Menopause

Question 1

Background

Answer 1

Menopause = when menstruation stops permanently due to the loss of ovarian follicular activity. (NO longer have children)
Average age is 51
Early menopause = 40-45

Perimenopause = the period before the menopause characterized by irregular cycles of ovulation and menstruation and ends 12 months after last menstrual period.
Last 2 - 8 years. Is a decline of oestrogen bc depletion of ovarian follicles. Also = progesterone decline.
So NO negative feedback = elevated FSH and LH.
Due to less oestrogen can get VMS symptoms. Which increases body temp, promote heat loss by vasodilation and sweating. Then the menstrual cycles become anovulatory (without ovulation(eggs)).
Estradiol production decreaes too so can’t stimulate endometrium and ammenorrohea begins.
Eventually pattern of low oestrogen and high FSH and LH established. (CHECK PACK TO SEE WHAT LESS ESTRADIOL LEADS TO)

Post menopause = no period for 1 year.

Premature ovarian insufficiency (POI) = transient or permanent loss of ovarian function before 40 years.

Question 2

Signs and Symptoms

Answer 2

Symptoms will start in perimenopause and carry on post menopause. Every person will have different experience.
- Mental symptoms:
Anxiety, mood swings, brain fog (concentration/memory issues)
- VMS vasomotor symptoms:
hot flushes, Night sweats, Sleep disturbance, daytime fatigue
- Irregular periods (shorter cycles <25 days possible) - eventually will stop having any periods
- Urogenital mucosa:
Vaginal dryness, irritation, infection chance increase, painful sex, reduced libido, dysuria
- CV:
Increase in BP, increase in cholesterol (BC estradiol decrease) = More risk of MI

Question 3

Diagnosis/Assessment

Answer 3

Diagnosis of periM or M should be sus if:
- Is a change to the menstrual pattern.
- Are symptoms inc. VMS, mood disorders, urogenital S, altered sexual function, sleep disturbance, and fatigue.
Diagnose if:
- PeriM = VMS + Irregular periods
- M = NO periods for 1 year (MIN)
- M = if women has no uterus = use symptoms

DONT USE Blood test for FSH levels in healthy women not on hormonal contraception >45 yrs.

USE BLOOD TEST for FSH IN:
- >45 years + atypical symptoms;
- Aged 40–45 years + symptoms; and
- <40 years + SUS POI.
- >50 Using DPMA (depot medroxyprogesterone) (if FSH in premenopausal range carry on for 1 year then review)

Assessment
ASK on:
- Symptoms
- Potential causes of amenorrhea
- Life style factors
- Co morbidities
- Family Hx of premature M or POI
- Treatment goals
EXAMINE BP, BMI.
IF sudden change in menstrual pattern urgent 2 week referral if gynaecological cancer sus

Question 4

Complications of P/M

Answer 4

Postmenapause ppl Increased risk of:
- Osteoporosis
- CVD
- Stroke

Early menopause ppl increased risk of:
- CVD
- T2DM
- Osteoporosis
- Depression

Question 5

Treatment/Management

Answer 5

Mainly to manage symptoms:
But give lifestyle advise and info on Menopause etc.

Mild symptoms = OTC, Vaginal lubricants.

SHORT TERM SYMPTOMS:
- VMS = HRT- (Combined can be oral or transdermal). Oestrogen only if no uterus
- Psychological S = Consider HRT (ORAL or TRANSDERMAL) + CBT
- Altered sexual function = consider HRT fail then Testosterone supplements for low libido
- Urogenital S = 1st line Low dose Vaginal oestrogen cream PRN
ALT trial of oral ospemifene
FOR HRT ALT can be tibolone reduces oestrogen deficiency and osteoporosis fragility fracture risk.

NON HORMONAL TREATMENTS:
Advise on lifestyle measures
VMS = Options:
- Trial SSRi or SNRi 2 weeks
Options = fluoxetine (20mg daily), citalopram (20mg daily), paroxetine (10mg daily), or venlafaxine MR (37.5mg daily for 1 week then increased to 75mg OD if needed).
- Clonidine - Initially 50 mcg BD for 2 weeks, then increased to 75mcg BD, if needed
- Gabapentin - Up to 300mg TDS, initial dose should be lower and titrated up over 3 days.
- CBT
Mood disorder= CBT trial, antidepressant if confirmed depression
- Urogenital S= Vaginal moisturizers( Replens MD®2/7)/lubricants

LONG TERM SYMTPOMS:
Refer complications/benefit of HRT

Question 6

OSTEPOROSIS

Answer 6

1ST LINE bisphosphonates - Alendronic acid or Risedronate sodium ALT oral Ibandronic acid
ALT parenteral Bisphosphonates or Denosumab If cant use ORAL.
EXTRA ALT raloxifene or strontium.
HRT another extra ALT BUT restricted to younger post Menopausal. HRT then tibolone

SEVERE osteoporosis Teriparatide. Romosozumab - severe osteoporosis who have previously EXP fragility fracture and at risk of another (within 2 yrs)
When 1 severe or 2 moderate vertebral fractures teriparatide or romosozumab > Oral bisphosphonates

MOA:
Bisphosphonate - Inhibit osteoclasts activity and promote apoptosis.
Raloxifene - increasing osetoblast acitivty and reduce osetoclast activity
Strontium - stimulates bone formation and reduces bone resorption
Teriparatide - stimulate osteoblast numbers and decrease osteoblast apoptosis
Romosozumab - humanised monoclonal antibody that inhibits sclerostin, = increase bone formation and decrease bone resorption.

Question 7

Complications/Benefits of HRT

Answer 7

COMPLICATIONS:
- VTE - Increased with HRT. >oral than patch. Transdermal 1st IF VTE risk and BMI>30.
- Stroke - Risk increases with age. HRT slight increase risk. Tibolone high increase.
- CVD - No affect IF started on <60 yrs
- Breast cancer - HRT combined = increase in risk. Treatment duration increases risk of BC, stopping HRT reduces risk.
- Endometrial cancer risk increased in oestrogen alone. BUT combined risk is reduced.
- Ovarian cancer small increased risk after long use but disappears within few years of stopping.

BENEFITS:
- Osteoporosis - Risk of fragility fracture decreased with HRT.
- VMS symptoms reduced
- Atrophy of urogenital organs reduced

Question 8

Starting and stopping HRT/ Other info

Answer 8

Vaginal bleeding can occur for 1st 3 months WHEN USING HRT should report at 3 month appointment. Can gradually reduce or rapid stop HRT.
- Gradual reduce = decrease short term symptom. Long term no difference.

Women with, or at high risk of, breast cancer:
- Give info on treatment available
- Inform that SSRi’s paroxetine and fluoxetine DONT TAKE WITH TAMOXIFEN

Question 9

Review/Referral

Answer 9

SHORT TERM/non Hormonal:
Review at 3 months then annually to asses safety and tolerability. Refer to HCP if symptoms don’t improve.
- Any AEs deal with them via change/reduce dose, change form. Switch to a combined oestrogen/ bazedoxifene acetate preparation if Progesterone only fails.

Referral to a specialist offered if:
- Ongoing symptoms despite treatment.
- Persistent, troublesome AEs.
- Uncertainty about the most suitable treatment option.
- Uncertainty about the diagnosis or management of POI.