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GOSH > Gynaecology: Menopause > Flashcards

Gynaecology: Menopause Flashcards

1
Q

What is natural menopause and when does it occur?

A

Natural menopause occurs at 52yo typically

- occurs 12 months after last menstrual period (LMP)

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2
Q

What is premature menopause and why and when does it occur?

A

Premature menopause in any patient age < 40

  • primary - chromosomal (turner’s, fragile x), autoimmune (hypothyroid, addisons), enzyme def (galactosaemia)
  • secondary - surgical, infection, chemo
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3
Q

What is peri-menopause?

A

The fist signs of emotional, behavioural and physical symptoms occurring during menopause

Physiology

  • Oestradiol is secreted by ovarian follicles (granulosa)
  • Follicles are less sensitive to FSH - causes response increase in FSH
  • Decreased sensitivity to FSH causes anovulatory cycles and decreased oestradiol and progestogen production
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4
Q

What is post-menopause?

A

Dated from final menstrual period

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5
Q

What is the most common symptoms of menopause?

A

Hot flushes and Night sweats (77%)

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6
Q

What is the treatment for menopausal symptoms?

How does this treatment vary fro those (a) with hysterectomy (b) without hysterectomy

A

HRT = Hormone replacement therapy

A. Hysterectomy - Oestrogen only

B. No Hysterectomy - Oestrogen and Progestogen (to avoid development of endometrial hyperplasia or carcinoma after unopposed oestrogen)

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7
Q

What is the treatment for menopausal symptoms?

How does this treatment vary fro those (a) with hysterectomy (b) without hysterectomy

A

HRT = Hormone replacement therapy

A. Hysterectomy - Oestrogen only

B. No Hysterectomy - Oestrogen and Progestogen (to avoid development of endometrial hyperplasia or carcinoma after unopposed oestrogen)

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8
Q

Name examples of Oestrogen HRT? How can they be administered?

A 
Natural = Oestradiol, Oestrion, Oestriol 
Synthetic = ethenyloestradiol (usually in COCP, not HRT)

Route = Oral, Transdermal (patch or gel), SC, Topical

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9
Q

Name examples of Progestogen HRT? How can they be administered?

A

Synthetics = Levonogestrel
- Mirena coil IUS delivers 20ug of levonorgestrel daily and acts as contraception for peri-menopausal women, it also treats HMB

Route = Oral, Transdermal (patch or gel), IUS

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10
Q

What other HRT treatments are there? (2)

A
  1. Tribolone = steroid that is converted to androgens
    - treats vasomotor, sexual dysfunction and psychological symptoms
  2. Testosterone
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11
Q

What are the common side effects of HRT and the specific ones for oestrogen and progesterone?

A

Common - Weight gain

Oestrogen - bloating, headache, breast tender and enlargement, nausea, dyspepsia, leg pain

Progestogen - bloating, headache, breast tender, lower back pain, acne, mood swings

Combined HRT - breakthrough bleeding

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12
Q

What are the common side effects of HRT and the specific ones for oestrogen and progesterone?

A

Common - Weight gain

Oestrogen - bloating, headache, breast tender and enlargement, nausea, dyspepsia, leg pain

Progestogen - bloating, headache, breast tender, lower back pain, acne, mood swings

Combined HRT - breakthrough bleeding

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13
Q

What are the benefits of HRT?

A

Reduces risk and incidence of:

  1. Vasomotor symptoms
    - hot flushes, night sweats, sleep disturbances
    - improvement within 3 months
    - must continue for at least 1 year
  2. Sexual symptoms
    - possible with oestrogen only
  3. Urogenital symptoms
    - takes months
  4. Osteoporosis
    - requires continuous life long HRT
  5. Colorectal Ca
    - reduces risk by 33%, not an indication for use
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14
Q

What are the benefits of HRT?

A

Reduces risk and incidence of:

  1. Vasomotor symptoms
    - hot flushes, night sweats, sleep disturbances
    - improvement within 3 months
    - must continue for at least 1 year
  2. Sexual symptoms
    - possible with oestrogen only
  3. Urogenital symptoms
    - takes months
  4. Osteoporosis
    - requires continuous life long HRT
  5. Colorectal Ca
    - reduces risk by 33%, not an indication for use
  6. CVD
    - not a clear benefit
    - may reduce risk of stroke and CVD
  7. Dementia
    - not a clear benefit
    - may slow progression of alzheimers
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15
Q

What are the risks of HRT?

A
  1. Endometrial cancer
    - more common with oestrogen only
    - due to unnopposed oestrogen which increases endometrial hyperplasia and carcinoma risk
    - must only use oestrogen only on patients with hysterectomy
  2. Breast cancer
    - more common with combined HRT
    - less common with oestrogen only - but risk of endometrial cancer
    - increased risk with duration of use
  3. VTE
    - increased risk of VTE in 1st year of use
  4. Gall bladder disease
    - increased risk with age and duration of use
  5. Ovarian cancer
    - not clear risk, may increase risk with long term use
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16
Q

What is the definition of post-menopausal bleeding?

What are the causes?

A

Bleeding at least 12 months after last menstrual period

Atrophic vaginitis - due to reduced oestrogen, wall of uterus is thin and easily damaged
Endometrial polyp
Endometrial hyperplasia/carcinoma or cervical carcinoma - 10%
Cervicitis
Withdrawal bleeds from sequential HRT - if reg, no need to worry
Break through bleeding from combined HRT

17
Q

What are the key history, examinations and investigations you must undertake in a patient with post-menopausal bleeding?

A

History

  • ascertain date of last-menopausal bleed
  • ask about post-coital bleed - may indicate cervical polyp or cancer
  • determine date and result of last smear

Exam

  • abdominal or pelvic exam - detect masses
  • bimanual and speculum - visualise cervical
  • take smear

Investigation

  • TV USS to measure endometrial thickness (if < 4mm = ok; if > 4mm= biopsy and hysteroscopy)
  • Biopsy and hysteroscopy
18
Q

What routine of HRT would you give for (a) peri-menopausal women (b) post-menopausal women

A

(a) Peri-menopausal - Cyclical HRT
- Oestrogen daily and
- Oestrogen and progesterone for 10-14d every 4 weeks –> regular monthly periods or
- Oestrogen and progesterone for 14d every 13 weeks –> 3 monthly periods

(b) Post-menopausal (i.e. not had period > 1 year or been on cyclonical HRT > 1 year) - Continuous HRT
- no bleeds ‘HRT’

19
Q

What is the contraception advice you must give to patients on the menopause and about to start HRT?

What are the options for contraception?

A

HRT does not provide contraception

Still at risk of pregnancy one year after last menstrual period, two years if < 50

Mirena IUS coil (progesterone) can be given as part of HRT and provides contraception

Progesterone only pill can be given in addition to HRT

GOSH (14 decks)

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