IC18 Menopause Flashcards
definition
permanent cessation of menses, following loss of ovarian follicular activity
natural etiology
stages & their production of hormones
perimenopause
Will have reduced production of progesterone & oestrogen; have suppression of FSH production (can be tested)
Difficult to predict menses
menopause, postmenopause
No longer produces progesterone & oestrogen
clinical presentation
- vasomotor symptoms
- genitourinary syndrome
- psychological
- bone fragility
clinical presentation: vasomotor symptoms
Hot flushes → intense feeling of heat on face + reddened face
* Possibly due to thermoregulatory dysfunction initiated at hypothalamus by oestrogen withdrawal
Perspiration → cold sweats, night sweats
Rapid/irregular HR
Sleep disturbances
Feeling of anxiety
clinical presentation: genitourinary syndrome
changes in structures
Changes to labia, clitoris, vestibule, vagina, urethra & bladder
Due to decreased oestrogen
Vulva & endometrium undergo atrophy → thinner layers will be easily irritated
clinical presentation: genitourinary syndrome
symptoms
- Genital dryness, burning/ irritation/ pain
- Sexual symptoms of lubrication difficulty, Impaired sexual function/ libido/ painful intercourse
- Urinary urgency, Dysuria, Recurrent UTI
clinical presentation: psychological symptoms
- Multifactorial
- Depression, anxiety (may be new onset/ relapse if previously diagnosed)
- Poor concentration/ memory
- Mood swings
clinical presentation: bone fragility
purpose of estrogen + problems in menopause
Oestrogen receptors present on bone → stimulates bone growth
Decreased oestrogen ⇒ no stimulation; more bone loss
clinical presentation: bone fragility
symptoms
- Risks of osteoporosis & fractures (esp early onset menopause)
- Joint pain
non-pharmacological indications
mild symptoms ONLY ⇒ first line before pharmacological therapy
non-pharmacological managements
- vasomotor symptoms
- genitourinary syndrome
non-pharmacological: vasomotor symptoms
- Layered clothing that can be removed/ added as necessary
- Lower room temperature
- Less spicy food/ caffeine/ hot drinks
- More exercise
- Dietary supplements
Isoflavones: soy beans, legumes (lentils, chickpea)
Black Cohosh: possible serotonergic activity at hypothalamus
non-pharmacological: genitourinary syndrome
Non Hormonal vaginal lubricants/ moisturisers
If have issues with intercours
pharmacological managements
- menopausal hormone therapy (MHT) -> first line, gold standard
- antidepressants
- gabapentin
- tibolone
pharmacological indication
moderate/ severe symptoms OR insufficient response to non-pharmacological
pharmacological: MHT types
- estrogen-only
- estrogen + progesterone
pharmacological: MHT
oestrogen-only
indication
NO intact uterus OR if patient is on levonorgestrel IUD
pharmacological: MHT
oestrogen-only
types
- systemic oral contraceptives
- systemic topical (gels & patch)
- local vaginal (cream & pessary)
pharmacological: MHT
oestrogen-only
administration
Systemic oral tablets
Take same time everyday
(once finish pack, start new one immediately)
Gel
Use the ruler provided to measure the dose.
Apply over arms/ thighs daily & let dry.
Rotate sites
Patch
Replaced twice a week on lower back, abdomen, thighs or butt → rotate sites
Cream
Squeeze cream from tube into applicator.
Lie down with knees drawn towards you.
Insert applicator into vagina & press applicator downward.
Wash the applicator with mild soap & warm water.
Pessary
Inserted 2x a week before bedtime (minimise movement)
pharmacological: MHT
oestrogen-only
advantages
Systemic oral tablets
Inexpensive
systemic topical
Lower systemic dose than oral
Convenient (external application)
Continuous oestrogen release
local vaginal
Lowest oestrogen dose → no need for concomitant progestin
Continuous oestrogen release
pharmacological: MHT
oestrogen-only
disadvantages
systemic oral tablets
Highest dose required → higher risks of SE
Potential for missed dose → irregular bleeding
systemic topical
Expensive
Skin irritation; Good to rotate sites
Gel → more variability in absorption
local vaginal
inconvenient/ uncomfortable
Vaginal discharge
Only for localised urogenital atrophy
pharmacological: MHT
combined
indication
INTACT uterus OR if patient does not have levonorgestrel IUD
pharmacological: MHT
combined
role of estrogen & progesterone
Oestrogen → causes growth in lining of endometrium
Progestin → To protect endometrium from overgrowth (increased risk of endometrial cancer associated with unopposed oestrogen
* If oestrogen not kept in check, endometrium will keep growing
pharmacological: MHT
combined
types
- combined cyclic
- combined continuous
pharmacological: MHT
combined (cyclic)
- Progestin added on either 1st or 15th of month, for 10-14 days
- Withdrawal bleeding when progestin stopped → menses occurs
- Regulate menses → predictable bleeding
pharmacological: MHT
combined (continouous)
- Oestrogen & Progestin daily
- No withdrawal bleeding although chance of breakthrough bleeding initially
spotting might occur until body is adjusted - After several months, amenorrhea likely to occur
pharmacological: MHT
combined
when will improve, tests upon initiation, problem of discontinuation
- Might require 2-3 months of use before improvements of menopausal symptoms
Should continue MHT if there is need
Tests Upon initiation
* Annual mammography
* Endometrial surveillance
Unopposed oestrogen: any vaginal bleeding
Continuous-cyclic: if bleeding occurs when progestin is still on
Continuous-combined: if bleeding is prolonged, heavier than normal, frequent, persists after >10 months after treatment started
Discontinuation of treatment ⇒ ~50% chance of symptoms returning
pharmacological: antidepressants
drugs & importance of evaluation
- Serotonin & norepinephrine reuptake inhibitors (SNRIs) → venlafaxine
- Selective serotonin reuptake inhibitors (SSRIs) → paroxetine
- Important to evaluate & differentiate mood changes from menopause & depression
pharmacological: gabapentin
purpose
Night sweating, sleep disturbances
pharmacological: tibolone
drug composition
Synthetic steroid with estrogenic, progestogenic & androgenic effects
* May have hirsutism & acne
pharmacological: tibolone
indication
postmenopausal women ≥ 12 months since last natural period
* Cannot be <12 months → will cause bleeding
pharmacological: tibolone
advantage
- Improves mood, libido, menopause symptoms, vaginal atrophy (less than oestrogen)
Affects ALL symptoms of menopause - Protects against bone loss
pharmacological: tibolone
disadvantage
Risk of stroke, breast CA recurrence, endometrial cancer
* Due to estrogenic component
