Gynaecology: Menopause Flashcards
What is menopause?
Cessation of menstruation for 12 months due to loss of ovarian follicular activity (retrospective diagnosis made after cessation of period for 12 months)
What is the average age of menopause?
51 years
What is the perimenopause?
Perimenopause is the time around menopause where they may be experiencing vasomotor symptoms & irregular periods; it includes time leading up to last menstrual period and the 12 months afterwards. Typically in women >45yrs.
What is the postmenopause?
Period from 12 months after the final menstrual period onwards.
What is premature menopause and what is the cause?
Menopause before 40yrs due to premature ovarian insufficiency
Discuss the pathophysiology of menopause
- In ovaries, process of primordial follicles maturing into primary & secondary follicles is always occurring independent of menstrual cycle
- At start of cycle, FSH binds to FSH receptors on secondary follicle causing further development of secondary follicles into antral follicles (see repro recap FC for more)
- Granulosa cells that surround follicles secretes oestrogen
- In menopause, there is a decline in the development of ovarian follicles
- Decline in follicular development results in decline in oestrogen production (by granulosa cells)
- Decline in oestrogen stops negative feedback to the pituitary hence get increase in LH and FSH
- Failing follicular development lead to anovulation and lack of oestrogen means endometrium doesn’t develop hence get lack of menstruation
- Low oestrogen levels cause perimenopause symptoms
State some symptoms women may experience during the perimenopause & menopause
- Vasomotor symptoms
- Hot flushes
- Night sweats
- Mood & cognition changes
- Emotional liability
- Low mood
- Poor concentration
- Urogenital changes
- Vaginal dryness
- Urinary frequency
- Frequent UTIs
- Sexual dysfunction
- Vaginal dryness
- Reduced libido
- Irregular periods
- Joint pains
- Headache
- Fatigue
- Sleep disurbance
- PMS
How is the menopause diagnosed?
- Diagnosis can be made clinically (without any investigations) in women >45yrs with typical symptoms
-
Can use FSH blood test to aid diagnosis; recommended to use in situation such as:
- Women <40yrs with suspected premature menopause
- Women aged 40-45yrs with menopausal symptoms or change in menstrual cycle
- Women >45ys with atypical symptoms
- Women >50yrs on progesterone only contraception
Note: the Faculty of Sexual and Reproductive Healthcare (FSRH) states that a single elevated serum FSH level (more than 30 IU/L) indicates a degree of ovarian insufficiency, but not necessarily sterility. The British Menopause Society (BMS) recommends checking for an elevated FSH level on two blood samples taken 4–6 weeks apart.
Diagnosing menopause in women taking hormonal contraception can be difficult; true or false?
True
What would you expect the following levels to be during perimenopause/menopause:
- Oestrogen
- Progesterone
- FSH
- LH
- Oestrogen: low
- Progesterone: low
- FSH: high
- LH: high
Discuss the guidance surrounding contraception & the menopause
Women need to use contraception for:
- 2yrs after last menstrual period if LMP was when <50yrs
- 1yr after last menstrual period if LMP was when >50yrs
Discuss the management of menopause- ensure you categorise your answers to help you remember it
Can split management into 3 categories:
Lifestyle modification/advice
- Hot flushes → regular exercise, weight loss, avoiding triggers e.g. caffeine/spicy foods/alcohol, light clothing, well ventilated room
- Mood → regular exercise, relaxation, sleep
- Sleep disturbance → avoid late-evening exercise, good sleep hygiene
- Cognitive symptoms → regular exercise, sleep
- Advice on contraception (HRT does not act as contraception)
- Increased CVD risk → weight loss, smoking cessation, regular exercise, healthy balanced diet
- Osteoporosis risk → weight bearing exercise, balanced diet, adequate vitamin D
Non-hormonal treatments
- Vasomotor symptoms → clonidine, SSRIs (e.g. fluoxetine, citalopram), SNRIs (e.g. venlafaxine)
- Psychological symptoms → self-help resources & groups, CBT, antidepressants (if confirmed diagnosis of depression or anxiety)
- Urogenital symptoms/vaginal dryness → moisturisers (e.g. Replens), lubricants
HRT
- Vasomotor symptoms:
- Uterus: oral or transdermal combined HRT (oestrogen & progesterone)
- No uterus: oral or transdermal oestrogen only HRT
- Urogenital symptoms:
- First line= low dose vaginal oestrogen (can be used alongside systemic HRT and moisturisers and lubricants)
- Reduced libido
- Can use testosterone (usually a gel or cream)
- Mood disorders
- Oral or transdermal HRT (following same rules as stated in vasomotor symptoms)
For clonidine, discuss:
- Mechanism of action
- What it is useful for in menopause
- Common side effects
- Agonist of alpha-2 adrenergic receptors and of imidazoline receptors in the brain. Lowers BP and decreases HR
- Helpful for vasomotor symptoms
- Common side effects:
- Dry mouth
- Headaches
- Constipation
- Dizziness
- Fatigue
- Sudden withdrawal → rapid increase BP and agitation
State some potential complications/risks associated with the menopause due to lack of oestrogen
- Increased risk cardiovascular disease
- Increased risk stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
When and why is HRT used?
HRT used in perimenopausal and postmenopausal women to alleviate symptoms associated with menopause due to low oestrogen levels.
Which women should go on cyclical HRT and which should go on continuous HRT?
- Cyclical HRT: for women that still have periods, or haven’t had 12 months without periods
- Continuous HRT: for women who are post-menopaual (e.g. not had period for 12 months or more)
- ???You can switch from* cyclical to continuous HRT after at least 12 months of treatment in women over 50, and 24 months in women under 50 (not sure where this has come from). Switch from cyclical to continuous HRT during the withdrawal bleed. Continuous HRT has better endometrial protection than cyclical HRT.
- *NOTE: cyclical combined HRT you take continuous oestrogen with progesterone added for specific periods during cycle (e.g. 1 monthly or 3 monthly). For continuous combined HRT you take both oestrogen & progesterone throughout.*
Explain why women with a uterus must have HRT with oestrogen and progesterone
To prevent endometrial hyperplasia and endometrial cancer due to unopposed oestrogen
State some indications for HRT
- Replacing hormones in premature ovarian insufficiency (even if pt not having troublesome symptoms. Should continue to give until age of 50yrs)
- Reducing vasomotor symptoms (hot flushes, night sweats)
- Improving other symptoms such as low mood, decreased libido, poor sleep, joint pain
- Reducing risk of osteoporosis in women under 60yrs (??CHECK)
In women under 60yrs, benefits of HRT generally outweigh risks; true or false?
True
State some benefits of HRT
- Improved symptoms
- Improved QoL
- Reduced risk of osteoporosis and fracture
What factors should you consider when choosing the HRT formulation for a pt?
