Menopause

Question 1

What are some presenting symptoms of early menopause/primary ovarian insufficiency?

Answer 1

Irregular periods, difficulties conceiving, sudden change in menstrual cycle (may have prolonged prodrome of oligomenorrhoea or develop sudden amenorrhoea)

Question 2

What are the criteria for primary ovarian insufficiency/early menopause?

Answer 2

Irregular menstrual cycles (oligo or amenorrhoea for >4 months) and 2 FSH levels of >25, four weeks or more apart

Question 3

What should you include in history specific to primary ovarian insufficiency/early menopause?

Answer 3

specific questions around childhood diseases, medications, medical conditions (hypothyroidism, diabetes), hx of CRTx, pregnancy, stress, weight loss, exercise, hyperprolactiemia (headaches and galactorrhoea), androgenic sx, previous uterine surgery (Asherman’s), FHx of premature ovarian insufficiency

Question 4

What are some causes (and frequencies) of primary ovarian insufficiency/early menopause?

Answer 4

Idiopathic 88%
X chromosome abnormalities e.g. Turners, among others 6.7%
Iatrogenic e.g. CRTx 2.1%
Autosomal causes e.g. FSH receptor mutation 1.6%
Autoimmune causes 0.8%
46XY gonadal dysgenesis 0.5%

Question 5

What investigations should be done specific to primary ovarian insufficiency/early menopause?

Answer 5

hCG, prolactin, TFTs, FSH x 2, LH, oestradiol, testosterone, day 21 progesterone; AMH may be considered
USS looking at ovarian volume, ET, follicle count
Karyotype – Turners, Y chromosome test, and fragile x
Consider adrenocortical antibodies, TPO antibodies

Question 6

What are complications of primary ovarian insufficiency/early menopause?

Answer 6

• Reduced life expectancy
• Infertility
• Reduced BMD and increased fractures
• Increased risk of CVD
• Negative psych and QOL as a result
• Sexual dysfunction and dyspareunia
• Increased risk of dementia

Question 7

What is the treatment of primary ovarian insufficiency/early menopause?

Answer 7

Tend to have more hot flushes - MHT used for symptoms of low oestrogen
 Good for the hot flushes
 Primary prevention for CV disease, BMD and dementia
 Not found to increase the risk of breast cancer before the natural age of menopause – give until the age of menopause then stop
 Give bio-identical oestrogen/progesterone replacement where possible and consider testosterone
 Contraception still needed as pregnancy is not impossible

Question 8

What bone mineral density defines osteoporosis?

Answer 8

BMD >2.5 SD below the mean
Note: FRAX score is useful to match bone density and risk factors

Question 9

What is the treatment for osteoporosis in menopause?

Answer 9

Lifestyle: avoid being underweight, stop smoking/reduce ETOH, PA (e.g. resistance training), falls prevention;
Pharm: vit D, bisphosphonates (1st line), OE2, denosumab or teriparatide (both special authority)

Question 10

How would you treat surgical menopause?

Answer 10

• Treat urogenital sx/dyspareunia with topical oestrogen therapy
• Treat sexual desire with transdermal testosterone patch/cream (only cream available in NZ); SSRI’s also have some efficacy

Question 11

How does surgical menopause differ to natural menopause with respect to hormones?

Answer 11

Get a sudden drop in androgen levels ( doesn’t happen in natural menopause) - therefore more likely to report sexual dysfunction

Question 12

What medications are contraindicated in menopause for those with a hx of ERPR+ Breast Ca?

Answer 12

HRT and tibolone

Question 13

What treatments can be used when the patient has a hx of ERPR+ Breast Ca?

Answer 13

For vasomotor sx use clonidine, gabapentin, SSRI/SNRI; if also on tamoxifen use Citalopram or venlafaxine
For urogenital sx use vaginal moisturisers, lubricants, or if no benefit discuss with the breast team about use of Ovestin.

Question 14

x % of women will have vaginal dryness and dyspareunia at menopause?

Answer 14

50% - topical vaginal oestrogen helps

Question 15

How would you treat low desire in those with menopause? What are the ADRs

Answer 15

Consider testosterone cream (warn it is being used off label).
ADRs: increased hair growth at the site of application or in areas prone to hirsuitism such as the chin and lip. High dose ADRs: acne, hirsutism, voice deepening, androgenic alopecia, and clitoromegaly. If the women does not respond – stop it.

Question 16

How should you stop HRT/MHT?

Answer 16

You can give women the choice - though quite a lot of them prefer to do a slow taper. You can prescribe ½ doses for them or they can cut tablets or take alternate days and decrease over a few months. Also the matrix patches are good here as women can cut little bits off the patch each week and so decrease the dose - need to continue the progestogen though if they have a uterus until they stop estrogen.

Question 17

Which sx typically flare when MHT is stopped?

Answer 17

Vasomotor sx
(Vasomotor symptoms improve or resolve spontaneously within a few months to a few years of onset in the majority of women, suggesting that most women should be able to discontinue HT within a few years of starting treatment. Approximately 75% of women who try to stop are able to stop HT without major difficulty)

Question 18

When should you investigate abnormal bleeding on MHT?

Answer 18

If <6 months since starting continuous MHT and exam, swabs and smear are normal it requires no further investigations for now.

Question 19

What symptoms can be associated with menopause (the climacteric)?

Answer 19

Heavy periods due to drop in progesterone; irregular (with reducing frequency) and often lighter periods (loss of oestrogen).
Cessation of periods is the only sign that happens to all menopausal women with a uterus.
Urogenital and Vasomotor symptoms: Vaginal dryness, dyspareunia, vaginal itching and burning, urinary frequency and urgency, recurrent low sexual desire.
Psych symptoms: Sleep disturbance, depressive sx, anxiety and irritability, reduced memory and concentration.
Metabolic symptoms: Central abdominal fat deposition, IR, increased risk of T2DM, dyslipidaemia.
Cardiovascular: impaired endothelial function
Skeletal changes: accelerated bone turnover and bone loss, increased bone fracture

Question 20

What examination and investigations should you do for someone at menopause?

Answer 20

BP, BMI, review recent smears and mammography, confirmatory bloods

Question 21

What are the evidence based non pharmacological treatments for menopause?

Answer 21

weight reduction, exercise, smoking cessation, behavioural modification, meditation, CBT, paced respiration; avoid hot drinks containing caffeine, avoid spicy food, avoid alcohol, fans on desk and beside the bed, cooling scarves/clothing, wearing layers of loose cotton clothing.

Question 22

What are the evidence based hormonal pharmacological treatments for menopause?

Answer 22

Gabapentin >900mg/day (ADRs drowsiness, headaches and GI upset);
SSRI/SNRIs (citalopram and venlafaxine);
clonidine;
stellate ganglion block (only if severe debilitating sx where other Rx are contraindicated or ineffective);
Unclear evidence: phytoestrogens, black cohosh, st John’s wort, Chinese herbal medicine.

Question 23

What are the overall main findings from the Women’s health initiative study?

Answer 23

Combined HRT is associated with increased risk of breast cancer - 6-9 extra cases of breast cancer (baseline 63) per 100 women in 5 years of use (9 in 60-69yr group) with combined vs 2-5 extra with oestrogen only.
Cardiovascular benefits in 50’s and reduction in all cause cardiovascular mortality; neutral risk for women in their 60’s and harm if initiated in 70’s.
4-6 extra cases of endometrial cancer with oestrogen only.
5-8 extra cases of VTE with combined vs oestrogen only with a baseline rate of 26.
1-3 extra cases of stroke with other combined or oestrogen only treatment.
No increased risk of ovarian cancer, CHD or femur fracture.

Question 24

What are the participant characteristics to consider in WHI?

Answer 24

WHI included 50% of women who were high risk (smokers, BMI, HTN, diabetes, unfavourable gail risk score, ETOH intake) and included women who had previously been on MHT

Question 25

Which hormone types were associated with lower risk?

Answer 25

Micronized progesterone, levonorgestrel IUS, bio-identical progesterone and oestrogen.
- If using hormones, use the lowest dose to achieve symptomatic relief for the shortest possible duration.

Question 26

What are the benefits of MHT?

Answer 26

Most effective for vasomotor symptoms and vulvovaginal atrophy. Increased QOL, improves all cause mortality, reduces osteoporotic # risk, reduces colon Ca risk, reduces dementia risk if started at menopause.

Question 27

How long should MHT be used if <50 years old?

Answer 27

2 years after LMP

Question 28

How long should MHT be used if >50 years old?

Answer 28

1 year after LMP

Question 29

What regime should be used if <1 year since menopause

Answer 29

Cyclical

Question 30

Do perimenopausal women who are sexually active still need contraception?

Answer 30

Yes

Question 31

What are the contraindications to MHT?

Answer 31

personal history of breast cancer, cardiovascular disease, stroke, DVT

Question 32

Are precancerous or cancerous lesions of the cervix contraindications to MHT?

Answer 32

No

Question 33

Should you do a cardiovascular risk check prior to starting MHT? Why or why not?

Answer 33

Yes, because women at an already high risk of CVD in the future will find the increase with HT unacceptable

Question 34

What is the sequential regime for MHT?

Answer 34

Oestrogen is taken every day and the progestogen (needed for endometrial protection) for 10-14 days each month.

Question 35

When is a combined continuous MHT regime used?

Answer 35

At least one year post- menopause

Question 36

What is a combined continuous regime of MHT?

Answer 36

Oestrogen and progestogen every day

Question 37

Does vaginal oestrogen need progesterone cover?

Answer 37

No

Question 38

What fully funded oestrogen only options are available and what route are they given?

Answer 38

Progynova - PO
Ovestin - PV
Oestradot - transdermal

Question 39

What fully funded progesterone only options are available and what route are they given?

Answer 39

Primolut or Noriday (norithisterone)- PO
Provera (methoprogesterone acetate)
Mirena/Jaydess - IU (Levonorgestrel)

Question 40

Why does progesterone type matter?

Answer 40

Type significantly contributes to breast cancer risk

Question 41

When is combined cyclical MHT used?

Answer 41

< 1 year of amenorrhoea with uterus present or at perimenopause with uterus present

Question 42

What is the cyclical MHT called and is it funded?

Answer 42

Trisequens - partially funded

Question 43

What is the combined continuous MHT called and is it funded?

Answer 43

Kliovance (low dose) or Kliogest - partially funded

Question 44

When is combined continuous MHT used?

Answer 44

If >12months amenorrhoea or >12 months of combined cyclical has been used

Question 45

What are the contraindications to combined MHT?

Answer 45

Hx breast Ca, CHD, previous VTE, active liver disease, previous stroke/TIA, unexplained vaginal bleeding, endometrial cancer, SLE, Otosclerosis