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Womens health > Menopause > Flashcards

Menopause Flashcards

1
Q

Premature menopause

A

Onset of amenorrhea (>4mo) due to follicular insufficiency before the age of 40 with high FSH on 2 occasions 1mo apart and low oestradiol

Causes: surgical, radiation to ovaries, fragile X carrier, turner’s syndrome (streak ovaries), autoimmune: thyroid, T1D, pernicious anaemia

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2
Q

Premature menopause SX + Diagnostic criteria

A

can be the same as menopause: vaginal dryness, hot flushes, sleep disturbances, aching joints
amenorrhea or infertility
mood: anxiety, depression, confusion, feeling sad

DX
- exclusion of amenorrhea differentials
- >4mo w/o periods
- FSH in menopausal range on 2 occasions 1 mo apart (usually 4-6wk apart)

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3
Q

MX of Premature menopause

A

HRT
- Estrogen tablets, patches, gels, topical MX if patient has has a hysterectomy
- COCP if no CI
- manage health risks
- manage infertility

Long term CX
- infertility
- CVD
- osteoporosis
- psychological distress
- memory and learning difficulties

Progesterone withdrawal test (Monash Q)
- Secondary amenorrhea
PT given Progesterone for 10d -> determine if bleeding on P withdrawal
If the bleed -> they still have E but are not ovulating (anovulation is the cause of secondary amenorrhea)
Nil bleeding: no or low E or anatomic outflow issue. Very low E in premature menopause: PT will not have withdrawal bleeding.

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4
Q

MX of Premature menopause

A

HRT
- Estrogen tablets, patches, gels, topical MX if patient has has a hysterectomy
- COCP if no CI
- manage health risks
- manage infertility

Long term CX
- infertility
- CVD
- osteoporosis
- psychological distress
- memory and learning difficulties

Progesterone withdrawal test (Monash Q)
- Secondary amenorrhea
- PT given Progesterone for 10days -> determine if bleeding on P withdrawal

Bleeding -> still have E but are not ovulating -> anovulation is the cause of secondary amenorrhea

No bleeding -> no or low E or anatomical outflow issue. In premature menopause PT has v low E -> no withdrawal bleeding (secondary amenorrhea)

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5
Q

Menopause Definition

A

defined as 12mo after last menstrual period
happens between 48-55y
diagnosed by signs not bloods

Perimenopause: transition to the end of women’s reproductive life. Will have menopausal signs but less than 12mo since irregular bleeding onset

Premature menopause: use COCP rather than HRT
AKA Premature ovarian insufficiency: premature menopause often assoc w genetic predisposition, chemo, trauma or autoimmune disease

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6
Q

Menopause signs

A

Menstrual changes: lengthening/irregular cycles, heavier or lighter periods, IMB
Vasomotor : hot flushes (can last 4 to 8 years)
Psycho/cognitive: anxiety, depression, insomnia, difficulty concentrating, memory issues
Post menopause: Urogenital atrophy: vaginal dryness, dyspareunia, vulval itch, PMB, ulceration, vaginal infections, incontinence, recurrent UTIs
CX
- CV risk: impaired GTT, increased BP, increased deposition of abdominal fat
- Osteoporosis/osteopenia -> increased Rx of fractures

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7
Q

Menopause IX

A

FHS/oestradiol rarely needed. No value in women on systemic hormonal contraception
P/LH/AMH levels are of no diagnostic value

General Health
CST, MMG, lipid, fasting BSL, TSH, renal and liver function, FBE, ferritin, FOBT, vitamin D at women at risk, DEXA scan for those at risk of OP and fracture

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8
Q

Menopause MX

A

Optimise health and lifestyle factors
Stress reduction, regular exercise, optimal weight mx, diet, avoid smokes, reduce excessive ETOH and caffeine

Localised urogenital signs
○ Exclude dermatological or infective signs
○ Vaginal therapy: moisturises, lubricants, estrogen creams, hormonal MX

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9
Q

management of Mod to Severe SX of menopause

A

E + P if they have uterus
E if no uterus (Estrogen improved Sx but progesterone counter balances the estrogen to prevent endometrial hyperplasia & adenocarcinoma)

methods of delivering E: oral, trans-dermal, topical
P methods: oral, implanon, mirena

Perimenopausal: cyclical (w withdrawal bleed) or continuous (e.g., if using mirena)
Post menopausal: continuous

Benefits
- MX of hot flushes -> sleep improvements and psychosocial settings
- Less RX of hip and vertebral fractures
- Reduction in ovarian, endometrial and CRC
ADRS
- DVT
- RX of BCA (0.45%)

After 6-8w no effect -> change dose or TX
Safest in younger patient. Start late 40s and early 50s
Transdermal estrogen is the safer.

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10
Q

CI to systemic HRT

A

Over 60yo, or >10yrs since menopause

Previous DVT, stroke, AMI
Uncontrolled HTN
HX of BCA or Endometrial CA that is E sensitive
Familial BCA
CLD
SLE

Abnormal menstrual bleedings should be Ix prior to initiation of HRT

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11
Q

Contraception in menopause

A

Contraception should be offered to all women under 50 until 2yrs post LMP

for women over 50 for 1yr post LMP (can use COCP and transition to HRT after cessation of fertility)

HRT is not a contraceptive

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12
Q

Migraine with Aura

A

Migraine without aura linked to changes in reproductive hormones - particularly fall in estrogen
Migraines with aura linked with increases in estrogen
Not a CI to HRT, transdermal recommended. Continuous rather than cyclical may be best

Mig + Aura is contraindication to COCP!

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13
Q

MX of Genitourinary signs in menopause

A

Common but under treated
Topical vaginal estrogen = very effective & low risk
Lubricants
Sexual medicine referral

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14
Q

HRT counselling

A

KEY POINTS
Address non-pharm Mx for each of: central Sx, urogenital atrophy, bone loss & CVD Rx
Consider DDx of hot flushes e.g., thyroid disease

Early ADRs after starting HRT: breast tenderness, N, headaches

BENEFITS
CVS protective if <60 (improved lipid profile, insulin resistance, BP & obesity)
Prevents bone loss
Mx hot flushes & urogenital atrophy
Protects against endometrial, ovarian & colorectal cancers

Rx
Thromboembolism
Breast Ca
Gallstones
Stroke

ABSOLUTE CI
UnDx PV bleeding
Age >60yo or >10yrs since menopause
Hx E dep Ca (endometrial or breast)
HX of Stroke, AMI
Thromboembolic disease
Active DVT

RELATIVE CI
Strong FHx breast Ca
Hx of thromboembolism

Contra to Oral E (have transdermal or patch)
- Risk of VTE (obesity, smoking, thrombophillia)
- Risk of CVD: DM, HTN, smoking
- Elevated TAGs
- Liver disease
- Gall bladder disease

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15
Q

COCP indication

A

premature menopause till 50

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16
Q

continuous combined hormonal replacement therapy

A

with uterus or uterine tissue (endometriosis)

Oral, transdermal, topical E
oral, implanon, mirena P

17
Q

cyclical combine oral HRT

A

menopausal transition with irregular spontaneous bleeding or very recently menopausal
can cause withdrawal bleeding

same methods as before

Always on E, but cyclical P -> withdrawal bleeding

18
Q

Estrogen only

A

no uterus or uterine tissue

post hysterectomy, severe VMS -> E only TX

19
Q

Tibolone (synthetic steroid with estrogen, progestogenic and weak androgenic affects, non PBS)

A

women >12mo since menopause for VMS and UG sx
effective against bone loss and low libido

causes bleeding if used prior to 12mo post menopause
also used in mastalgia

20
Q

Bazedonxifene (SERM combine with E)

A

to prevent OP and manage MX menopausal SX without P use in person with a uterus
estrogenic effects on bone. no effect on uterus

21
Q

Testosterone

A

Post menopausal women with hypoactive sexual desire

22
Q

Venlafaxine (SNRI)

A

for hot flushes and VMS symptoms. improves sleep
can cause N, constipation, sexual dysfunction

23
Q

Clonidine

A

Alpha 2 R inverse agonist. overall antagonist action

Dry mouth, constipation

24
Q

Perimenopause

A

Transition to the end of a women’s reproductive life presenting with menopausal signs and <12mo of irregular bleeding onset

25
Q

Perimenopause MX

A
  • E and P COCP
    ○ Controlling PMS, bleeding, Mastalgia
    ○ Relief from VMS, cycle control, prevents bone loss
    ○ Rx must be assessed, including smoking status, blood pressure, lipid profile, VTE Rx
    • Oral estrogen and levonorgestrel IUD
      ○ Eliminates bleeding but not cyclic symptoms
      ○ Can protect endometrium from estrogen
    • Continuous estrogen and cyclical progesterone
      ○ May suit some women
    • Cyclical (sequential) MHT may be initiated during the peri-menopause for alleviation of VMS however it is not a contraceptive & will not regulate menstrual cycles
26
Q

Perimenopause MX of bleeding

A
  • TXA
    • Mirena to thin lining
      ○ Protective against endometrial cancer
      ○ Can reverse precancerous changes
      ○ Take BX while under GA
      ○ Still go through menopause normally
    • Ablation (surgical)
      ○ Must be no cancerous changes (will mask progression)
      ○ If precancerous changes -> hysterectomy
    • Hysterectomy
27
Q

Endometrial hyperplasia

A

Non dysplastic overgrowth of the endometrium this is not malignant but can predispose to precancerous state. Usually due to unopposed estrogen action
Dysplasia = abnormal cell type = polyp

RX (same as endometrial cancer)
- Nulliparous
- Prolonged estrogen (early menarche, late menopause)
- Unopposed estrogen therapy
- Tamoxifen
- Obesity
- FHX of endometrial and colonic cancer
- PCOS

- Normal is less than 5mm in post menopausal women who present with PV bleeding 
- Normal is 8 to 11mm in post menopausal women who do not have a HX of bleeding ?
28
Q

endometrial hyperplasia management

A

MX
- Manage RX factors where possible (weight, smoking)
- 1st line Mirena (progesterone) + repeat D+C in 3-6mo to ensure effective MX
○ Can also use continuous oral progesterone
○ Hysterectomy + BSO
- Regular 6-12 surveillance (endometrial BX)

RX counselling
- The risk of endometrial hyperplasia without atypical progressing to endometrial Ca is less than 5% over 20 years
- The majority of cases of endometrial hyperplasia will regress spontaneously during follow up

- Simple or complex -> <5% RX of CA
- Atypical -> Rx of Ca 30%
29
Q

endometrial cancer

A

most common GYN cancer
mostly in post menopausal women

Adenocarcinoma: most common type (90%)
Endometrioid (90%) - estrogen dependent, better prognosis
E -> hyperplasia -> AUB -> caught earlier
Serous papillary (10%) - worse prognosis
Stromal carcinoma

RFs for endometrial hyperplasia & Ca
○ >35yo
○ Prolonged estrogen exposure (early menarche, nulliparous, late menopause, obesity)
○ PMHx: DM, PCOS, gallbladder disease or thyroid disease
○ Obesity
○ FHx (ovarian, colon or uterine Ca) - lynch syndrome
○ Medications: tamoxifen (the cumulative risk of endometrial cancer w tamoxifen use is 1.6% at five years and 3.1% if used for 5-14yrs)

30
Q

endometrial cancer Signs

A

PMB, watery d/c, abnormal menses in perimenopausal women, pain not common

fatigue, night sweats, weight loss, anemia due to AUB

31
Q

endometrial cancer IX

A

Premenopausal women -> Biopsy (TVUS not of use as they are undergoing menstrual cycle with endometrial proliferation.

Bimanual -> uterine mass
CST -> R/O cervical malignancy
FBE + Iron studies -> Anemia

Postmenopausal women -> TVUS -> thickened endometrium >4mm on women not on HRT

MRI for detecting level of myometrial involvement to inform on prognosis once cancer is diagnosed

Pipelle biopsy -> very sensitive but need >50% of endometrium to be effected.

D+C w biopsy -> detects smaller lesions, better in obese women, better in patients with Lynch

32
Q

PMB DDX

A

menopausal hormone therapy -> normal to have spotting 3-6mo after starting. beyond this -> IX

Atrophic vaginal changes (atrophic vaginitis or atrophic endometritis) -> DX on speculum via presence of thin, friable vaginal wall +/- bleeding

Trauma

Infection

Endometrial/cervical polyps

Cervical carcinoma

Vaginal carcinoma

33
Q

Endometrial cancer MX

A

Hyperplasia without atypia
Educate
weight loss
cease estrogens
failure to regress -> progestin therapy (mirena, oral P)
F/U with 2 biopsies 6mo

Endometrial adenocarcinoma or EIN -> Total hysterectomy and bilateral salpingo-oophorectomy
- ideal for any stage as most women will be post menopausal

BRACA1/2 or Lynch -> Prophylactic total hysterectomy and bilateral salpingo-oophorectomy

prognosis mostly depends on myometrial invasion

Surgical: hysterectomy* & bilateral salpingo oophorectomy + LN dissection (for staging 7 to exclude nodal disease)
Adjuvant chemo & radiotherapy will depend on the grade & stage of the cancer (typically required if LN are positive)
Medical (if patient isn’t fit for surgery or wants to maintain fertility) Mirena , Progesterone

types of hysterectomy
- Subtotal: uterus only
- Total: uterus & cervix
- Radical: uterus, cervix & parametrium (common in cervical ca)

34
Q

Vulvo-vaginal atrophy

A

includes conditions of the vagina, vulva, pelvic floor tissues, urinary tract, sexual dysfunction & loss of libido caused by hypoestrogenism.

Signs result from declining estrogen levels
Investigate PMB and malodourous DC
Changes in vaginal and urethral health occur with natural and surgical menopause

35
Q

Vulvovaginal atrophy SX

A
  • Genitourinary syndrome of menopause
    ○ Dryness, irritation, itching, dyspareunia, recurrent UTIs, sexual dysfunction and loss of libido
    • Vaginitis -> light bleeding
    • Persistent malodourous discharge (commonly mistaken for thrush)
    • 50% of post menopausal women
      • Worsens over time

DDX
- Dermatological condition (lichen sclerosus, eczema, dermatitis, chronic vulvovaginitis)
- Vulvodynia, vaginismus
- Malignancy
- Infection
- Chronic pelvic pain
- Diabetes
- Lupus

36
Q

Vulvovaginal atrophy AKA genitourinary syndrome

A

Management
- Reassure that it is common
- Lifestyle: cotton underwear, no undies whist sleeping, avoid tight fitting clothing, limit time in damp sweaty clothing, avoid fabric softeners and scented feminine hygiene products, stop smoking
- Vaginal lube for sex
- Pelvic floor exercises
- Medications
○ Vaginal oestrogen (ADRs Mastalgia, vaginal bleeding)
○ Systemic MHT
○ Tibolone

37
Q

Endometrial cancer staging

A

Stage 1 -> endometrium
Stage 2 -> cervical os or myometrium
Stage 3 -> vagina, perimetrium, LNs
Stage 4 -> rectum/bladder or elsewhere

Womens health (8 decks)

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