Menopause

Question 1

Define menopause

Answer 1

Permanent cessation of menses following loss of ovarian follicular activity

Question 2

Describe the etiology of menopause

Answer 2

Natural: Occurs in stages where FSH levels are variable and intervals of amenorrhea occur before it stabilizes during postmenopause

Induced: Happens due to removal of ovaries or iatrogenic ablation of ovarian function

Question 3

What are the 4 broad categories of clinical presentations in those with menopause?

Answer 3

Vasomotor
Genitourinary
Psychological
Bone fragility

Question 4

What are the vasomotor clinical presentations? Why do they happen?

Answer 4

Intense feeling of heat on face
Rapid/ irregular HR
Flushing
Perspiration
Cold sweat
Sleep disturbances
Feeling of anxiety

Happens due to estrogen withdrawal

Question 5

Describe the genitourinary symptoms of menopause. Why does it happen?

Answer 5

Genital dryness
Burning/ Irritation/ Pain
Sexual symptoms of lubrication difficulty
Impaired sexual function
Urinary urgency
Dysuria
Recurrent UTI

Happens due to low estrogen

Question 6

Describe the psychological symptoms of menopause. Why does it happen?

Answer 6

Depression
Anxiety
Poor concentration
Poor memory
Mood swings

Happens due to stress and hormone fluctuations

Question 7

Describe the bone fragility symptoms of menopause. Why does it happen?

Answer 7

Increased osteoporosis and fractures
Increase joint pain

Happens due to low estrogen

Question 8

What are some non pharmacological advice to give patients with mild vasomotor symptoms?

Answer 8

Removed layered clothes
Lower room temperature
Eat less spicy food, caffeine and hot drinks
Exercise
Consider dietary supplements such as isoflavones and black cohosh

Question 9

How does dietary supplements such as isoflavones and black cohosh help with mild menopause symptoms?

Answer 9

Isoflavones: Natural source of phytoestrogen

Black cohosh: serotonergic activity at the hypothalamus

Question 10

What are some nonpharmacological advice to give patients with mild vulvovaginal symptoms?

Answer 10

Non hormonal vaginal lubricants / moisturizers

Question 11

When should hormone replacement therapy be considered?

Answer 11

Those with moderate or severe symptoms

Those with insufficient response to non pharmacologicals

Question 12

When should HRT be avoided?

Answer 12

Treatment for low libido
CVD prevention
Depression / Anxiety / Cognitive / Memory impairment
Itchy skin
Hair loss
Treatment of osteoporosis

Question 13

What are the types of HRT?

Answer 13

Estrogen only

Estrogen and progestin

Question 14

What are the indications to using estrogen only HRT?

Answer 14

Women with no more uterus; can be seen by extended periods of no menses

Local vaginal use

Question 15

Why do we not give women who are still premenopausal estrogen only pills?

Answer 15

Risk of cancer as estrogen can increase endometrial size

Question 16

What are the indications of estrogen and progestin HRT?

Answer 16

Patients with an intact uterus

Question 17

What are the types of estrogen HRT?

Answer 17

Oral tablet
Dermal patch
Pessary
Gel
Creams

Question 18

List the advantage and disadvantages of using systemic oral estrogen tablets.

Answer 18

Advantage: Inexpensive

Disadvantage: High dose lead to risk of endometrial cancer, potential missed doses can cause breakthrough bleeding

Question 19

List the advantage and disadvantages of systemic topical estrogen HRT.

Answer 19

Advantage: Lower systemic dose; Convenient; Provides continuous estrogen release

Disadvantage: Expensive, can cause skin irritation, gel can have variable absorption

Question 20

List the advantage and disadvantages of local vaginal HRT such as pessary and creams.

Answer 20

Advantage: Lower estrogen dose (lesser ADR), continuous estrogen release

Disadvantage: Inconvenient and uncomfortable, vagina discharge can occur and is only recommended for those with localized urogenital atrophy

Question 21

What are the two types of estrogen + progestin HRT?

Answer 21

Continuous cyclic and continuous combined

Question 22

What is the difference between continuous cycle and continuous combined?

Answer 22

Continuous cyclic:
- Progestin added only on 1st or 15th of each month for 10-14 days
- Can cause withdrawal bleeding when stopped
- Regulates menses and allow predictable bleeding

Continuous combined:
- Progestin with estrogen
- No withdrawal bleeding but has chance of breakthrough bleeding
- Can cause amenorrhea

Question 23

What is the ideal duration to see improvement of menopause symptoms?

Answer 23

2-3 months

Question 24

What are the monitoring parameters of HRT?

Answer 24

Annual mammography

Endometrial surveillance to check with patients if:
- On estrogen only: check for vaginal bleeding
- On continuous cycle: Check for bleeding when progestin added
- Continuous combined: Check for frequent bleeding, bleeding prolonged, bleeding heavier than normal, symptoms persisting after > 10 months of treatment

Question 25

What are the other alternative options to consider for menopause?

Answer 25

Antidepressants
- Serotonin and norepinephrine reuptake inhibitors: venlafaxine
- Selective serotonin reuptake inhibitors: paroxetine

Gabapentin

Tibolone

Question 26

What are the indications towards using tibolone?

Answer 26

Postmenopausal women with 12 months since last menstrual period

Question 27

What are the advantages and disadvantages of using tibolone?

Answer 27

Advantage
- Improve mood, libido, menopause symptoms and vaginal atrophy
- Protect bone loss

Disadvantages:
- Expensive
- Risk of stroke, breast cancer recurrence and endometrial cancer.