L9: menopause

Question 1

Define menopause

Answer 1

Permanent cessation of menstruation for 12 consecutive months
Happens when there are no primary follicles left
Ovaries are no longer able to produce follicles – oestrogen levels start to decline

Question 2

List the different stages of menopause

Answer 2

Pre-menopause
Peri-menopause
Menopause
Post-menopause

Question 3

What happens in the pre-menopause stage?

Answer 3

Initial changes that occur to a menstrual cycle
Menstrual cycle often shortens, ovulation is early or absent & so problems with fertility can occur
Oestrogen levels fall -> LH and FSH rise (FSH rises more due to removal of inhibin)

Question 4

What happens in the peri-menopause stage?

Answer 4

Transition phase

Mood swings & hot flushes occur, leading ultimately to greater infrequency of menstruation

Question 5

What happens in the menopause stage?

Answer 5

Complete cessation of menstrual periods for 12 months

Question 6

What happens in the post-menopause stage?

Answer 6

Unable to conceive – no follicles left

Question 7

Describe the symptoms of menopause

Answer 7

Early stages – hot flushes, sweating, insomnia, mood swings & depression
Intermediate stage – dyspareunia, increased frequency of UTIs, stress incontinence, reduction in pubic hair, breast tissue reduces, changes to hair and voice, bloating & constipation
Late stages – osteoporosis, increased atherosclerosis & Alzheimer’s disease

Question 8

Describe ovarian cancer

Answer 8

Can present with symptoms as vague as bloating = IMPORTANT DIFFERENTIAL in post-menopausal women
Been a link with HRT and ovarian cancer

Question 9

Describe the effect of oestrogen on bone

Answer 9

Reducing levels of oestrogen enhances osteoclast activity
More bone is absorbed and there is increased calcium loss from bone
Causes changes to skeletal structure -> reduced height due to reduced bone mass

Question 10

Describe the effect of oestrogen on CVS

Answer 10

Low levels of oestrogen and progesterone cause changes in the lipid profile in postmenopausal women
Increased circulating lipid levels -> increased risk of atherosclerosis -> embolic events, eg. MI & stroke

Question 11

Describe non-hormonal management of menopause

Answer 11

General lifestyle advice that can help with vasomotor symptoms & dietary advice to reduce weight gain & cardiovascular risk

Question 12

Describe hormonal management of menopause

Answer 12

Involves replacing oestrogen locally – cream for vaginal atrophy/patches or given orally
Main indications for HRT are to help manage the symptoms related to low levels of oestrogen

Question 13

Describe advantages and disadvantages of HRT (oral, vaginal, MIS, transdermal)

Answer 13

Oral – cheap & effective, however: variable plasma levels & higher doses required
Transdermal – avoids first pass metabolism, reduced risk of VTE, however: cost & skin reactions
Vaginal – good for urogenital symptoms, however: unlikely to treat other symptoms
Mirena intrauterine system – licensed for 4 years to provide the progesterone arm of HRT contraceptive, however: patients will still need oestrogen

Question 14

Describe the levels of hormones in a menopausal woman

Answer 14

Decreased oestrogen: supply of ovarian follicles is diminished
Elevated FSH: reduced negative feedback (lower levels of oestrogen) on anterior pituitary
Increase in vaginal pH