Menopause Flashcards
Definition of the menopause
A biological stage in a woman’s life that occurs when she stops menstruating and reaches the end of her natural reproductive life.
When a woman has not had a period for 12 consecutive months (for women reaching menopause naturally)
What is the physiology of the menopause
Changes associated with menopause occur due to loss of ovarian follicular activity and absence of oestrogen and progesterone secretion (high LH and FSH).
* The process begins with a decline in the development of ovarian follicles, without which there is reduced production of oestrogen
* As the level of oestrogen falls, there is an absence of negative feedback (reduced inhibin B) on the pituitary gland, resulting in increased GnRH pulsatility and levels of LH and FSH
* Ovulation does not occur, leading to amenorrhoea
* Lower levels of oestrogen cause perimenopausal symptoms
* After menopause oestrone becomes the prominent oestrogen (peripheral adipose conversion)
* Ovaries also produce 30-50% of circulating androgen levels (rest in adipose tissue and adrenals)
Normal hormone levels during perimenopause, early and late menopause
Normal course of presentation in menopause
- Symptoms typically last up to 7 years
- (symptoms by time of onset)
- Immediate (0-5 years): Vasomotor symptoms (hot flushes, night sweats), psychological symptoms (labile mood, anxiety, tearfulness), cognitive symptoms (loss of concentration, poor memory), musculoskeletal symptoms (dry hair, itchy skin, joint aches), loss of libido
- Intermediate (3-10 years): Vaginal dryness, dyspareunia, urgency of urine, recurrent UTI, urogenital prolapse
- Long term (>10 years): Osteoporosis, cardiovascular disease and stroke, dementia
Common CNS symptoms of menopause
- Vasomotor symptoms (occur in 80%- severe impact on life in 25%) including hot flushes and night sweats are some of the earliest symptoms seen in menopause.
- Occur due to the loss of the modulating effect of oestrogen on serotoninergic receptors in the thermoregulatory centre of the brain- leads to an exaggerated peripheral vasodilatory response to slight changes in environmental temperature
- Night sweats can disrupt sleep and cause exhaustion- triggers include alcohol, caffeine and smoking
- Menopause is also associated with a low mood, lack of energy, tiredness and impaired QOL.
- Many women additionally complain of some change in memory/ global cognitive function
Common genital tract symptoms of menopause
- An initial scanty or irregular vaginal bleeding is due to the reduction in oestrogenic endometrial stimulation with failing ovarian function (eventually results in secondary amenorrhoea)
- Irregular heavy bleeding can occur due to episodic infrequent ovulation with fluctuations in oestrogen and unpredictable progesterone levels
- Loss of oestrogenic support to the vaginal epithelium leads to reduced cellular turnover and reduced glandular activity -> vaginal dryness, irritation, dyspareunia
- The urogenital system also becomes more susceptible to infection due to increased pH
Common bone health symptoms in menopause
- Bone density reaches a peak at 20-30 years- after this peak is reached, there is a steady decline in BMD until menopause- after this point bone loss is accelerated (until 60 years) due to loss of oestrogenic protective function
- Leads to development of osteoporosis: characterised by compromised bone strength predisposing an increased fracture risk
- Risk factors: FH, Smoking, alcohol, long-term steroid use, immobility, malnutrition and liver disease
Common cardiovascular disease presentations in menopause
- Oestrogen has a protective effect on cardiovascular system → supportive effect on the vessel wall favouring vasodilation and preventing atherogenesis
- In menopause there is a change from a gynaecoid (breast and hip fat) to android (abdominal fat) pattern of fat distribution, rise in triglycerides, total cholesterol and LDLs + reduction in HDLs
Investigations for menopause
The following diagnoses can be made without laboratory testing in otherwise healthy women aged over 45 years with menopausal symptoms:
* Perimenopause, based on vasomotor symptoms and irregular periods
* Menopause, in women who have not had a period for at least 12 months and are not using hormonal contraception
* Menopause, based on symptoms in women without a uterus
Consider using an FSH test to diagnose menopause:
* In women aged 40 to 45 with menopausal symptoms, including change in menstrual cycle
* In women aged under 40, in whom menopause is suspected
MUST DO A PREGNANCY TEST
How can a diagnosis of Premature menopause be made
Diagnose premature menopause in women < 40 years based on
* Menopausal symptoms AND elevated FSH on 2 blood samples 4-6 weeks apart
* Do not if taking COCP or high-dose progestogen
* If doubt about diagnose: consider AMH testing after seeking specialist advice
Causes of premature menopause
- Primary: Chromosomal abnormalities (Turner’s syndrome, fragile X), autoimmune disease (hypothyroidism, Addison’s, myasthenia gravis), enzyme deficiencies (galactosaemia, 17a-hydroxylase-deficiency)
- Secondary: Chemotherapy, radiotherapy, infections (TB, mumps, malaria, varicella)
- Idiopathic (most common)
The risk of premature or early menopause may be increased in women with a history of early menarche, nulliparity or low parity, smoking (dose-response effect), being underweight
Menopause differentials
- Irregular vaginal bleeding: during the perimenopause possible causes include endometrial polyps; uterine fibroids; adenomyosis; endometrial hyperplasia or cancer; and vulval, vaginal, or cervical lesions
- Hot flushes: Endocrine (hyperthyroidism and phaeochomocytoma), tumours (carcinoid syndrome, pancreatic cancer, medullary thyroid cancer, RCC), excess alcohol consumption, anxiety and panic disorder, TB, drugs (opiates, nitrates, selective serotonin reuptake inhibitors (SSRIs), calcium-channel blockers, levodopa, GnRH agonists)
Does a woman require contraception during the menopause (for how long are they fertile?)
- Although natural decline in fertility occurs with age and spontaneous pregnancy is rare after age 50, effective contraception is required until menopause. Additionally women should be advised about condom use and protection against STIs (should also be asked about urogenital issues and sexual dysfunction)
- A woman is potentially fertile for 2 years after her last menstrual period if she is younger than 50 years of age, and for 1 year if she is over 50 years of age
- In general, all women can cease contraception at age 55 as spontaneous conception after this age is exceptionally rare even in women still experiencing menstrual bleeding.
Does contraception effect the onset of menopause. Which contraceptives are appropriate in older women
- Contraception does not affect duration or onset of menopause, but may mask its symptoms
- CU-IUD is recommended until menopause (when inserted at age 40 or over)
- LNG-IUS is supported until age 55, if inserted at age 45 or over
- Women should not use the DMPA depot aged over 50 (initial bone loss)
- Progesteone-only implant and POP are safe until menopause
- Women opting for the COCP should use levonorgestrel or norethisterone and ethinylestradiol when aged over 40, due to lower VTE risk, but should use an alternative contraceptive after 50
How should women be advised on contraceptive use when taking HRT
Women using sequential HRT should be advised not to rely on this for contraception
* All progesterone-only methods of contraception are safe to use as contraception alongside sequential HRT
* CHC can be used in eligible women under 50 as an alternative to HRT for relief of menopausal symptoms and prevention of loss of BMD
