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OBGYN > Menopause > Flashcards

Menopause Flashcards

1
Q

What is the menopause?

A

Permanent cessation of menstruation due to loss of ovarian follicular activity

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2
Q

When is a woman said to be in menopause?

A

12 months after FMP

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3
Q

What is the median age of menopause?

A

51

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4
Q

What is perimenopause?

A

From beginning of menopausal symptoms to 12 months after the final menstrual period

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5
Q

What is post-menopause?

A

From FMP (cannot be determined for 12 months)

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6
Q

What are the 3 types of unnatural menopause?

A
  • premature menopause (1%)
  • post oophrectomy
  • post chemo or radio-therapy
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7
Q

What is premature menopause?

A

Menopause before 40yrs

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8
Q

What causes premature menopause?

A

Often no cause for premautre ovarian failure

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9
Q

What are some other causes of un-natural menopause? (4)

A

Infections

Autoimmune disorders
- schmidt’s – addison’s, hashimotos, hypoparathyroidism, gonadal failure

Ovarian dysgenesis

Resistant ovary syndrome

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10
Q

How is premature ovarian insufficiency managed?

A

HRT or COCP until the age of the natural menopause

HRT may have beneficial effect on BP compared with COCP

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11
Q

What is the physiology of natural perimenopasue?

A

Perimenopause: irregular menses (unpredictable ovarian function means that cycles can vary in length and be heavy)

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12
Q

What is the physiology of natural post menopause?

A

Post menopause: oestrogen falls as granulosa cells no longer produce oestradiol

-> loss of negative feedback -> raised FSH and LH

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13
Q

What is the physiology of natural menopause?

A

Supply of responsive oocytes is exhausted
(born with millions – about 400 ovulations
20-30 primordial follicles/cycle ? Add up)

Therefore more lost through aging than through ovulations. That is why menopause is not necessarily related to parity of age of menarche.

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14
Q

How common are menopausal symptoms/effects?

A
  • affect 2/3 women
  • 10-20% describe them as distressing
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15
Q

What are the short term symptoms/effects of menopause? (3)

A
  • irregular or absent menstruation
  • vasomotor
  • psychological
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16
Q

What are the medium term symptoms/effects of menopause?

A
  • urogenital disease
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17
Q

What are the long term symptoms/effects of menopause? (2)

A
  • cardiovascular
  • osteoporosis
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18
Q

What is menopause a protective factor for?

A

Breast disease

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19
Q

What are the short term vasomotor effects of menopause?

A

Hot flush: subjective uncomfortable feeling of
warmth in the upper part of the body
night sweats
? Hypothalamic in origin

 (also musculoskeletal – joint and muscle pain)
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20
Q

How common are the short term vasomotor hot flushes of menopause?

A

75% experience (25% severe)

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21
Q

What is the average duration of the vasomotor hot flushes of menopause?

A

average duration 4-7 yrs, but up to

12 years in 10%.

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22
Q

What are the short term psychological effects of menopause?

A

irritability, low mood, confusion, lethargy
insomnia, memory loss, loss of libido

? Due to oestrogen deficiency ? Other processes

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23
Q

What are the urogenital medium term effects of menopause?

A

Vagina, urethra and trigone are affected by lack of oestrogen and atrophy

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24
Q

How long do the urogenital effects of menopause last?

A

Symptoms years after menopause. Do not diminish with time

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25
Q

What are some of the symptoms of the urogenital effects of menopause?

A
  • Superficial dyspareunia
  • itching
  • burning
  • dryness
  • FUNI
  • recurrent infections
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26
Q

What does the risk of osteoporosis as a long term effect of menopause depend on?

A

Risk depends on peak bone mass and rate of loss

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27
Q

How does menopause increase the risk of osteoporosis?

A

Increase rate of loss after menopause due to decreased osteoblastic activity

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28
Q

How common is osteoporosis after menopause?

A

1 in 3 women over 50 will have an osteoporotic fracture

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29
Q

What is osteoporosis?

A

Bone strength: BMD + bone quality (architecture, turn over, damage accumulation). Osteoporosis is a problem with bone strength that leads to increase risk of fractures

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30
Q

What scan can be done to diagnose osteoporosis?

A

DEXA scan

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31
Q

What score from the DEXA scan means it is osteopenia?

A

T-score = -1 to -2.5

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32
Q

What score from the DEXA scan means it is osteoporosis?

A

T-score = >/= -2.5

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33
Q

How does menopause change the longterm cardiovascular risk?

A

-CVD unusual in women before menopause, but gap closes between men and women by age 60

-? Menopause removes the protective influence of oestrogen (not universally accepted)

-Clustering of obesity, hypertension and dyslipidaemia

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34
Q

How does menopause change the long term effect of breast cancer?

A

-the risk of breast ca increases with age but the rate of increase slows after menopause

-a women who has menopause in her late 50s has x2 the risk of breast ca as one who has menopause in her early 40s.

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35
Q

How does a woman discover if she is menopausal?

A
  • primarily clincial diagnosis
  • biochemical tests
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36
Q

What do the NICE guidelines 2015 say is needed for a clinical diagnosis of menopause?

A

a) ‘Women who have not had a period for at least 12 months and are not on hormonal contraception’

b) Based on symptoms in women without a uterus

37
Q

What biochemical test can be done to aid the diagnosis of menopause?

A

FSH >30 mIU/ml X 2 (weeks apart), are most likely post-menopausal

38
Q

Who is FSH testing not recommended in?

A

Women >45 yrs

39
Q

How does menopause cause high FSH/LH?

A

Unresponsive ovaries produce no oestrogen therefore lack of feedback on hypothalamus-pituitary axis causes high FSH/LH

PICTURE

40
Q

What are other useful bloods for the diagnosis of menopause?

A
  • Anti-mullerian hormone

To out-rule other possible causes of sx and give info on current general health esp if considering starting HRT:
* FBC, TFTs (if not responding to HRT or symptoms), Glucose, Lipids

  • Consider Urinary catecholamines and 5HIA
    (if not responding to HRT)
  • Consider LH, oestradiol, progesterone
41
Q

What is AMH?

A

Produced by ovarian follicles and gives a direct measure of ovarian response

AMH is produced by the granulosa cells and inhibit the recruitment of follicles and decrease responsiveness to FSH.

42
Q

What do low levels of AMH mean?

A

Ovarian failure

43
Q

How do levels of AMH change throughout a cycle?

A

Levels stable throughout cycle

44
Q

When are these blood tests to help diagnose menopause not recommended?

A

NICE not recommended in women >45 yrs

45
Q

What are the DDx for the vasomotor symptoms fo menopause?

A

Pregnancy
Hyperthyroidism
Alcohol
Narcotic withdrawal
Phaeochromocytoma
Carcinoid
Other malignancy
Meds

46
Q

What are the DDx for the abnormal bleeding in menopause?

A

Malignancy
Fibroids
MUST be investigated

47
Q

What are the 2 options for treatment of menopause?

A
  • non HRT
  • HRT
48
Q

What did the women’s health initiative find with regard to HRT?

A

Studied 16,608 women in 40 US centres
Aged 50-67, taking 0.625mg conjugated oestrogen + 2.5mg medroxyprogesterone
Trial stopped after 5.6 years (July 2002)
Findings: increased risk of breast cancer, CHD, CVA and PE

49
Q

What did the WHI - 2017 follow up find?

A

Use of HRT v placebo in postmenopausal women for 5-7 years was not associated with risk of all-cause, cardiovascular or cancer mortality during 18 years of follow-up.

50
Q

What did the million women study find about HRT?

A

Started in UK in 1997
Women aged 50-64
Findings:
2x increased risk of breast cancer with oest/prog
1.3x increased risk of breast cancer with oest
Risk of fracture decreased by 40%
Slight inc risk of ovarian cancer

51
Q

What are general non HRT options to manage menopause?

A

avoid caffeine, alcohol

Increase aerobic exercise

52
Q

What are non HRT options to manage the vasomotor symptoms of menopause? (4)

A

-Progestogens
-Clonidine (limited)
-SSRIs or SNRIs
-Gabapentin

53
Q

What are the non HRT options to manage the urogenital symptoms of menopause?

A

lubricants and moisturisers for vaginal atrophy

54
Q

What are the non HRT options to manage osteoporosis in menopause?

A

-mainly inhibiting bone resorption (except strontium/PTH)

-bisphosphonates, strontium, raloxifene (serm), PTH, Denosumab monoclonal ab – 6/12 injection

-calcium and Vit D3 -? Dangers

55
Q

What are the issues with alternative treatments for menopause?

A

Widely used
Little evidence that they reduce symptoms
Can be concerns regarding production, drug interactions, and oestrogenic side effects

56
Q

What are some of the alternative treatments used for menopause?

A

Phyoestrogens: plant substances similar to oestrogen

isoflavones: soya beans, chickpeas
lignans: oilseeds

Herbal remedies: black cohosh, evening primrose oil, gingko, ginseng, st johns wort

Progesterone transdermal creams

57
Q

What are the NICE guidelines on non HRT vasomotor treatments for menopause?

A

Looked at 32 trials on vasomotor symptoms and performed a meta-analysis

-SSRIs/SNRIs not effective and high discontinuation rates (though have been shown to be effective in other trials)
-Clonidine not commented on as studies reported different outcomes
-Alternatives: St. johns’ wort, isoflavones, black cohosh more effective than placebo but some safety concerns.

58
Q

What do the NICE guidelines suggest about psychological treatments for menopause?

A

Consider CBT to improve mood/anxiety symptoms arising out of menopause
No clear evidence for use of SSRIs or SNRIs in those with menopause associated mood problems, not diagnosed with depression.

59
Q

What are the two hormones involved in HRT regimens?

A

Oestrogen:
-> this is what treats the symptoms/effects
(taken from plants or the urine of
pregnant horses)

Progestogens:
-> if uterus: avoid endometrial hyperplasia
or endometrial ca.

60
Q

What are the two options for administration of progesterone as part of HRT?

A
  • cyclical
  • continuous
61
Q

What are the options of admin of cyclical progesterone as part of HRT?

A

->10-14 days every month (second half of pack) – monthly bleed (if you are having regular periods)

-> 14 days every 13 weeks – 3 monthly bleed
(if you are having irregular periods)

62
Q

Why is continuous admin of progesterone as part of HRT preferred?

A

No bleed. Preferred post-menopausally

(may reduce endometrial ca –v-sequential tx)

63
Q

What needs to be done with regard to hysterectomy and progesterone admin?

A

Must be given post TCRE or TCRA
Post subtotal hysterectomy maybe left with some endometrium in cervical stump - caution

64
Q

What hormones need to be given when as part of HRT for menopause?

A

PICTURE of table

65
Q

What does NICE suggest is the most effective form of HRT for vasomotor symptoms?

A

combined HRT patches

66
Q

What are the options for HRT admin of oestrogen?

A

Oral
Transdermal Patch
Transdermal Gel
Intra-vaginal Gel
Intra-vaginal Pessary
Intra-vaginal Ring
Intra-nasal Spray
Intra-abdominal implant

67
Q

What are the options for HRT admin of progesterone?

A

Oral
Transdermal Patch
Mirena

68
Q

How long should HRT be continued for to treat menopause symptoms?

A

Up to 5 yrs

can experience temporary recurrence of symptoms (3-6 months) so gradual withdrawal may be appropriate

69
Q

How long should HRT be continued for osteoporosis?

A

lifelong – may need to change to other treatment

70
Q

How long should HRT be continued for for premature menopause?

A

Up to age of expected menopause - 51

71
Q

What are the benefits of HRT?

A

Improvement in vasomotor, musculoskeletal, low mood, sexual symptoms and urogenital atrophy

Osteoporosis: reduced risk of #s

Colorectal Ca: decreased by 1/3
(? When come off does risk stay low)

72
Q

How long does it take for HRT to improve vasomotor symptoms of HRT?

A

4 weeks

73
Q

What are the risks of HRT?

A

Breast Ca: Increased risk of breast cancer especially with combined preparations. Risk decreases on stopping therapy ( new lancet study 2019 –some increased risk can persist beyond 10 years)

VTE: increased risk of VTE (oral x two fold): highest in first year of use: Patches and gel may reduce this risk (consider transdermal rather than oral in women with increased risk of VTE e.g. BMI> 30)

Stroke (higher with oral)

Cholecystitis/Cholelithiasis/Cholecystectomy: increased with oral

Endometrial Ca: with unopposed oestrogens

74
Q

What is the reason for the higher risk with oral HRT?

A

Higher steroid bolus in the liver with metabolic effects including on lipids and glucose tolerance

75
Q

What are some of the doubts surrounding HRT use?

A

Cardiovascular disease
HRT does not increase the risk of cardiovascular
disease in women <60 years
Risk of coronary artery disease:
-Oestrogen alone: no increased or decreased risk
-Oes+Progest: little or no increased risk

Dementia and cognition
Unknown if HRT alters risk

Ovarian Ca
- small Increased risk: Lancet found increased risk of
1: 1000 in women using HRT > 5yrs.

76
Q

What are the CI to HRT use?

A
  1. Active VTE or past hx of hormone-related VTE
  2. Active or past hx breast cancer
  3. Pre-existing CVD
  4. Unexplained vaginal bleeding
  5. Endometrial cancer
  6. Active liver disease
77
Q

What is the indication of HRT?

A

Indication: perimenopausal and early post menopausal women with menopausal symptoms
(especially vasomotor)

78
Q

What is the type of HRT used to manage vaginal symptoms only?

A

Topical oestrogen

79
Q

What are the risks/benefits of HRT?

A

< 50, 50-60: benefits outweigh risks
60-70: benefits equal risks
>70: risks outweigh benefits

80
Q

What is post menopausal bleeding (PMB)?

A

Vaginal bleeding 12 months after last menstrual period

81
Q

What is PMB a 🚩 for?

A

Endometrial Cancer present in 10% of women with PMB.

82
Q

What are the endometrial etiologies of PMB? (4)

A

-> carcinoma
-> hyperplasia (+/- atypia)
-> polyps
-> endometritis

83
Q

What are the cervical etiologies of PMB? (3)

A

-> carcinoma
-> polyps
-> cervicitis

84
Q

What is the ovarian etiology of PMB?

A

Carcinoma

85
Q

what are the other etiologies of PMB? (2)

A

Atrophic vaginitis (exclusion only)

Withdrawal bleed from sequential HRT (or in the initial 6 months of use of rTibolone or continuous HRT)

86
Q

What examinations and investigations would you do if there was a history of PMB?

A

Bimanual, speculum.

TVUS: E. thickness, fluid in endometrial cavity, other pelvic pathology

Smear test

87
Q

What is suggested about investigations for PMB?

A

If 1 bleed and E. thickness < 4mm no biopsy

RCPI guidelines suggest hysteroscopy endometrial sampling in women with thickened endometrium on ultrasound or if recurrent bleed as above

Irish guidelines suggest ET < 3mm in women not on HRT or on continuous HRT: < 5mm on sequential HRT

88
Q

Which one of the following is correct in relation to premature ovarian failure?
Affects 1 in 1000 women
Fertility has been restored in some women with the diagnosis
Ovarian function is necessary for implantation, development of the pregnancy and live birth
It is not a concern following childhood chemotherapy
Hormonally P.O.F. is defined by abnormally low levels of oestrogen and FSH

A

Fertility has been restored in some women with the diagnosis

89
Q

Which one of the following conditions does HRT reduce the risk of developing
Breast cancer
Ovarian cancer
Colon cancer
VTE
Stroke

A

OBGYN (25 decks)

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