Menopause Flashcards
Define menopause
Cessation of menses for at least 12 months, without a clear reason, due to loss of ovarian follicular activity and therefore oestrogen release
Define perimenopause
Period before menopause when the endocrinological, biological, and clinical features of approaching menopause starts. Characterised by irregular cycles of ovulation and menstruation and ends 12 months after the last menstrual period
What are the symptoms of menopause
Amenorrhoea
Hot flushes (sudden feeling of heat in the upper body that spreads) ± palpitations, anxiety
Night sweats
Vaginal symptoms: Dryness, Itching, Dyspareunia, Burning/irritation/discomfort
Reduced libido
Mood changes: Irritability, Mood swings
Recurrent UTIs
Sleep disturbance
Poor concentration and memory
What are the signs of menopause on examination
Height, weight, Blood pressure
Vaginal exam ( do NOT routinely do): Pale, dry vaginal mucosa
What are the differentials for menopause
Secondary amenorrhoea
Irregular bleeding: Endometrial polyps, fibroids, adenomyosis, endometrial hyperplasia
Hot flushes: hyperthyroidism, phaeochromocytoma, carcinoid syndrome, pancreatic cancer
Vaginal atrophy: trauma, infection, lichen sclerosis
Urinary incontinence: UTI, multiparity
What investigations should be done for menopause
Clinical diagnosis: if the woman (>45yo) has not had a period for at least 12 months (and is not using hormonal contraception)
Bedside: urine pregnancy test
Bloods: FSH (raised >30 2x 4-6 weeks apart), LH, oestradiol <110, androgens, TFTs, cortisol, HbA1c
Other: pelvic USS (endometrium <5mm)
When are investigations indicated for menopausal symptoms
NOT Taking contraception:
- Aged over 45 years with atypical symptoms.
- Aged between 40–45 years with menopausal symptoms, including a change in menstrual cycle.
- Younger than 40 years with a suspected diagnosis of premature ovarian insufficiency (POI)
- Over 50 years of age using progestogen-only contraception, including depot medroxyprogesterone acetate (DMPA).
If the FSH level is in the premenopausal range, the woman should continue contraception and the FSH level should be rechecked in 1 year.
What is the management for menopause
Assess treatment goals and refer to menopause clinic
Conservative
Non-hormonal
Hormonal
± contraception
+ follow up 3 months later
Describe the conservative measures for menopause
Hot flushes and night sweats: regular exercise, weight loss (if applicable), wearing lighter clothing/layers of clothing, turning down central heating, sleeping in a cooler room, using fans, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).
Sleep disturbances: avoiding exercise late in the day and maintaining a regular bedtime. Sleep hygiene
Low mood and anxiety: adequate sleep, regular physical activity, and relaxation exercises.
Cognitive symptoms: exercise and good sleep hygiene
CBT
What are the non-hormonal pharmacological measures for menopause
SSSRIs e.g. citalopram, fluoxetine, venlafaxine (Increases serotonin → improves Vasomotor symptoms)
Clonidine (alpha adrenergic receptor agonist)
Gabapentin
Evening primrose oil
What are the hormonal pharmacological measures for menopause
Oestrogen or progesterone or combined
- Hysterectomy → oestrogen only
- Uterus present → combined
Continuous or cyclical (perimenopause - oestrogen daily and progesterone for the last 10-14 days)
Oestrogen: oral, transdermal (gel or patch - BMI >30, VTE risk), implant
Progesterone: oral, pessary/gel, mirena coil
Women on HRT may get unscheduled bleeding within the first 4-6 months
Amenorrhoea desired → tibolone (oestrogen and androgen properties)
How long should contraception be used to women with menopause
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
What are the complications of the oestrogen-only HRT
Metabolised by the liver into its active form → affects cholesterol metabolism (lipidaemia) and clotting (increased DVT risk)
VTE (increased if oral, not if transdermal)
Stroke
coronary heart disease
Ovarian cancer
Breast tenderness/swelling, nausea, leg gramps, headache
What are the side effects of combined HRT
Increased risk of breast cancer (5 extra cases per 1000 women)
VTE → Increased stroke risk
Breast tenderness, coronary heart disease
Ovarian cancer (1 extra case per 1000)
Acne
What are the complications of menopause
Osteoporosis and fracture
CVD
Stroke
Cognitive decline
Parkinsonism
Vaginal atrophy, sexual dysfunction
Genitourinary syndrome of menopause, due to oestrogen depletement + natural ageing process