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Phase 3a Gynaecology > Management of the menopause > Flashcards

Management of the menopause Flashcards

1
Q

Define menopause

A

Cessation of menstruation

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2
Q

What is the normal age of menopause?

A

45-55 yrs (av. 51 yrs)

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3
Q

When would you diagnose the menopause?

A

after 12 months of amenorrhoea

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4
Q

What exception to the rule is there when defining menopause?

A

When a woman has had a hysterectomy without oopherectomy, her periods will stop,. but she is not in menopause

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5
Q

What are the symptoms of perimenopause?

A

irregular periods
hot flushes
mood swings
urogenital symptoms

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6
Q

What does the hypothalamus produce in the HPA?

A

GnRH - gonadotrophin releasing hormone

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7
Q

How is GnRH released from the hypothalamus?

A

Pulsatile manner

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8
Q

What does GnRH do?

A

causes the anterior pituitary gland to produce LH and FSH

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9
Q

What happens to LH and FSH levels in the menopause and why?

A

increase - this is because the ovaries are not producing oestrogen due to lack of follicles and so the hypothalamus keeps stimulating the anterior pituitary gland to produce LH and FSH

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10
Q

What does oestrogen due to LH and FSH levels?

A

Reduces them by inhibiting the anterior pituitary

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11
Q

What do LH and FSH do?

A

Cause the ovary to produce oestrogen

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12
Q

What are the main categories of symptoms of the menopause?

A 
Vasomotor 
MSK 
Urogenital symptoms 
Low mood 
Sexual difficulties - reduced libido
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13
Q

What are the vasomotor symptoms of the menopause?

A

Hot flushes

Night sweats

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14
Q

What are the MSK symptoms of the menopause?

A

Joint pain

Muscle aches

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15
Q

What are the urogenital symptoms of the menopause?

A 
Vaginal dryness 
Vulval itching 
Dyspareunia 
recurrent UTIs 
PMB
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16
Q

What are the short term symptoms of the menopause?

A 
loss of memory
concentration
headaches
dry and itchy skin
joint pains
loss of confidence
lack of energy
mood change/irritability
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17
Q

What are the medium term symptoms of the menopause?

A

Urogenital atrophy causing:

  • Dyspareunia
  • Recurrent UTIs
  • PMB

also atrophy of pelvic floor muscles causes incontinence and prolapse

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18
Q

Why does urogenital atrophy occur?

A

the urogenital tract is lined by an epithelium that has oestrogen receptors in it

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19
Q

What are the long term impacts of the menopause?

A

Osteoporosis
Cardiovascular disease - increased lipid levels
Dementia

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20
Q

When should we start treatment to reduce the risk of the long term effects of the menopause?

A

At the time of the menopause

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21
Q

What are the risks of taking HRT?

A

Stroke
Thrombosis
Breast cancer

22
Q

What are the benefits of HRT in the long term other than symptom control?

A

bone mineral density protection

potentially reduced risk of heart disease but hypothesised only to protect against heart disease if given early in the menopause, as HRT has also been shown to increase the risk of heart disease

23
Q

How would you manage the menopause?

A
  • holistic approach
  • lifestyle advice - lose weight, stop smoking, reduce alcohol, reduce caffeine - as these make symptoms better and reduce risk of breast cancer
  • HRT
  • vaginal oestrogen creams
  • non-hormonal - Clonidine for hot flushes
  • Venlafaxine and other antidepressants
  • CBT
24
Q

How do oestrogen only and oestrogen and progesterone preparations of HRT compare in their risk of breast cancer?

A

Oestrogen only - no increased risk of breast cancer, but oestrogen on its own without progesterone increases risk of endometrial cancer, so would only give to women who have already had a hysterectomy

Oestrogen and Progesterone - increased risk of breast cancer

25
Q

What would you do if a women on HRT develops breast cancer?

26
Q

Would you prescribe HRT to a woman with history of breast cancer?

A

Not routinely

27
Q

What are the types of HRT and how do they relate to risk of VTE?

A
  1. oral - increased risk of VTE
  2. transdermal - no increased risk of VTE, unless BMI >30
  3. vaginal pessary or cream
  4. Skin Gel
28
Q

What is the difference between continuous and sequential HRT?

A

sequential HRT usually given in the perimenopausal symptoms to prevent irregular bleeding, as the sequential one gives you a predictable bleed every 4 weeks - has oestrogen only for 16 days and then oestrogen and progesterone for 12 days

Continuous combined HRT which does not cause bleeding if given after 12 months of amenorrhoea and has oestrogen and progesterone throughout - the advantage is that it is bleed free

29
Q

How can a Mirena coil be used as HRT?

A

The Mirena can be used as the progestogen component of HRT and then can give oestrogen on top to act as a continuous combined HRT

30
Q

What does Tibolone contain?

A

Androgenic
Oestrogenic
Progestrogenic functions/properties

given on a daily basis so equivalent of continuous combined HRT

31
Q

How often would you change a mirena when using it as HRT?

A

every 4 years (usually would change every 5 years when used as contraception)

32
Q

What dictates the dose you use?

A

Symptomatic relief - aim for lowest effective dose

33
Q

Who should have transdermal HRT?

A 
malabsorption eg chron's
migraines, epilepsy - due to steady release 
increased risk of VTE 
older women
medical conditions eg hypertension
patient choice
34
Q

Define premature ovarian insufficiency

A

menopause < 40 yrs

35
Q

What are the causes of premature ovarian insufficiency?

A
  1. idiopathic
  2. natural - chromosomal abnormalities, gene abnormalities, autoimmune
  3. iatrogenic - surgery, chemo, radiotherapy
36
Q

How would you diagnose primary ovarian insufficency?

A

FSH >25IU/l – 2 samples >4 weeks apart

AND

4 months of amenorrhoea

37
Q

What is the recommended guidance on HRT for pts who have primary ovarian insufficiency?

A

To take HRT until at least the age of average menopause

To reduce risk of:

  • early onset cardiovascular disease
  • osteoporosis
  • early onset cognitive decline
38
Q

Fertility stops immediately when menopause starts. T or F?

A

FALSE!

If menopause starts <50 years, then fertile for 2 years after start of menopause

If menopause starts >50 years, then fertile for 1 year after start of menopause

39
Q

Which is the most effective treatment of symptoms of the menopause?

40
Q

What are the non-hormonal methods of treating the menopause?

A

Clonidine
antidepressants eg venlafaxine
antiepileptics eg gabapentin

41
Q

What is clonidine’s mechanism of action?

A

Alpha adrenergic receptor agonist- reduces vasodilation

42
Q

Which drugs should not be given to pts who are on tamoxifen and why?

A

Paroxetine
Fluoxetine
Sertraline

as these are CYP450 inducers so make tamoxifen less effective

43
Q

What are the contraindications for HRT?

A

undiagnosed abnormal vaginal bleeding
breast lump
acute liver disease

44
Q

What are the cautions for HRT?

A 
Migraines 
Over age of 60 - as HRT increases risk of cardiovascular disease if started over 60
uncontrolled BP 
endometriosis 
VTE family history 
Fibroids
45
Q

What is the difference between primary ovarian insufficiency and early menopause?

A

POI = menopause before 40

early menopause = menopause between 40-45

46
Q

What are the risk factors for early menopause?

A 
smoking 
menarche
parity
previous oral contraceptive history
BMI
ethnicity
family history
47
Q

What is the pathophysiology of the menopause?

A

the follicles become depleted

48
Q

Would you routinely do investigations for diagnosis of the menopause?

A

No

Just use clinical symptoms if the pt is around the age of a normal menopause ie over 45

49
Q

When would you use FSH levels to diagnose the menopause?

A
  • when the woman is using contraception
  • when aged 40-45 years to diagnose early menopause
  • when aged under 40 and POI is suspected

do 2 levels 4 weeks apart

50
Q

What investigations would you do to exclude other diseases in the menopause?

A

TFT
- to differentiate thyroid disease symptoms from menopausal symptoms.

Blood glucose
- may be considered in some women, as diabetes can cause similar symptoms.

A pelvic scan
- may be considered for those women with atypical symptoms.

Phase 3a Gynaecology (13 decks)

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