Gynae: menopause and FGM Flashcards
What symptoms should you ask about when taking a history for menopause?
- Periods? – becoming irregular, stopping
- Vasomotor changes – “hot flushes”
- Psychological – insomnia, poor concentration, anxiety, lethargy, reduced libido
- Skin and breast changes, hair loss
- Increased risk of prolapse, urinary incontinence
- Bone mineral loss à osteoporosis – fractures
- Increased cardiovascular risk
- Sexual dysfunction
What background Hx should you elicit for pt undergoing menopause?
- PGHx
- Periods previously regular? No menstrual or other gynaecological problems? Fibroids? Cancer? Endometriosis?
- No previous operations? (e.g. BSO)
- Infections, smears up to date, smears all normal
- Mammograms? (if 50)
- PMHx – any medical illnesses now or in the past?
- Fractures
- Heart attack, stroke
- DVT, PE
- Liver disease
- Cancer – endometrial, breast, ovarian, bowel
- FHx – of any of the above?
- DHx – on any medications? (steroids à osteoporosis) Any allergies?
- SHx – hysterectomy, BSO or other gynae surgery
Define peri, premature and normal menopause
- Menopause: the permanent cessation of menstruation resulting from the loss of follicular activity. Occurs at median age of 51 yrs. Now recognised after 12 consecutive months of amenorrhoea.
- Perimenopause- Period between first noticing features (eg-menstrual irregularity) and ends 12 months after last menstrual period.
- Premature menopause- before age 40, affects 1% of women. Can be surgical (after bilateral oophorectomy), due to infection, chemo etc. Give HRT to age 50
What investigations would you do to confirm normal or premature menopause?
- Confirm the menopause: low oestrodiol with a high FSH and LH (due to loss of negative feedback); the useful diagnostic test is a high FSH.
Menopause before age 40 is defined as premature menopause.
- Anti-Mullerian hormone produced by small ovarian follicles, direct meaure of ovarian reserve.
- Thyroid (T4+TSH), progesterone (low in PCOS), and catecholamine/ 5-hydroxyindolacetic acid (phaechromocytoma/ carcinoid)
Describe the types of HRT and their respective indications
Women without uterus: oral or transdermal oestrogen only preparation taken continuously
Women with uterus: oral or transdermal combined (oestradiol + progestogen HRT preparation b/c unopposed oestrogen increases risk of endometrial cancer
Peri-menopausal: cyclical HRT (still need contraception)
- Monthly: oestrogen every day and take progestogen for last 14 days (better for regular bleeding)
- 3 monthly: oestrogen every day and take progestogen for last 14 days of 3 month cycle (better for irreg bleeding)
Post-menopausal: continuous HRT: take oestrogen and progestogen every day without break
*Topical oestrogens alone treat urogenital sxs, no systemic action so no progesterone needed
**Methods of delivert: tablet, skin patch, oestrogen gel, implants, PV cream/pessary
What are the advantages of HRT?
- Short-term relief of the symptoms of the menopause
- Reduces bone density loss and pathological fractures, and partially reverses established osteoporosis
- Reduces collagen loss in the skin, may preserve a “younger” appearance
- Reduces bladder dysfunction, may increase libido, protects against bowel cancer, tooth loss and possibly Alzheimer’s, macular degeneration and cataracts
What are the disadvantages of HRT?
- Short term side effects: oestrogenic or progestogenic side effects, continued menstruation, headaches, breast tenderness, fluid retention, pre-menstrual symptoms – most diminish after 3 months
- Menstruation
- Slightly increased risk of breast cancer (4 extra per 1000 after 5 years, not in women who start HRT for premature menopause, risk falls again after 5 years no therapy)
- 2-4x risk of thromboembolic disease
- Possibly slightly increased risk endometrial cancer, even with progestogens
What other treatments might you provide for a women undergoing menopause?
- Hot flushes/ night sweats- progesterone, SSRIs, clonidine or gabapentin (poor evidence)
- Vaginal atrophy- lubricants + moisturisers available but less effective than local oestrogen
- Osteoporosis prevention- Bisphosphonates, strontium, raloxifene (SERM), denosumab, Ca+vit D
What is FGM? Describe the 4 types
Procedure where female genitals have been deliberately changed/injured/cut and where there is no medical reason for doing so. It is very painful, harmful and can cause long term problems with sex, childbirth and mental health
Outline UK law on FGM
- FGM act 2003 (NI, England, Wales) and Scotlant 2005
- FGM is illegal unless is necessary for physical/mental health or is associated with labour/purposes associated wtih birth
- It is illegal to arrange/assit for UK national/resident to be taken overseas for FGM
- It is an offence for those with parental responsibility who fail to protect a girl from FGM
- If FGM is confirmed in girl under 18 years of age (on examination or b/c patient or parent says it has been done), it is mandatory to report it to police within 1 month
- Re-infibulation is illegal
What should you do if you encounter FGM in clinical practice?
- Offer non judgemental/kind attitude
- Recond examination findings accurately in clinical records
- All woman/girls with acute/recent FGM require police and social services referals
- Refer women to a hospital gynae clinic or to direct FGM services if possible
- Explain requirement for pts’ personal data to be submitted without anonymisation (to prevent data duplication) to HSCIC FGM dataset but that data will be anonymised for analysis/publication
Describe some short and long term complications of FGM
Short term: haemorrhage, severe pain, urinary retention, genital swelling, infection, sepsis, death
Long term: genital scarring (cysts, keloid, neuromas), urinary complicaations, dysparunia/apareunia/disturbed sexual function, menstrual difficulties, genital infections, HIV/Hep B (due to country of practice), obstetric complications (higher incidence stillbirth/neonatal death)
