Menopause Flashcards
Mechanism of hot flush
Disruption in thermoregulatory centre in hypothalamus resulting in reduced thermoneutral zone (due to reduced oestrogen levels).
Theories:
- GnRH bursts near medial pre- optic area of hypothalamus which is thermoregulatory area in mammals
- withdrawal of oestrogen resulting in decreased activity of central opioid peptide centres
Results in frequent misinterpretation that body temperature is too high therefore activates cutaneous flushing (heat loss by radiation) and perspiration (heat loss by evaporation)
Differential diagnoses of hot flushes
Endocrine
- hyperthyroidism
- phaeochromocytoma
- carcinoid syndrome
- acromegaly
Psychological
- anxiety
- panic disorder
Cancer
- lymphoma
- renal
- thyroid
- pancreas
Dietary
- alcohol
- caffeine
- spicy foods
Medications
- chronic opioid use
- opiate withdrawal
- SSRIs
- CCBs
- medications that block oestrogen action or biosynthesis
Neurological
- MS
- migraine
- horners
Pathogenesis of postmenopausal osteoporosis
2 mechanisms that interplay.
Ageing:
- leads to vitamin d deficiency due to decline in intestinal Ca absorption and impaired renal synthesis of 1, 25 (OH) vitamin D3 leading to secondary hyperparathyroidism, increased bone resorption, leading to low bond mass and loss of bone architecture causing low- trauma fracture.
- reduced physical activity and sarcopenia leads to loss of mechanical stimulation of osteocytes, decreased bone formation and leads to low bone mass and loss of bone architecture and low- trauma fracture.
Menopausal oestrogen decline leads to increase in osteoclast activity leading to increased bone resorption etc
Behavioural managements of menopause
Wear layers
Use small fab
Sleep in cool room
Exercise- may improve sleep, decrease obesity, decrease osteoporosis
Avoid excess alcohol and caffeine
Stop smoking
Don’t forget mammograms, bone density scan, cervical smears, metabolic health testing
Non- pharmacological management of menopause
CBT
Acupuncture- no effect
Hypnotherapy
Vaginal moisturisers for vaginal sx
Stellate ganglion blockade
Pharmacological, non- hormonal management of menopause
Gabapentin- equally effective as low- dose E2 for VMS. Reduces sx by 31%
SNRIs ie venlafaxine- reduces VMS sx to a lesser extent than HRT. Ok with tamoxifen
SSRIs- paroxetine (first line) and fluoxetine. Reduces VMS to a lesser extent than HRT. Avoid use with tamoxifen as potent CYP2D6 inhibitors and reduces conversion of tamoxifen to its active metabolites
Clonidine- alpha 2 adrenergic agonist. Mildly effective
Hormonal management of menopause
SERMs
- Duavive (conjugated equine + basedoxefine)- replaces progestogen + blocks adverse effects of oestrogen on uterus +/- breast, maintains positive effects on bones. Not funded
- Ospemifeme- for dyspareunia due to atrophy. Not available in NZ
Tibolone
- synthetic steroid with weak oestrogenic, progestogenic and androgenic action
- effective for VMS, (30-50%) and sexual dysfunction
- as effective as bisphosphonates in preventing post- menopausal osteoporosis fractures
- some concerns about increased breast cancer recurrence risks
- less vaginal bleeding than combined MHT, no increase in endometrial hyperplasia
Testosterone- androfeme
- can be used for hypoactive sexual desire
- use with oestrogen or E+P
Topical vaginal oestrogen- minimal systemic absorption, ok if hx of breast cancer
Bio identical hormones- no evidence of safety of efficacy
Definition of primary ovarian insufficiency
Loss of ovarian function before the age of 40
Diagnosis of POI
<40 years
Amenorrhea >4 months
FSH >30, x2 4-6 months apart
Exclusion of secondary causes (hypogonadotrophic hypogonadism)
Causes of POI
III GA
idiopathic
Infection (mumps oophoritis)
Iatrogenic (surgery, radiation, chemotherapy, uterine artery embolization)
Generic (Turners, Fragile X)
Autoimmune (autoimmune oophoritis usually associated with autoimmune adrenal pathology)
Investigations to diagnose POI
High FSH, low oestradiol
Exclude other causes (pregnancy)
Attempt to identify cause:
- karyotype
- FMR-1 gene mutation
- autoimmune screen
Management of POI
Fertility counselling
- likelihood of spontaneous conception 5-10% (low)
- ovulation induction has low success rates
- pregnancy would need to be achieved by IVF with donor egg or embryo
- if pregnancy not desired, need contraception as HRT not sufficient
- other options for fertility- surrogacy with donor egg/ embryo, adoption
Hormone replacement
- until the natural age of menopause
- higher dose than those who undergo menopause at natural age
- if not desiring pregnancy- OCP or oestrogen patch + mirena
- no increased risk of breast cancer
CVD risk
- review risks annually
- weight loss, smoking cessation, exercise and diet
- treat HTN and dyslipidaemia
Bone health
- DEXA scans 2-5 yearly
- weight bearing exercises
- adequate vitamin D exposure and calcium intake
Psychological well-being
