Menopause Flashcards
Definition
- Permanent cessation of menstruation secondary to loss of ovarian follicular activity
- > 12 months of amenorrhoea
- If occurs prior to age 40: Premature menopause
Clinical Assessment
HISTORY
Vasomotor symptoms
- hot flushes
- Night sweats
- Headaches
- Palpitations
- Interupted sleep
- Usually last 4-5 years
Urogenital symptoms: Secondary to withdrawal of Oestrogen
- vaginal dryness, dyspaurenia, trauma/bleeding, infections
Psychomotor changes
- Anxiety, mood changes
- Poor concentration, memory
Cardiovascular and Osteoporosis risk
- Normal bone loss accelerated in Menopause
Contraindications to HRT
- Breast Cancer
- Cardivascular disease and associated risk factors
- Previous VTE
- Include family histry
- Lifestyle: Smoking, exercise
- ? Uterus present
Routine Screening
- Mammogram
- CST
Assess quality of life
EXAMINATION
- BMI
- BP
- Cardiovascular exam
- Breast/thyroid
- Pelvic exam/Pap smear
INVESTIGATIONS
- FSH and Oestradiol not necessary if >12 months amenorrhoea over the age of 50 years
- FBE, ferritin
- Cardiac/general health risk screen: fasting BSL, lipids, TFTs, UEC, LFTs
- Mammogram if due
- Consider DEXA scan
- ? Pelvic ultrasound: ET/Presence of Uterus
Management
LIFESTYLE ADVICE
Vasomotor symptoms
- Dressing in layers/ fans
- Weight management and healthy diet
Urogenital symptoms
- Lubrication
Osteoporosis risk
- Vitamin D and Calcium supplementation
- Weight bearing exercise regularly
- Cease smoking, decrease ETOH and caffeine intake
Stress reduction
CONSERVATIVE MANAGEMENT
-Mindfullness training
- Cognitive behavioural therapy
- Hypnosis
- Black cohosh and phytoestrogens not shown to be effective
- Red Clover: 5RCT show improvement in V symptoms
MEDICAL MANAGEMENT
Non Hormonal
- Improve vasomotor symptoms compared to placebo
- Venlafaxine 37.5-75mg daily
* Has the most evidence supporting efficacy, causes nausea
- Gabapentin 300-900mg daily
- Parotexine/fluoxetine (contraindicated with Tamoxifen)
- Citalopram/escitalopram
- Clonidine: Limited benefit for vasomotor symptoms
Hormonal
- Indicated for women with POI (<40 years) or early menopause (<45 years) until age 51 or women with debilitating symptoms
- Treat with lowest effective dose aiming for treatment <5-7 years (although longer depending on individual patient factors)
- Benefits
* Most effective treatment for vasomotor symptoms
* Significant reduction in bone loss after menopause and
fracture risk
* Likely protective against CVD if commenced around the time of menopause
* Reduction in colorectal cancer risk and no impact on overall cancer risk
- Risks
* VTE
o Doubles the risk of VTE, although absolute risk low
o Risk reduced with transdermal cf oral
* Breast cancer
o Increased incidence of and mortality from breast
cancer but absolute risk low
- Additional 8/10,000 cases per year over 5 years
- Background risk 30/10,000 cases per year
o Relative risk 1.24
o Reduced (or no) risk with oestrogen-only (compared
with combined)
* Increased risk of stroke
o Additional 2/10,000 women years
Hormone Like options
- Tibolone
* A synthetic steroid with oestrogenic, progestogenic and weak androgenic effects
* Improves vasomotor symptoms and urogenital symptoms
* May improve sexual interest in some women (due to
androgenic effects)
* Proven to reduce bone loss and fracture risk
* Dose not activate endometrium or increase VTE risk
* Impact on breast cancer risk unknown
* Contraindicated if history of breast cancer (as proven
increased recurrence risk)
* Increases stroke risk in those >65 years
- SERM +/- oestrogen
* Emerging therapy but not widely used in Australia
* Raloxifene – reduces breast cancer and improves BMD but increases risk for VTE and vasomotor symptoms
Regimes
- Use vaginal oestrogen for isolated urogenital symptoms
- Oestrogen-only treatment required post-hysterectomy
- Progesterone required for at least 14/7 per month with
women with an intact uterus - Combined oestrogen and progesterone patch
o Continuous or cyclical
o Ie Estalis patch (Estradiol and norethisterone) - Oestrogen only treatment with a progesterone if required
o Oestrogen - Patch (ie Estradot 25mcg)
- Oral (ie Progynova 0.5-2mg)
o Progesterone (for at least 14/7 per month) - Oral (ie medroxyprogesterone acetate 5mg or
norethisterone 1.25mg) - Mirena IUD
- Combined oral contraceptive pill
o Other regimes (excluding Mirena) are not
contraceptive so should not be used in the
perimenopause if contraception required
Specific group approaches
o Postmenopausal (>12/12 since LNMP)
- Uterus intact
* Combined continuous patch
* Oestrogen patch with continuous oral progesterone or Mirena
* Oral oestrogen and continuous oral progesterone or Mirena
* Tibolone
- Post hysterectomy
* Transdermal oestrogen patch
* Oral oestrogen
* Tibolone
o Perimenopausal
- Combined OCP
* Aim low dose (ie 20mcg EE) or 17bE (however not PBS listed)
* Provide reliable contraception in this population
* Control irregular bleeding and cyclical symptoms
* VMS symptoms may recur in pill-free week so can use
continuously or give oestrogen in the pill free week
- Oral oestrogen and Mirena
* Improves VMS and bleeding but not cyclical symptoms
- Oestrogen (oral or patch) and cyclical progesterone
* May cause irregular bleeding
* Not contraceptive
o Hx breast cancer
- Osteoporosis risk
* Lifestyle advice
* Pharmacological treatment
o Bisphosphonates
o Raloxifene (if VMS not an issue)
- Vasomotor symptoms
* Venlafaxine first line
* Avoid paroxetine/fluoxetine if on Tamoxifen
- Urogenital symptoms
* Vaginal oestrogen not contraindicated
* Ovestin preferred to Vagifem as less systemic absorption
- HRT
* Combined HRT and Tibolone increase breast cancer risk and recurrence risk
o HABITS trial – HRT doubled recurrence risk
* May be indicated on individual basis for severe debilitating symptoms in consultation with multidisciplinary team
* Avoid oral progesterone (Mirena may be safer if uterus intact)
* Use for shortest possible duration with annual review
o Hx endometrial cancer
- HRT not shown to increase recurrence risk in early stage disease (except in oestrogen-sensitive sarcomas)
- In young women (ie <40 years) with low recurrence risk benefits of oestrogen HRT outweigh risks
o Hx ovarian cancer
- No evidence HRT affects prognosis
- Avoid in granulosa cell tumours
