Menopause Flashcards
What are the 4 endogenous estrogens?
E1 - estrone - predominates in menopause
-> made in peripheral tissues
E2 - estradiol - predominates in reproductive years
-> made in granulosa cells of the ovary
E3 - estriol - predominates during pregnancy
-> made by placenta
E4 - estetrol - produced only during pregnancy
In a patient with an implant that has been in situ for 3.5y, how would you manage a patient requesting insertion of LNG-IUS?
PT - if negative, replace and advise 7 days additional precautions
When would an FSH measurement be indicated when managing menopause?
If under 40y when signs of menopause - 6 weeks apart
Consider if <45y with amenorrhea and signs of menopause
If >50 y on POC who which to know whether they can stop contraception or not
What are the differential diagnoses for hot flushes and what tests would you do to rule them out if necessary?
Thyroid disease - TSH
Phaeochromocytoma - catecholamines
Carcinoid - 24h urinary 5-hydroxyindoleacetic acid
Why is measuring estradiol levels not recommended when on PO estrogen is used in HRT?
Major circulating metabolite in oral preparations is estrone
Why do you use free androgen index?
Gives guide to the level of free testosterone (2/3 bound to SHBG, 1/3 bound to albumin) only 2% is free and metabolically active
How do you calculated free androgen index?
FAI = 100 x (total testosterone / SHBG)
What does QRISK2 indicate?
Risk of having MI or stroke in the next 10y
How often is cervical screening indicated?
25-50y - every 3y
50-64y - every 5y
How often is breast screening undertaken?
50-71y - every 3y
>71y - can request every 3y
What is the cardiovascular timing hypothesis?
Window of opportuniy for prevention of CV disease if HRT is initiated before the age of 60. HRT commenced <10y from onset of menopause is associated with lower risk of CV disease
What is the background risk of breast cancer in menopausal aged women?
23/1000 cases
How would you counsel a patient regarding the increased risk of breast cancer?
Increased risk in combined HRT group
Increased risk emerges 3y after exposure
3 extra cases of breast cancer per 1000 women
5 y following cessation, background risk returns
How is osteoporosis diagnosed?
BMD assessment via DXA scan
osteoporosis is BMD > 2.SD below mean BMD for young adult population
What is the prevalence of POI?
1%
What blood tests are indicated in POI?
2 FSH measurements 6-8 weeks apart >30
By how much can fibroids expect to decrease in size during menopause?
40%
How would you counsel a patient regarding the effect of HRT on her pre-existing fibroids
May cause enlargement of existing fibroids but will not cause new ones to develop
What effect does HRT have on on hypertension?
No evidence that estradiol-based HRT has an adverse effect on existing HTN
How much does combined HRT increase the risk of VTE?
RR = 2 with oral preparations
No increased risk with transdermal preparations
What are contraindications to HRT?
Current or past breast cancer
Other types of estrogen dependent cancer
Untreated endometrial hyperplasia
Active liver disease
What are the 3 main groups of drugs used to help manage troublesome menopausal symptoms in cases where HRT is contraindicated?
A- blocker - clonidine
SSRIs/SNRIs
Neuropathic pain killers / antiepileptics
What are the side effects of clonidine?
dry mouth, sedation, dizziness, nausea, nocturnal restlessness
What are the first line SSRI/SNRIs used in menopause in women without a past medical of breast cancer?
Paroxetine
Sertraline
Fluoxetine
