Menopause Flashcards
What is the menopause?
- Permanent cessation of menstruation resulting from loss of ovarian follicular activity
- Recognised to have occurred after 12 consecutive months of amenorrhoea without pathological or physiological cause
What is climacteric?
- Physiological period in a woman’s life during which there is regression of ovarian function
- Perimenopause
What is menopausal transition?
- Time between onset of irregular menses and permanent cessation of menstruation
- Around 4 years long
What is early menopause?
- Menopause occurring under age of 45
What is premature menopause?
- Cessation of menstruation due to depletion of ovarian follicles before age of 40
- Also called premature ovarian failure
What is physiologic menopause?
- Normal decline in ovarian function due to aging
- Begins in most women between ages 45 and 55
- Average age 51
- Results in infrequent ovulation
- Decreased menstrual function
- Eventual cessation of menstruation
What are the 4 phases of menopause?
- Pre-menopause - slight changes to FSH/LH levels but cycle relatively normal
- Peri-menopausal - cycle disrupted
- Menopause
- Post-menopause
Outline the pre-menopause phase
- Time prior to menopause
- Typically from age 40+
- Slight reduction in oestrogen
- LH and FSH levels may rise; FSH rises more
- May be reduced negative feedback
- Fertility potentially reduced
- Cycles can remain relatively normal
Outline the perimenopause phase
- Transition phase
- Physiological changes characterise phase
- Follicular phase shortens
- Ovulation early or absent
- Terminating with completion of menopause
Outline the menopause phase
- Permanent cessation of menstruation
- Caused by ovarian follicular development failure
Outline the post-menopause phase
- Time after which a woman has experienced 12 consecutive months of amenorrhoea
- FSH levels stabilise in early post-menopause
How many primordial follicles mature and ovulate?
- 100 000s of ova degenerate leaving ~400 follicles that can mature and complete ovulation
- By ~45 years old only a few follicles remain to be stimulated by FSH and LH
What happens as we get closer to having 0 primordial follicles left?
- Oestrogen production by ovaries decreases
- When oestrogen production falls below a critical value, it can no longer inhibit production of LH/FSH
- See a rise in LH and FSH production
- FSH increases more due to lack of inhibin
When do we use an FSH to diagnose women with menopause?
- If woman is aged 40-45 years with menopausal symptoms
- If woman is under 40 years old in whom menopause is suspected
When would we diagnose premature ovarian insufficiency?
- Diagnose premature ovarian insufficiency in women <40 years
- If menopausal symptoms and elevated FSH levels on 2 blood samples taken 4-6 weeks apart
What are the symptoms of menopause?
- Vasomotor symptoms - hot flushes and night sweats
- Change to menstrual pattern
- Cognitive impairment and mood disorders
- Urogenital symptoms
- Altered sex function
- Sleep disturbance
- Skin and hair changes
- Joint and muscle pain
- Fatigue
Explain the vasomotor symptoms of menopause in further detail
- Hypothalamic origin due to pulsatile release of GnRH
- Affects ~80% of women
- Hot flushes especially at night
- Can last from a few months up to more than 5 years
- In 90% of cases exogenous oestrogen or progesterone will relieve symptoms
What changes to the menstrual pattern are caused by menopause?
- Dysfunction in uterine bleeding such as:
- Spotting between periods
- Heavy bleeding
- Mid-cycle bleeding
- Irregular cycles
What causes changes to the menstrual pattern in menopause?
- Changes in oestrogen
- Causes hyperplasia of endometrium
- Leads to a late menstrual period followed by irregular bleeding/spotting
- No corpus luteum so no progesterone
- Unopposed oestrogen = increased risk of carcinoma
Give examples of psychological changes noticed in menopausal women
- Irritability
- Confusion
- Lethargy
- Memory loss
- Loss of libido
- Depression
How does the skin change during menopause?
- Loses elasticity
- Becomes thin and fine
- Loss of elastin and collagen
How does weight change during menopause?
- Weight increase
- Likely to be due to irregular food habit due to mood changes
- More deposition of fat around hips, waist and buttocks
How does hair change due to menopause?
- Becomes dry and coarse
- Hair loss may occur due to decreasing oestrogen level
How does the voice change due to menopause?
- Becomes deeper
- Due to thickening of vocal cords
How does menopause affect the GI tract?
- Diminished motor activity of entire GI tract
- Sluggish intestines lead to constipation
How is the urinary system affected by menopause?
- Tissue lining urethra and bladder becomes drier, thinner and less elastic
- Loss of pelvic tone
- Urinary incontinence
- Reduced elasticity of bladder (urinary frequency and urgency, nocturia, dysuria)
- Increased susceptibility to UTIs
What changes occur in the genital organs due to menopause?
- Absence of oestrogen causes: thinning of vaginal skin (dyspareunia and bleeding) and lack of glycogen (rise in vaginal pH)
-Treat with topical oestrogens - Uterus can become small and fibrotic due to atrophy of muscles
- Regression of endometrium
- Shrinkage of myometrium
- Thinning of cervix
How do the breasts change after menopause?
- Decreased fat and tissue in breasts
- Mammary gland tissue shrinks
- Breasts begin to sag as connective tissues lose elasticity
How do the bones change as a result of menopause?
- In first 5 years after menopause, Ca2+ loss from bones causes loss in bone density
- Bone mass reduces by 2.5% per year for several years
- Reduced oestrogen enhances osteoclast ability to resorb bone
- Can lead to osteoporosis and risk of fragility fractures
How can we reduce risk of osteoporotic fracture in younger post-menopausal women?
- HRT
How does menopause affect the cardiovascular system?
- Risk of CHD is increased significantly
- Potentially due to withdrawal of protective effect of oestrogen
- Menopause leads to obesity, hypertension and dyslipidaemia (LDL and VLDL cholesterol increases)
What is the conservative management for symptoms of the menopause?
- Regular exercise
- Wear light-weight clothing for sleep
- Sleep in a cooler room
- Avoid triggers: spicy food, caffeine, smoking, alcohol etc
- Contraceptive advice
How can the vasomotor or mood disorders that accompany menopause be treated?
- Offer oral or transdermal HRT
- Combined oestrogen and progesterone if woman has a uterus
- Oestrogen alone if she does not have a uterus
Why do women with uteruses have combined oestrogen and progesterone HRT?
- Progesterone protects endometrium from hyperplasia
How are the urogenital symptoms of menopause treated?
- Low-dose vaginal oestrogen
What are the benefits of HRT?
- Reduction in vasomotor symptoms
- Improvement in mood changes
- Improvement of urogenital symptoms
- Reduction in osteoporosis risk
- Lower risk of colorectal cancer
- Maintains and enhances muscle mass
- Quality of life improves
What are the risks of HRT?
- Venous thromboembolism associated with oral HRT
- HRT tablets slightly raise risk of stroke
- Oestrogen and progesterone HRT may increase breast cancer risk
What are the advantages and disadvantages of oral HRT?
- Cheap and effective
- Higher doses required as it enters first pass metabolism
What are the advantages and disadvantages of transdermal HRT?
- Avoids first-pass metabolism
- Reduces risk of venous thromboembolism
- Continuous administration
- Cost
- Skin reactions
What are the advantages and disadvantages of vaginal HRT?
- Good for urogenital symptoms
- Minimal systemic absorption
- Can be used for 3 months without progesterone opposition
- Unlikely to treat other symptoms
What are the advantages and disadvantages of mirena intrauterine system as HRT?
- Can be used for 4 years to provide progesterone arm of HRT contraceptive
- Only provides progesterone - pt will still need oestrogen
