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MFSRH 2021 > Meno/PMS > Flashcards

Meno/PMS Flashcards

1
Q

A 35 year old women presents with cyclical mood changes, tearfulness and anger outbursts, these are impacting on her work and relationships. She is G2P2 and was sterilised at c/s following the birth of her 2nd child. She would like to have something to help. You suspect luteal phase PMD. What initial assessment would do you require?

A

2/12 symptom diary BEFORE treatment to establish symptomatology.

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2
Q

What is core PMDD?

A

Luteal phase, resolves with menstruation, symptoms free interval, absence of psychiatric disorder.

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3
Q

What are the variants of PMDD?

A

Anovulatory but cyclical (eg with IUS/after hysterectomy/ablation)

progestin induced (on HRT/contraception)

premenstrual exacerbation of existing condition (eg epilepsy).

Continuous symptoms are not PMDD.

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4
Q

What % of women suffer PMS?

A

40%

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5
Q

What % of women suffer PMDD?

A

5-8%

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6
Q

Aetiology of PMS/PMDD?

A

Not clear, thought to be sertatonin/GABA link or progestin/progesterone intolerance.

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7
Q

1st line treatment for PMS?

A 
Lifestyle advice (diet/exercise), 
vitamin B6 (variable evidence limit to 10mg OD – risk of peripheral neuropathy), 
adequate calcium/vit d intake. 
CBT

CHC drospirenone containing, cyclical 24/4 or continuous,
SSRI/SNRI (cyclical or continuous)

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8
Q

If first line treatment of luteal phase PMDD fails – what’s next?

A

Transdermal oestrogen, with IUS or micronized progesterone 200mg 12/28, or increase SSRI/SNRI

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9
Q

3rd line treatment for luteal phase PMDD?

A

GnRH analogues and add back HRT with tibolone

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10
Q

4th line treatment for luteal phase PMDD if family complete?

A

Hysterectomy and BSO with add back HRT

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11
Q

Placebo response rate with PMDD treatment?

A

~35-45%

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12
Q

Average age of menopause in UK?

A

51yo

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13
Q

Define menopause in terms of menstruation?

A

1 year after last period over 50yo (2 years if <50)

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14
Q

How long on average is the perimenopause?

A

~2-7 years, 10% transition abruptly

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15
Q

Pathophysiology of menopause?

A

Decreased number of sensitive primordial follicles, need more FSH to stimulate, eventually ovaries don’t respond to any level of FSH.

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16
Q

Initial assessment of meopause/pre-treatment?

A 
Symptoms inc impact on life
PMHx (inc liver/breast/migraine/bone/cvd risk)
FHx, 
o&g hx (smears, contraception, uterus present, menstrual hx)
How's the sex life
meds/allergies. 
Smoking/ETHO/lifestyle. 
BP/BMI, 
patient’s goals, ICE
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17
Q

Treatment options for menopause?

A

None, lifestyle, hormonal, non-hormonal

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18
Q

Most effective treatment for menopausal sx?

A

HRT

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19
Q

What is the increased VTE risk with oral HRT?

A

X 2 with MPA as progestin (much lower with digesterone or utogestan)

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20
Q

How many additional breast cancer cases are seen in women on HRT?

A

4/1000 (baseline is 15/1000)

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21
Q

What HRT is recommended for women with endometrial hyperplasia without atypia?

A

continuous progestogen intake using the LNG-IUS or a continuous combined HRT preparation, sequential doesn’t provide enough progestin.

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22
Q

Chance of spontaneous conception in POI?

A

8%

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23
Q

POI bone monitoring with dexa?

A

Baseline, if normal no repeat,
If osteoporosis refer to bone team,
If osteopenia 2x repeats 2-4 years apart, if stable no repeat.

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24
Q

Is breast cancer risk increased by using HRT in POI?

A

No, supplementing normal range oestrogen not supraphysiological

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25
Q

Contraindications to HRT?

A

Past/current breast cancer,

oestrogen dependent cancer,

unexplained vaginal bleeding,

untreated endometrial hyperplasia,

idopathc VTE - present or past unless on anticoagulation (in reality can have transdermal)

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26
Q

Which conditions is transdermal HRT likely to be safer in?

A

VTE risk, raised BMI, migraine, endometrial hyperplasia, diabetes, porphyria.

27
Q

A 53 yo woman attends with hot flushes sweats and vaginal soreness, mood swings, anxiety, and poor memory/loss of concentration. Her periods have become increasing spaced and her last one was 3/12 ago, she was sterilised at c/s. Her BMI is 30, her BP is 120/68. She is a non-smoker, and takes citalopram for anxiety. He has no relevant family or personal history. What preparation of HRT would you recommend?

A

Sequential combined (transdermal in view of BMI), could have IUS and transdermal if would like to be bleed free

28
Q

Follow up for HRT?

A

3/12, symptoms, bleeding, satisfaction, medical hx. If settle 12/12 rx.

29
Q

How long after being on sequential combined hrt should a women switch to continuous?

A

2 years.

30
Q

At what age would you start continuous combined hrt rather than sequential?

A

> 54 or >1 year since LMP.

31
Q

A 53 yo woman was started on oral sequential HRT for menopausal symptoms, she has been using it for 8/12. She complains of irregular vaginal bleeding since starting the HRT. Prior to starting hrt her LMP was 3/12 ago, she was sterilised at c/s. Her BMI is 27, her BP is 120/68. She is a non-smoker, and takes citalopram for anxiety.
She has no relevant family or personal history. Smears are up to date and she is in a long term relationship, is up to date with STI screen and has no vaginal discharge or pain. She has not missed any tablets. She saw your colleague 4/12 ago, took a history and performed an examination which was unremarkable, they reassured her that bleeding within 6/12 of starting HRT can be observed and may settle. What is the next step in her management?

A

If there is no suspicion of pathology from history or examination, you can discontinue the HRT for 6 weeks, if bleeding persists ix as per PMB.
If the patient does not want to stop HRT try changing the HRT.

If risk factors for endo ca or bleeding persists beyond 6 months – EB +/- hysteroscopy.

32
Q

Unscheduled bleeding on HRT history/examination?

A

Hx, smears, STI risk, time on HRT, drug interactions, missed doses, malabsorption,

assess risk of endometrial malignancy – if risk factors consider uss and EB <6/12 symptoms
(obesity, diabetes, nulliparity, history or chronic anovulation, history of polycystic ovarian syndrome, late menopause, FH of hereditary nonpolyposis colorectal, endometrial or ovarian cancer)

examine to exclude cervical pathology consider swabs.

Any risk of pregnancy?

33
Q

What is the utility of USS in investigation of unscheduled bleeding on HRT?

A

USS can assess the thickness of the endometrium. Technically post-menopausal cut off of 4mm does not apply as the patient is taking hormones.

However on continuous combined HRT, the endometrium should be thin (<4-5mm) because of the continual effect of progestogens. On sequential HRT, the endometrium will vary according to where she is in the pack. Measuring the thickness is therefore less useful and the thickness can be similar to pre-menopausal levels. Endometrium of <7-8mm unlikely to be pathological. pipelle +/- hysteroscopy is indicated if the endometrium looks abnormal, is significantly thickened or hyperplastic, or if it cannot be clearly defined or >6/12 duration. If the patient does not want to stop HRT try changing the HRT.

34
Q

Irregular or heavy bleeding with sequential HRT management options when pathological cause excluded?

A

Double the dose of progestin/Change the type of progestgin/Increase the duration of progestin to 21 days/Consider LNG-IUS as the progesterone combined with oral or transdermal oestrogen. Bleeding early in the progesterone phase – increase the dose or change the type of progesterone. Lack of withdrawal bleed can result from an atrophic endometrium. Exclude pregnancy if peri-menopausal. Ensure compliance.

35
Q

Management of new vaginal bleeding for established Hrt user previously amenorrhoeic on continuous HRT or previously regular cyclical bleeds if on sequential?

A

Vaginal bleeding of new onset while established on HRT, or persistent vaginal bleeding needs USS and possibly EB/hysteroscopy.
Can try 6/52 off HRT - if stops not likely to be pathological.

36
Q

management of irregular or heavy bleeding on continuous combined hrt (pathology exlcuded)?

A

HRT/Try increasing the progestin/Consider IUS plus transdermal or oral oestrogen/Try tibolone

37
Q

% risk of endometrial hyperplasia with sequential combined HRT?

A

2.5-5%

38
Q

% risk of endometrial hyperplasia with combined continuous HRT?

A

1%

39
Q

Cut off on sequential combined HRT endometrium thickness on USS to Ix?

A

As on HRT technically not reliable but <8mm is less likely to be pathological.

40
Q

Cut of on continuous combined HRT endometrium thickness?

A

As on HRT technically there isn’t one but <5mm is unlikely to be pathological.

41
Q

Management of early progestin phase bleeding on sequential combined HRT?

A

Increase progestin (days or dose or change progestin type or IUS)

42
Q

Causes of lack of withdrawal bleed on sequential combined HRT?

A

Pregnancy, atrophic endometrium

43
Q

Management of late phase spotting on sequential combined HRT?

A

Increase progestin or increase oestrogen dose (stabilise endometrium)

44
Q

Management of bleeding on continuous combined HRT (pathology excluded)?

A

Change progestin type, increase progestin dose, try tibolone, revert back to sequential

45
Q

If risk factors for endometrial cancer and <6/12 HRT use what change to management of unscheduled bleeding?

A

Lower threshold for hysteroscopy and pippelle.

46
Q

Monitoring of bone health in menopause?

A

FRAX score – low risk r/v 5 years, intermediate risk DEXA, high risk treatment (alendronic acid, calcium/Vit D, consider tibolone if not on HRT)

47
Q

Osteopenia cut of on DEXA T score?

A

-1 to -2.5

48
Q

Osteoporosis cut off on DEXA T score?

A

> -2.5

49
Q

Non hormonal treatments for menopausal sx?

A 
SSRI/SNRI 10-65% reduction. 
Clonidine 40-40% reduction (not in hypertension)
Gabapentin 40-70% reduction, 
CBT, lifestyle, 
phytoestrogens, 
red clover black cohosh
50
Q

Testosterone therapy in menopause – interactions?

A

Insulin (increased sensitivity)

anticoagulants (more INR monitoring required)

glucocorticoids (oedema risk)

51
Q

Monitoring of testosterone in menopause ?

A

Testosterone indicated if symptomatic and T=<1.4 or FAI <1% (although arbitrary no guideline figure and non linear relationship between libido and T levels)

Baseline testosterone levels, 6-8/52 and then 6/12.
The annually if levels stable (possibly stop if 2 x stable).
Aim T <2.0 or FAI <5%.

If high/low 6-8/52 change dose abs repeat in 6-8/52.
Free androgen index can be more useful that testosterone.

52
Q

Contraindications to testosterone therapy in menopause?

A

CVD

liver tumours

allergy

breast cancer

53
Q

Risk of ovarian cancer with HRT?

A

0.1%

54
Q

Risk of breast cancer with combined hrt?

A

4/1000 additional cases (15/1000 = baseline) if on combined, no additional cases if on oestrogen only

55
Q

VTE risk of transdermal HRT?

A

No increased risk (OR = 0.93)

56
Q

VTE risk of oral HRT?

A

X2 (OR with MPA 2.10, 1.18 with dydesterone)

57
Q

CVD risk of HRT if started <10 years since LMP?

A

No increased risk.

58
Q

First line HRT with no contraindications and uterus?

A

Combined oral

59
Q

Does topical vaginal oestrogen have an age limit?

A

No, 365 days of topical local is equivalent to 1 day of systemic HRT.

60
Q

Risk of breast cancer with oestrogen only hrt?

A

4 LESS/1000

61
Q

Drinking >2 units alcohol/day does what to breast cancer risk?

A

5/1000 more

62
Q

BMI >30 does what to breast cancer risk?

A

24/1000 more

63
Q

smoking does what to breast cancer risk?

A

3/1000 more

MFSRH 2021 (13 decks)

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