Gynaecology: Menopause Flashcards
What is natural menopause and when does it occur?
Natural menopause occurs at 52yo typically
- occurs 12 months after last menstrual period (LMP)
What is premature menopause and why and when does it occur?
Premature menopause in any patient age < 40
- primary - chromosomal (turner’s, fragile x), autoimmune (hypothyroid, addisons), enzyme def (galactosaemia)
- secondary - surgical, infection, chemo
What is peri-menopause?
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
What is post-menopause?
Dated from final menstrual period
What is the most common symptoms of menopause?
Hot flushes and Night sweats (77%)
What is the treatment for menopausal symptoms?
How does this treatment vary fro those (a) with hysterectomy (b) without hysterectomy
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)
What is the treatment for menopausal symptoms?
How does this treatment vary fro those (a) with hysterectomy (b) without hysterectomy
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)
Name examples of Oestrogen HRT? How can they be administered?
Natural = Oestradiol, Oestrion, Oestriol Synthetic = ethenyloestradiol (usually in COCP, not HRT)
Route = Oral, Transdermal (patch or gel), SC, Topical
Name examples of Progestogen HRT? How can they be administered?
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
What other HRT treatments are there? (2)
- Tribolone = steroid that is converted to androgens
- treats vasomotor, sexual dysfunction and psychological symptoms - Testosterone
What are the common side effects of HRT and the specific ones for oestrogen and progesterone?
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
What are the common side effects of HRT and the specific ones for oestrogen and progesterone?
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
What are the benefits of HRT?
Reduces risk and incidence of:
- Vasomotor symptoms
- hot flushes, night sweats, sleep disturbances
- improvement within 3 months
- must continue for at least 1 year - Sexual symptoms
- possible with oestrogen only - Urogenital symptoms
- takes months - Osteoporosis
- requires continuous life long HRT - Colorectal Ca
- reduces risk by 33%, not an indication for use
What are the benefits of HRT?
Reduces risk and incidence of:
- Vasomotor symptoms
- hot flushes, night sweats, sleep disturbances
- improvement within 3 months
- must continue for at least 1 year - Sexual symptoms
- possible with oestrogen only - Urogenital symptoms
- takes months - Osteoporosis
- requires continuous life long HRT - Colorectal Ca
- reduces risk by 33%, not an indication for use - CVD
- not a clear benefit
- may reduce risk of stroke and CVD - Dementia
- not a clear benefit
- may slow progression of alzheimers
What are the risks of HRT?
- 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 - Breast cancer
- more common with combined HRT
- less common with oestrogen only - but risk of endometrial cancer
- increased risk with duration of use - VTE
- increased risk of VTE in 1st year of use - Gall bladder disease
- increased risk with age and duration of use - Ovarian cancer
- not clear risk, may increase risk with long term use
What is the definition of post-menopausal bleeding?
What are the causes?
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
What are the key history, examinations and investigations you must undertake in a patient with post-menopausal bleeding?
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
What routine of HRT would you give for (a) peri-menopausal women (b) post-menopausal women
(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’
What is the contraception advice you must give to patients on the menopause and about to start HRT?
What are the options for contraception?
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
