Menopause Flashcards

1
Q

Define menopause.

A

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

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2
Q

Define perimenopause.

A

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

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3
Q

Define urogenital atrophy.

A

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.

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4
Q

Define vasomotor symptoms.

A

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

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5
Q

What is the average age of menopause in the UK?

A

51 years

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6
Q

What are the main two complications associated with prolonged lack of oestrogen in women?

A

Osteoporosis

Cardiovascular disease

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7
Q

When can you diagnose menopause without laboratory tests?

A

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)
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8
Q

When should you consider using FSH to diagnose menopause?

A
  • 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
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9
Q

What are the symptoms of menopause?

A
  • 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)
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10
Q

How long do menopausal symptoms usually last?

A
  • 80% experience symptoms
  • Most last 4 years
  • In 10% they last up to 12 years
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11
Q

What three categories of treatment are available for menopausal symptoms?

A
  • hormonal, for example hormone replacement therapy (HRT)
  • non-hormonal, for example clonidine
  • non-pharmaceutical, for example cognitive behavioural therapy (CBT).
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12
Q

Which lifestyle modifications can be used to manage menopausal symptoms?

A
  • 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
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13
Q

What is the main management of vasomotor symptoms in menopause?

A

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

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14
Q

What is the main management of premature menopause?

A

HRT continued until age 50 years - TO PREVENT OSTEOPOROSIS is the primary inication, unline in menopause where vasomotor symptoms are the primary indication

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15
Q

What are the routes of HRT? When is a specific route indicated?

A

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.

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16
Q

What are the principles of the HRT treatment combination?

A

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.

17
Q

What types of hormone are included in HRT?

A

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

18
Q

What is tibolone (sometimes used in HRT)?

A

Synthetic compound with both oestrogenic, progestogenic, and androgenic activity

19
Q

What is the major risk associated with unopposed oestrogen use?

A

Endometrial cancer

20
Q

What are the common side effects of HRT use?

A
  • nausea
  • breast tenderness
  • fluid retention and weight gain
21
Q

What are the complications of HRT use?

A
  • 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
22
Q

What is the main management of psychological symptoms of menopause?

A
  • Consider HRT
  • Consider CBT to alleciate low mood or anxiety

NO evidence for SSRIs or SNRIs

23
Q

What is the main management of altered sexual function symptoms in menopause?

A

Testosterone supplementation if HRT alone not effective

24
Q

What is the main management of urogenital atrophy in menopause?

A
  • 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
25
Q

When should you review any treatment for menopause?

A

After 3 months

26
Q

How do you manage vaginal bleeding on HRT?

A

Unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment

But is abnormal if it occurs after the first 3 months of treatment

27
Q

Can HRT be suddenly stopped?

A

Yes - although gradual reduction may limit recurrence of symptoms in the short term, no effect on long term symptoms

28
Q

Does HRT have an effect on blood glucose?

A

No and no association with T2DM

29
Q

What are the contraindications for HRT use?

A
  • Current or past breast cancer
  • Any oestrogen-sensitive cancer
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
30
Q

What is premature ovarian insufficiency?

A

Menopause symptoms and elevated gonadotrophin levels ocurring before the age of 40 years

31
Q

How is premature ovarian insufficiency diagnosed?

A

Diagnose premature ovarian insufficiency in women aged under 40 years based on:

  • menopausal symptoms, including no or infrequent periods (taking into account whether the woman has a uterus) AND
  • elevated FSH levels on 2 blood samples taken 4–6 weeks apart.
32
Q

What are the laboratory findings in premature ovarian insufficiency?

A

raised FSH, LH levels e.g. FSH > 40 iu/l; should be demonstrated on 2 samples taken 4–6 weeks apart

low oestradiol e.g. < 100 pmol/l

33
Q

How common is premature ovarian insufficiency?

A

1 in 100 women affected

34
Q

What is the management of premature ovarian insufficiency? When is treatment contra-indicated?

A
  • HRT
  • or COCP

Continued until at least the age of natural menopause.

Contraindication: e.g. hormone-sensitive cancer

35
Q

What are the causes of premature menopause?

A
  • idiopathic - most common; there may be FH
  • bilateral oophorectomy - having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
  • radiotherapy
  • chemotherapy
  • infection: e.g. mumps
  • autoimmune disorders
  • resistant ovary syndrome: due to FSH receptor abnormalities
36
Q

What are the symptoms of premature ovarian insufficiency?

A

Similar to those of normal climacteric but presenting problem may differ.

  • climacteric symptoms: hot flushes, night sweats
  • infertility
  • secondary amenorrhoea
37
Q

Does HRT use provide contraception?

A

No - tell the patients this in case spontaneous ovarian activity resumes

38
Q

What alternative medicines may some patients be using for relief of vasomotor symptoms and what are their risks?

A
  1. Black cohosh
  2. Isoflavones
  3. St John’s wort

These may relieve symptoms but risks include:

  • multiple preparations available and safety is uncertain
  • preparations may vary
  • interaction with other medicines may occur