increases CVD risk
small increase ovarian cancer risk if used 10+ yrs
list side effects of HRT?
Oestrogenic: breast tenderness, nausea, headaches
Progestogenic: fluid retention, mood swings, depression
what are some non-hormonal treatments in HRT?
For vasomotor sx:
Clonidine (alpha-adrenoceptor agonist)
SSRIs
Gabapentin
Vaginal atrophy:
Lubricants and moisturisers OTC
Osteoporosis:
Bisphosphonate - alendronate - stops resorption
SERM - raloxifene. reduces fracture risk
Calcum + vit d supplements - if insufficiency
Lifestyle advice eg regular exercise
If BMI > 30, oestrogen only HRT should be given as ____?
transdermal patch rather than oral!
a woman has undergone an endometrial ablative technique such as transcervical resection of endometrium (TCRE).
which hrt can she have?
combined: estrogen + PROGESTERONE
as not all the endometrium may have been removed.
how are the estrogen and progesterone components of HRT usually taken?
Take oestrogen without stopping but only take progestogen every few weeks:
Taken sequentially:
A. Last 2 weeks every month -> monthly bleeds
B. Last 2 weeks every 3 months -> 3 month bleeds
Taken continuously:
Continuously -> no bleeds
Real case i saw Rapid access clinic with miss Abdi:
42 y/o woman present with 9 month hx continuous bleeding. often spotting, not very heavy bleeding. uses panty liners.
She has a pmh of breast cancer. she has undergone radiotherapy and is now on tamoxifen.
Her period have stopped/become very irregular since starting tamoxifen 3 years ago.
How would you ivx and manage this case?
This is technically postmenopausal bleeding as her periods have stopped for 3 years.
Bimanual
Speculum
Lucky she has a TVUS done the previous week so:
pipelle biopsy of endometrium was done with speculum
Hysteroscopy was booked.
remember tamoxifen can put her at risk of endometrial hyperplasia and cancer
What is tamoxifen? what effects does it have in breast and endometrium?
It is a selective estrogen receptor modulator aka as an anti-estrogen
it acts as an antagonist in breast tissue - so is used in ER+ breast cancers but
it acts as partial agonist on the endometrium so increases risk of endometrial cancer
how would you manage vulvovaginal atrophy / symptoms in menopause?
mild symptoms:
Topical oestrogen’s - come in many forms :
- ring inserted into vagina - lasts 3 months (minimal work) - oestraDiol
- creams and pessary - oestriol
severe symptoms:
1. oral tablet eg ospemifene a SERM
topical estrogens improve which symptoms of menopause?
Vaginal dryness,
soreness, superficial dyspareunia,
urinary frequency and urgency
all respond well to oestrogens, which may be
given either topically or systemically or both together
how long do estrogens take to improve vasomotor sx?
Oestrogen is effective in treating
hot flushes, usually within 4 weeks.
a woman has a T score of -1.5. since taking hrt, t has improe to -1. she has been on hrt for 5 years now, so it is time to stop. 5 months since stopping, her T score is -2. what should she do?
we know hrt is protective agaisnt osteoporosis
stopping hrt reaults in a drop in bone density
swithc to other options eg bisphosphonates. but shouldnt restart HRT.
what are contraindications to HRT?
Hx of Breast, Ovarian, Endometrial cancer
Hx blood clots; dvt, pulm emboli
Hx Liver disease
Hx untreated hypertension - control b4 starting hrt
Pregnant
A 48 year old woman comes with vasomotor symptoms. her last period was 12 months ago. Her BMI is 36. what are her risks?
sounds like she is menopausal
BUT since she is under 50, she will need contraception for 2 years (1 year left for her).
so you can give her HRT for her sx BUT she will need contraception as well because HRT does not protect from pregnancy.
Can give Mirena coil + patch estrogen - 2 birds with 1 stone.
remember cant give oral estrogen in HRT when BMI is >30
which hrt wont increase your risk of breeast cancer?
vaginal oestrogen
what type of drugs is clonidine?
action?
centrally acting alpha-adrenoceptor agonist
may help reduce hot flushes and night sweats in some women
what is tibolone?
efficacy?
indications?
Synthetic steroid compound
its metabolites have estrogenic, progestogenic and androgenic actions
may not be as effective as HRT and is
only suitable for women who had their last period more than 1 year ago
what is the use of antidepressants in menopause?
SSRIs e.g. paroxetine, fluoxetine, citalopram
can help with hot flushes and night sweats, although they can also cause unpleasant side effects such as agitation and dizziness
