Menopause Flashcards
What is menopause?
The point in a woman’s life where menstruation stops permanently due to loss of ovarian function
How is menopause typically diagnosed?
Retrospectively - 12 months of amenorrhea
What is peri-menopause?
The period before the menopause characterised by irregular periods
What is post menopausal?
The time after a woman has had no period for 12 months
When is early menopause and premature?
40-45 years old and <40
What hormonal changes occur during menopause?
- During peri-menopause - the ovaries begin to fail and oestrogen production decreases
- Reduced negative feedback to the pituitary
- FSH and LH levels increase
- FSH levels fluctuate on a daily basis during this stage
- Falling oestrogen levels disrupt the menstrual cycle and cause typical menopausal symptoms
- Cycles become anovulatory and follicular development stops
- Estradiol levels become too low to stimulate the endometrium and amenorrhea occurs
- Final result is high levels of FSH and LH and low levels of oestrogen
What are the symptoms of menopause?
- Low mood
- Low sex drive
- Muscle and joint pain
- Vaginal dryness
- Difficulty concentrating
- Hot flushes
- Changes to period
- Trouble sleeping due to night flushes
- Palpitations
- Headaches can become worse
- Changes in body shape and weight
- Dry and itchy skin
- Recurrent UTI
How would you diagnose menopause?
Women over 45 - symptoms alone
Any abnormal bleeding - investigated and underlying pathology ruled out
Women less than 45 - FSH levels are checked providing they aren’t taking combined HC or HRT
What lifestyle advice would you give for menopause?
- Regular exercise
- Maintain a healthy BMI
- Stop smoking
- Reduce alcohol consumption
- Avoid triggers
- Reduce stress
- Sleep hygiene
- Relaxation exercises
- Frequent showers to cool down
- Wear layers of clothes
HRT has a beneficial effect on…
- Sexual function
- Urogenitak atrophy
- Musculoskeletal symptoms
- Bone mineral density
Used for first line treatment of vasomotor symptoms and low mood
Why is transdermal chosen over oral HRT?
Used in women women with:
- Increased risk of VTE
- S/E’s from oral preps
- Concomitant use of hepatic enzyme inducing drugs
- Malabsorption condition
- Lactose sensitivity
- History of migraine
What are the C/I’s for HRT?
- Current, past or suspected breast cancer
- History/active VTE
- Oestrogen dependant cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- Active liver disease
- Pregnancy
- Thrombophillic disorder
- Active or recent arterial thromboembolic disease
What is unopposed HRT?
Oestrogen only
What is opposed HRT?
Oestrogen and Progestogen
Who would unopposed be used in?
Women who have had a total abdominal hysterectomy or mirena in situ
Who would opposed HRT be used in?
Women with a uterus to reduce the risk of endometrial hyperplasia or endometrial cancer
Women with a history of endometriosis who have had a hysterectomy
How does sequential HRT work?
Mimics menstrual cycle and causes a monthly bleed
Oestrogen taken continuously and Progestogen taken for the last 12-14 days of the 28 day cycle
How does combined HRT work?
Bleed free regimen
Oestrogen and Progestogen are taken together with no break
Recommended in post-menopausal patients 1 year since last period
A lower dose of Progestogen is used
What are the risks for HRT?
- VTE
- oral greater than transdermal
- risk with transdermal HRT at standard doses no greater than baseline risk - CHD
- baseline risk will vary from woman to woman
- HRT with oestrogen alone no/reduced risk of CHD
- combined little or no increase risk of CHD - Endometrial cancer
- reduced by using opposed - Ovarian cancer
- small increased risk with both HRT
- risk disappears after a few years of stopping
What are the benefits associated with HRT?
- Fragility fractures
- risk reduced taking HRT - Colorectal cancer
- 5-10 years of use halves the risk
What is tibilone?
Synthetic steroidal compound with oestrogenic, Progestogenic and androgenic activity licensed for the treatment of menopause in post menopausal women
Patients do have a withdrawal bleed
What are the risks of tibilone?
- Stroke
- Endometrial cancer
- Breast cancer
What is the treatment for urogenital symptoms?
Low dose oestrogen
Blissel gel - 1 applicator contains 50 micrograms estriol
Vagifem - 10 micrograms vaginal tablets
Ovestin - 0.1% cream 1mg cream
Estring - replaced every 3 months max 2 years
How do you treat vasomotor symptoms?
- fluoxetine OD
- citalopram 20mg OD
- paroxetine 10mg OD
- venlafaxine 37.5mg for one week then 75mg if tolerated
- clonidine 50 micrograms bd for two weeks then increased to 75 bd if needed
- gabapenin 300mg tds
How do you treat urogenital symptoms?
- ky jelly for sec
- vaginal moisturisers such as replens MB
- used in conjunction with vaginal oestrogen
What are alternative therapies to HRT for symptomatic relief?
Isoflavones and black cohosh may relieve vasomotor symptoms but the quality, purity, constituents and safety may be unknown and diff preps may vary
How often should women be reviewed?
Every 3 months after starting/changing HRT then annually
What should you review?
Efficacy and tolerability, side effects, monitor BP and weight
Ensure she doesn’t need to transition from sequi to conti
Enquire ab unscheduled bleeding
