Menopause Flashcards
Define menopause (2)
Natural menopause as at least 12 consecutive months of amenorrhea not due to physiological/pathological causes.
Natural event reached upon exhaustion of primordial follicles
Menopause background : (3)
The global age at menopause is on average 51 years (range 40- 60 years) suggesting a distinct genetic control; strong correlation exists between mothers and daughters
Menopausal health aspects include bone density, breast, the cardiovascular system, mood/cognitive function and sexual wellbeing
Effective health care support should be individually tailored to all aspects of the menopause when women feel particularly vulnerable
Menopause symptoms (10)
Common symptoms include:
* Hot flushes, night sweats, vaginal dryness and discomfort during sex,
difficulty sleeping, low mood/anxiety, reduced libido
* Physical and emotional changes strongly affect women
* 1:10 women experience suicidal thoughts due to the perimenopause
Ovarian reserve - explained (3)
max. no. of follicles in our lifetime -ovarian reserve will determine the onset of subfertility to sterility and to complete loss of menstrual cycles – the menopause
Estimated that for 95% of women by 30yrs only 12% of max. pre-birth NGF population is present
and
by 40yrs only 3% remains.
Various factors affecting ovarian reserve (7)
genetics
autoimmunity
Ethnicity/geography
Androgens/PCOS
Nutrition
In-utero
abnormalities, medications, drugs
AMH marker for ovarian reserve? (2)
The levels of AMH in the human circulation vary during the life cycle, with a sexually dimorphic pattern. Females produce virtually no AMH in utero
Declining levels of AMH with age, AMH secretion from growing follicles
What happens to levels of Inhibin B and FSH as approach peri-menopause? (2)
rise in FSH: loss of -tve feedback
dec. in InhibinB: decrease in follicles
Can only AMH predict ovarian reserve? (3)
no - it is a good indication of function + potential marker of ovarian reserve + menopause
but w/ Measurements of AMH, AFC, InhibinB + FSH are used to diagnosed premature ovarian failure/insufficiency, predict menopause + prediction of ovarian response in IVF
Hormonal changes during the menopause (6)
Ovarian senescence begins around 35 years ends with menopause ~51 years.
Decline in ovarian oestrogen largely related to number of primordial follicles, number of recruitable follicles in each ovarian cycle and proportion of follicles that reach adequate maturity
Rise in FSH – loss of negative feed back
Decline in inhibin B and AMH
Decline in androgen synthesis in adrenal glands and ovaries
Marked decline in fertility after age of 35 although this depends on ovarian reserve
What symptoms are related to the drop of estrogen? (7)
Climacteric compounds - hot flushes etc. DRAMATIC
normal lag:
vaginal wall atrophy, incontinence, Skin atrophy, Stress incontinence, oesteoporosis, athersclerosis
How are the symptoms recorded and thus…? (2)
self-reported = bias
= a big spread in data of when and what is experienced
Hot flushes and night sweats (6)
approximately 80% menopausal women ( 5-13 years though number of episodes decrease with time
Measuring frequency = most objective way of assessing severity of menopausal symptoms
Typically occurs on the face but can occur in other body areas such as arms and the torso
Aetiology unknown:: but oestrogen interacts with the noradrenergic system in the brain which plays a major role in thermogenesis. Other neural systems have also been implicated such as the endorphin pathways
Wet’ flushing occurs through inappropriate vasodilation and activation of sweat glands through both central and peripheral mechanisms. Hormone withdrawal and emotions are both causes
Dry’ flushing (no sweat!) can be caused by several drugs, the carcinoid syndrome, phaeochromocytomas (rare cancer of adrenal medulla) &
mastocytosis (accumulation of mast cells in tissues including the skin)
Osteoporosis in Menopause (4)
Can lose up to 20% of their bone density in the 5 to 7 years after the menopause
The drop in bone density is caused by falling levels oestrogen, which impairs the normal cycle of bone remodelling
i.e. increases amount of bone resorbed (osteoclastic activity) over the amount deposited (osteoblastic activity), leading to net loss of bone
Although bone density decreases at the menopause, the risk of osteoporosis and fractures stays relatively low until women get much older, because bone density is only one of the things that affects bone strength.
Treatment option include the use of bisphosphonate compounds, maintaining calcium and Vit.D levels, weight-bearing exercises
Genitourinary Syndrome of Menopause (GSM) (4)
Previously known as vulvovaginal atrophy, atrophic vaginitis or urogenital atrophy.
Chronic, progressive, vulvovaginal, sexual and lower urinary tract condition characterised by a broad spectrum of signs and symptoms
GSM more accurately describes the post-menopausal hypoestrogenic state of the genitourinary tract.
Can have a significant impact on quality of life
Treatment aimed at symptomatic relief.
GSM for BSSM
Premature ovarian failure (POF)/insufficiency (POI) definition
Defined as cessation of ovarian function before 40 years
Various causes of premature ovarian failure/insufficiency (9)
Genetic
Gonadal dysgenesis
Autoimmune anti-ovarian antibodies
Congenital enzymatic deficiencies (e.g. galactosemia)
Vaccination
Anti-HPV
Oncologic treatment
Viral infections e.g. mumps
UNKNOWN(idiopathic) : Up to 50% of all cases
Investigating POF (5)
will presnt w/ Hypergonadotrophic-hypogonadism:
Low estradiol (<20 IU/l)
Elevated FSH (>20 IU/l)
Low AMH levels (< 0.5 ng/ml)
Low inhibin B levels
Assessed day 3 of the menstrual cycle
Symptoms of POF (2)
Symptoms are those similar to those observed at a normal menopause. - - - Loss of oestrogen
e.g. oligomenorrrhea, hot flushes, sweating, nervousness, skin
changes, mucous membrane dryness decreased bone mineral
density (osteoporosis), metabolic changes, CVD, urogenital atrophy
and early mortality
treatment of POF (2)
HRT - to prevent CVD/ death etc.
Combined oral contraceptive pill (but contain higher doses of steroids)
Long term consequences and treatment of premature menopause (5)
Adverse effects on health and mortality
HRT can lessen some of these risks but not all
Provide HRT at least until natural age of menopause
Psychological aspects of early menopause
Individualising treatment both in terms of HRT and the psychological impact
Treatment of menopausal symptoms (5)
Menopausal hormone therapy (MHT/HRT)
- Tablets, skin patches, gels and implants to replace oestrogen
- Vaginal oestrogen creams/lubricants/moisturisers
Plant-based, bioidentical hormones
- unregulated & no evidence of effectiveness
CBT plus relaxation techniques
- To help with low mood and anxiety
For treatment of hot flushes
- NKB hypothalamic neuropeptide involved in GnRH secretion and thought to stimulate activity of the vasomotor centre, resulting in hot flushes
Non-Hormonal prescription medications (but not as useful as MHT)
- e.g SSRI (selective serotonin reuptake inhibitors)
- Bisphosphonates for bone density
= Regular exercise and good diet
- To maintain bone strength and reduce weight and hence risk of various pathologies
Why should HRT always be monitored + tweaked? (2)
Unopposed oestrogens cause proliferation of the endometrium – endometrial cancer
Different preparations of oestrogen and progesterone used for HRT and different routes of administration
Bad press HRT - 3 large studies – 1990’s to early 2000’s (3)
Heart and Estrogen/Progestin Replacement Study (HERS)
(CCEPT in postmenopausal women with CHD)
- HERS ended after 4.1 years due to risks
- Women’s Health Initiative (WHI) (healthy postmenopausal women)
Prospective, randomised, double-blind, placebo-controlled studies of continuous- combined estrogen progestin therapy (CCEPT) or CEE only
- Evaluated only one hormone combination; no perimenopausal women
- WHI was stopped at 5.2 years –increased risk of breast cancer
Million women study – started recruiting participants in 1996 to investigate effect of use of HRT amongst other things.
- Study includes 1 in 4 women in UK born between 1935 and 1950
- Participants sent postal resurvey questionnaires every 3-5 year
The tides began to change again when data from the studies were re-evaluated and analysed (3)
Subsequent re-examination of the data from the WHI and Million Women study showed certain flaws in interpretation and study designs and that risks of the WHI study were not statistically significant apart from
venous thrombosis and ischaemic stroke
The follow up from the WHI trials showed benefits for the use of MHT in younger women (50-59 years) have decreased coronary disease and all causes of mortality
The tides began to change again when data from the studies were re-evaluated and analysed NICE recommends its use for menopausal symptoms!
Menopause and Society (3)
Ageing is often associated by women with a loss of status – feeling of becoming invisible
Closely associated with psychosocial events in midlife and ageing i.e. health issues, family and marital relations, sociocultural back ground and attitudes toward a sex life determine women’s experience of the menopause
Campaigning by women resulted in recent publication (Oct.2022) of all-party parliamentary group on menopause report. Five key recommendations:
1. Funding research into benefits of HRT
2. Ensuring doctors are trained
3. Scrapping prescription charges for HRT in England
4. National drug formulary for HRT
5. Summoning all women aged 45 to GP to discuss menopause
