Menopause Flashcards
What is the menopause?
permanent cessation of menstrauation resulting from loss of ovarian follicular activity
Median age of 51
natural menopause is recognised to have occurred after 12 consecutive months of amenorrhoea
What is the perimenoapause?
includes the time beginning with the first features of the approaching menopause and ends 12 months after the last menstrual period
What is premature menopause?
arbitrarily defined as menopause occurring <40yrs some will be surgical following bilateral oophorectomy other causes include o Infection o Autoimmune disorders o Chemotherapy o Ovarian dysgenesis o Metabolic disease
What are the causes of postmenopausal bleeding?
• 20% of cases are carcinoma of the endometrium/cervix or premalignant endometrial hyperplasia with cytological atypia
purulent blood-stained discharge should be investigated to rule out endometrial CA or a diverticular abscess draining via vagina
• Withdrawal bleeds occur with sequential menopausal HRT
poorly oestrogenised vaginal wall (atrophic vaginitis)
What are the investigations for postmenopausal bleeding?
bimanual & speculum examination and a cervical smear if one has not been taken
• Transvaginal sonography (TVS) is a routine procedure for initial assessment, as it measure endometrial thickness and gives information of other pelvic pathology (fibroids and ovarian cysts)
less invasive than endometrial biopsy or hysteroscopy, but does not give a hisological diagnosis
What does a thickened endometrium show?
indicates an increased risk of malignancy or other pathology (hyperplasia or polyps)
if endometrium <4mm and only one episode of PBM then endometrial biopsy ± hysteroscopy are not required
if thicker than 4mm or multiple episodes of PBM then an endometrial biopsy ± hysteroscopy must be performed
What is the process for an endometrial biopsy?
- Procedure can be done as an outpatient under local anaesthetic or as a day case under general anaesthetic
- Once malignancy is excluded- topical oestrogen or oral ospemifene (SERM) can be used to treat atrophic vaginitis
What are the vasomotor symptoms of the menopause?
• Hot flushes and night sweats are the most common symptoms
• Night sweats can cause sleep disturbance leading to tiredness and irritability
may begin before periods stop
usually present for <5yrs, but some can continue into 60s & 70s
What are the urogenital problems of the menopause?
• Oestrogen deficiency can cause vaginal atrophy and urinary problems
• Vaginal atrophy can also affect women on systemic HRT
can be extremely uncomfortable and result in dyspareunia, cessation of sexual activity, itching, burning and dryness
What are the urinary symptoms of the menopause?
o Frequency o Urgency o Nocturia o Incontinence o Recurrent infection
What are the sexual problems associated with menopause?
interest in sex declines in both sexes with increasing age, but is more pronounced in women o Loss of sexual desire o Loss of sexual arousal o Problems with orgasm o Sexual pain
How are bones affected by the menopause?
with 1 in 3 women >50yrs having one or more osteoporotic fracture
o Bone density is expressed as grams of mineral/area or volume- determined by peak bone mass and amount of bone loss
o Bone quality refers to architecture, turnover, damage accumulation and mineralisation
• Fractures are the clinical consequence of osteoporosis
most common sites are wrist (Colles’ fracture), hip or spine
How are FSH levels affected by the menopause?
- FSH levels estimate the degree of ovarian reserve remaining, increased levels suggest fewer oocytes
- Levels are helpful with suspected premature ovarian failure, but in women >45yrs who have hot flushes the diagnosis is often clear
- Limited value in perimenopause as levels vary daily
- If taken in a women who has not had a hysterectomy- they are best taken between days 2-5 of the cycle to avoid mid-cycle preovulatory increase and luteal phase suppression of FSH
- In women who have had a hysterectomy or with oligomenorrhoea/amenorrhoea- two samples, 2 weeks apart are obtained
What are anti-mullerian hormone?
- AMH gives a direct measure of ovarian reserve- low levels are consistent with ovarian failure
- AMH levels are stable throughout menstrual cycle -can be measured on any day
- Its interpretation in predicting menopause age needs to make in a clinical context
What are the other blood tests for the menopause?
- Thyroid function tests- free T4 & TSH are checked if there is an inadequate symptomatic response to MHT, thyroid disease can cause hot flushes
- Catecholamines and 5-HIAA- raised in phaechromocytoma and carcinoid syndrome, can also be measured in these circumstances
- LH, oestrogen & progesterone- oestrogen is naturally low early in the menstrual cycle in women with normal ovarian function, a low progesterone level indicates anovulation
