Menopause Flashcards
What is menopause and how can it be diagnosed?
- defined as the permanent end to menstruation
- it is a retrospective diagnosis made after a woman has had no periods for 12 months
most women go through the menopause around the age of 51
What is meant by postmenopause?
the period from 12 months after the final menstrual period onwards
What is meant by perimenopause?
- this includes the time leading up to the final menstrual period and the 12 months afterwards
- women may experience vasomotor symptoms + irregular periods during this phase
What is meant by premature menopause?
- menopause occurring before the age of 40 years
- it is a result of premature ovarian insufficiency
How are the hormone levels different in menopause?
- menopause is caused by a lack of ovarian follicular function
- oestrogen + progesterone levels are LOW
- FSH + LH levels are HIGH
- this is due to a lack of negative feedback from oestrogen
How does development of follicles occur in the ovaries independent of menstruation?
- primordial follicles ALWAYS mature into primary + secondary follicles
- this occurs independently of menstruation
How does follicular development occur during menstruation?
- FSH stimulates further development of the secondary follicles
- the granulosa cells surrounding the follicles secrete increasing amounts of oestrogen
How does the process of menopause begin?
- begins with a decline in the development of ovarian follicles
- without follicular growth, there is reduced production of oestrogen
What is the result of a decline in oestrogen production as a result of a decline in follicular development?
- oestrogen usually has a negative feedback effect on the pituitary gland, suppressing the amount of FSH + LH produced
- as the level of oestrogen falls, the levels of FSH + LH increase
- this is due to an absence of negative feedback
How does failing follicular development + lack of oestrogen lead to symptoms of menopause?
- failing follicular development means that ovulation does not occur (anovulation)
- this results in irregular menstrual cycles
- without oestrogen, the endometrium does not develop
- this results in amenorrhoea
- low levels of oestrogen cause the perimenopausal symptoms
What are the symptoms associated with perimenopause?
- hot flushes
- emotional lability / low mood
- premenstrual syndrome
- irregular periods
- joint pains
- heavier / lighter periods
- vaginal dryness / atrophy
- reduced libido
all of these symptoms occur due to a lack of oestrogen
What are the risks associated with a lack of oestrogen?
- cardiovascular disease / stroke
- osteoporosis
- pelvic organ prolapse
- urinary incontinence
How is a diagnosis of menopause made?
- a diagnosis of menopause OR perimenoapuse can be made without investigations
- ONLY if symptoms are present in women over 45
When might a blood test be needed to aid in the diagnosis of menopause?
FSH blood test
- women < 40 with suspected premature menopause
- women aged 40-45 with menopausal symptoms / change in menstrual cycle
For how long after the menopause should women use contraception for?
- 2 years after the last menstrual period in women < 50
- 1 year after the last menstrual period in women > 50
this is important as pregnancy > 40 is associated with increased risks + complications
How do hormonal contraceptives affect the menopause?
- they do not affect the menopause, when it occurs or how long it lasts
- they may suppress / mask the symptoms
- menopause can be more difficult to diagnose in women on hormonal contraception
What are the good contraception options (UKMEC1) in women approaching menopause?
- barrier methods
- Mirena / copper coil
- progesterone only pill
- progesterone implant
- progesterone depot injection (if < 45)
- sterilisation
What are the regulations around use of the COCP in older women?
- it is considered UKMEC2 in women > 40
- it can be used up to 50 if there are no contraindications
- COCPs containing norethisterone or levonorgestrel should be used in women > 40 due to lower risk of VTE
What 2 side effects are unique to the progesterone depot injection (Depo-Provera)?
Why does this make it unsuitable in women > 45?
weight gain + reduced bone mineral density
- unsuitable in women > 45 due to the risk of osteoporosis
reduced bone mineral density = osteoporosis
When do vasomotor symptoms associated with menopause resolve?
they tend to resolve after 2-5 years without any treatment
What are the management options available for management of perimenopausal symptoms?
- HRT
- tibolone (acts as continuous HRT)
- clonidine
- SSRI antidepressants
- testosterone (gel or cream) used to increase libido
- vaginal oestrogen (cream / tablets) used to help vaginal dryness / atrophy
- vaginal moisturisers
What are the management options available for management of perimenopausal symptoms?
- HRT
- tibolone (acts as continuous HRT)
- clonidine
- SSRI antidepressants
- testosterone (gel or cream) used to increase libido
- vaginal oestrogen (cream / tablets) used to help vaginal dryness / atrophy
- vaginal moisturisers
What is premature ovarian insufficiency and why does it occur?
- menopause occurring before the age of 40
- occurs due to a decline in normal activity of the ovaries at an early age
What is premature ovarian insufficiency characterised by?
hypergonadotrophic hypogonadism
- hypogonadism is due to underactivity of the gonads
- there is a lack of negative feedback on the pituitary gland
- this results in hypergonadotropism - an excess of gonadotropins being produces (FSH / LH)
What would hormonal analysis show in premature ovarian insufficiency?
- raised LH + FSH (gonadotropins)
- low oestradiol (oestrogen)
What are the potential causes of premature ovarian insufficiency?
- idiopathic
- iatrogenic
- autoimmune
- genetic
- infectious
the cause is unknown in > 50% cases
What is meant by an iatrogenic cause of POI?
- this occurs as a result of an intervention
- e.g. chemotherapy, oophorectomy or radiotherapy
What autoimmune diseases are potentially associated with POI?
- coeliac disease
- adrenal insufficiency
- type 1 diabetes
- thyroid disease
What infections are associated with POI?
- mumps
- tuberculosis
- cytomegalovirus
How does premature ovarian insufficiency present?
- irregular menstrual periods
- secondary amenorrhoea (lack of menstrual periods)
- symptoms of low oestrogen - vaginal dryness, hot flushes + night sweats
How can premature ovarian insufficiency be diagnosed?
- diagnosed with women under 40
- with typical menopausal symptoms
AND
- an elevated FSH
What is meant by an “elevated FSH” in the diagnosis of premature ovarian insufficiency?
- the FSH must be persistently raised > 25 IU/l
- on 2 consecutive samples
- separated by more than 4 weeks
!! results are difficult to interpret in women using hormonal contraception !!
What conditions are women presenting with POI at an increased risk of?
- CVD / stroke
- osteoporosis
- cognitive impairment
- dementia
- Parkinsonism
What is involved in the management of POI?
hormone replacement therapy (HRT)
- this is continued until the age at which women typically go through the menopause
- contraception is still required as a there is a small risk of pregnancy in women with POI
HRT reduces the risks of CVD, osteoporosis + cognitive impairment
What are the 2 options for HRT in POI?
- traditional HRT
- combined oral contraceptive pill
What are the benefits of choosing HRT / COCP in POI?
- HRT is associated with a lower blood pressure than COCP
- COCP additionally acts as contraception
What is the increase in risk of cancer in women using HRT in POI?
- HRT before 50 is NOT considered to increase the risk of breast cancer
- women would ordinarily produce the same hormones at this age
What is HRT in women < 50 associated with an increased risk of?
venous thromboembolism
- this risk is reduced through the use of transdermal patches
