Menopause Flashcards
Define menopause.
A biological stage in a woman’s life that occurs when she stops menstruating and reaches the end of her natural reproductive life.
Usually it is defined as having occurred when a woman has not had a period for 12 consecutive months.
The changes associated with menopause occur when the ovaries stop maturing eggs and secreting oestrogen and progesterone
Define perimenopause.
The time in which a woman has irregular cycles of ovulation and menstruation leading up to menopause and continuing until 12 months after her final period. The perimenopause is also known as the menopausal transition or climacteric
Define urogenital atrophy.
Thinning and shrinking of the tissues of the vulva, vagina, urethra and bladder caused by oestrogen deficiency –> vaginal dryness, vaginal irritation, a frequent need to urinate and UTIs.
Define vasomotor symptoms.
Menopausal symptoms such as hot flushes and night sweats caused by constriction and dilatation of blood vessels in the skin that can lead to a sudden increase in blood flow to allow heat loss. These symptoms can have a major impact on ADLs
What is the average age of menopause in the UK?
51 years
What are the main two complications associated with prolonged lack of oestrogen in women?
Osteoporosis
Cardiovascular disease
When can you diagnose menopause without laboratory tests?
In otherwise healthy women aged over 45 years with menopausal symptoms:
- based on vasomotor symptoms and irregular periods (perimenopause)
- no period for at least 12 months and are not using hormonal contraception (menopause)
- symptoms in women without a uterus (menopause)
When should you consider using FSH to diagnose menopause?
- in women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle
- in women aged under 40 years in whom menopause is suspected
What are the symptoms of menopause?
- vasomotor symptoms (e.g. hot flushes and sweats)
- musculoskeletal symptoms (e.g. joint and muscle pain)
- effects on mood (e.g. low mood)
- urogenital symptoms (e.g. vaginal dryness)
- sexual difficulties (e.g. low sexual desire)
How long do menopausal symptoms usually last?
- 80% experience symptoms
- Most last 4 years
- In 10% they last up to 12 years
What three categories of treatment are available for menopausal symptoms?
- hormonal, for example hormone replacement therapy (HRT)
- non-hormonal, for example clonidine
- non-pharmaceutical, for example cognitive behavioural therapy (CBT).
Which lifestyle modifications can be used to manage menopausal symptoms?
- Hot flushes - regular exercise, weight loss and reduce stress
- Sleep disturbance - avoiding late evening exercise and maintaining good sleep hygiene
- Mood - sleep, regular exercise and relaxation
- Cognitive symptoms - regular exercise and good sleep hygiene
What is the main management of vasomotor symptoms in menopause?
HRT -primary indications is treatment of flushing, insomnia and headaches*
- oestrogen and progestogen to women with a uterus
- oestrogen alone to women without a uterus
*other indications such as reversal fo vaginal atrophy should be treated with other therapies first-line
What is the main management of premature menopause?
HRT continued until age 50 years - TO PREVENT OSTEOPOROSIS is the primary inication, unline in menopause where vasomotor symptoms are the primary indication
What are the routes of HRT? When is a specific route indicated?
HRT can be taken orally or transdermally* (via a patch or gel)
*transdermal is preferred if the woman is at risk of VTE, as the rates of VTE do not appear to rise with transdermal preparations. Also preferred if BMI >30kg/m2.
What are the principles of the HRT treatment combination?
HRT generally consists of an oestrogenic compound, which replaces the diminished levels that occur in the perimenopausal period. This is normally combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer.
What types of hormone are included in HRT?
oestrogens - ‘natural’ such as estradiol, estrone and conjugated oestrogens are used rather than synthetic such as ethinylestradiol (which is used in the COCP)
progestogens - ‘synthetic’ such as medroxyprogesterone, norethisterone, levonorgestrel, and drospirenone are usually used; a levonorgestrel-releasing IUS may be used as the progestogen component of HRT
tibolone - synthetic compound with both oestrogenic, progestogenic, and androgenic activity
What is tibolone (sometimes used in HRT)?
Synthetic compound with both oestrogenic, progestogenic, and androgenic activity
What is the major risk associated with unopposed oestrogen use?
Endometrial cancer
What are the common side effects of HRT use?
- nausea
- breast tenderness
- fluid retention and weight gain
What are the complications of HRT use?
-
breast cancer
- risk increased by the progestogen
- x1.26 risk at 5 years which relates to the duration of use
- risk declines when HRT is stopped and reaches normal level by 5 years
-
endometrial cancer
- unopposed oestrogen - should not be given as HRT to women with a womb
- reduced by the addition of a progestogen but not eliminated
-
VTE
- risk increased by the progestogen
- transdermal HRT does not increase risk of VTE - but if high risk for VTE, refer to haematology before starting any HRT
- stroke - oral only
- ischaemic heart disease - if taken more than 10 years after menopause
What is the main management of psychological symptoms of menopause?
- Consider HRT
- Consider CBT to alleciate low mood or anxiety
NO evidence for SSRIs or SNRIs
What is the main management of altered sexual function symptoms in menopause?
Testosterone supplementation if HRT alone not effective
What is the main management of urogenital atrophy in menopause?
- Vaginal oestrogen (even if on HRT) - as long as needed, adverse effects uncommon
- +/- moisturisers and lubricants
If failed:
- Increase dose of vaginal oestrogen
- Referral to specialist
