Menopause

Question 1

Definition

Answer 1

Defined as amenorrhoea > 12 months
- Women have a finite number of oocytes (eggs) at birth
- These gradually decline with each menstrual cycle
- When the oocyte store is depleted, menstruation stops = MENOPAUSE

Question 2

Epidemiology and riskfactors

Answer 2

• Early menarche
• Nulliparity or low parity
• Smoking
• Overian surgery or cancer treatment
• Loose association with maternal age of menopause

Question 3

Perimenopause Pathophysiology

Answer 3

Menopause can cause problematic symptoms which can start before menstruation stops = perimenopause = can last several years.
Hormonal changes during perimenopause:
- Oestrogen and inhibin levels decrease + FSH, LH increased
- Estradiol levels drop with reduced ovarian activity
- Eventually, the level becomes insufficient to stimulate the endometrium, and menstruation stops
- The reduction in oestrogen = contributes to the development of vasomotor symptoms

Question 4

Menopause classification

Answer 4

• Early menopause = between 40 to 45 years
• Premature menopause = under the age of 40. This may be secondary to surgery or chemo radiotherapy.
• Premature ovarian failure: This is a clinical syndrome defined by loss of ovarian function before the age of 40
  = Unlike in premature menopause, this loss of function may be temporary and there may be a return of ovulation and menstruation.

Question 5

Signs

Answer 5

• Reduced bone mineral density
• Vaginal atrophy

Question 6

Symptoms

Answer 6

Vasomotor symptoms:
- hot flushes
- night sweats
Change in menstrual pattern
- during perimenopause = may become more irregular
- eventually ceases completely
Psychological symptoms
- cognitive impairment: ‘brain fog’, poor connection, poor memory
- mood disorders: anxiety, low mood, irritability
- sleep disturbances.
Genitourinary symptoms:
- Vulvovaginal dryness and discomfort or atrophy
- Urinary symptoms: dysuria, frequency, urgency, recurrent UTI
Sexual dysfunction:
- Reduced libido
- Dyspareunia and itching secondary to vaginal dryness
General symptoms
- Fatigue and headache
- Joint and muscle pain

Question 7

Diagnosis

Answer 7

Clinical diagnosis
Investigations to consider:
- FSH levels: in women with suspected menopause < 45 years + atypical symptoms
= 2 FSH levels done 4-6 weeks apart
= >30 IU/L suggestive of menopause.
= FSH levels may be normal during the perimenopause due to variability in levels throughout the cycle.
Pregnancy test
Investigations to rule out other hot flushes: hyperthyroidism, phaeochromocytoma, malignancy
Investigations to rule out other causes of irregular menstrual bleeding: vaginal swabs, pelvic USS, colposcopy/hysteroscopy

Question 8

Treatment (Hormonal)

Answer 8

FIRST LINE = HRT: ALWAYS PRESCIBE OESTROGEN WITH PROGESTERONE IN WOMEN WITH UTERUS!!!
- Oestrogen therapy: for women with intact uterus, no hysterectomy
- Combined regimes: can either be continuous or sequential
= Continuous regime: offered to women who have had amenorrhoea for >12 months. Oestrogen and progesterone administered continuously throughout the month
= Sequential/Cyclical regime: monthly or 3-monthly HRT where progesterone is added for only part of the month = causes regular monthly bleed. Recommended for perimenopausal women who are still getting their period.

Question 9

Forms of HRT

Answer 9

Tablets, patches, and gels

Question 10

When is vaginal oestrogen used

Answer 10

If symptoms are predominantly vulvovaginal, or in combination with systemic HRT

Question 11

Benefits of HRT

Answer 11

• Symptom control
• Improved quality of life
• Maintenance of bone mineral density and reduction in osteroporotic fractures
• Reduced risk of colorectal cancer

Question 12

Risks of HRT

Answer 12

Endometrial cancer: if oestrogen is used alone in women with an intact uterus
DVT: greated risk in first 12 months on HRT
Breast cancer: HRT> 5 years
CVD : HRT in women +60

Question 13

Non hormonal treatments

Answer 13

Less effective than HRT
- Vaginal moisturisers and lubricants
- For vasomotor symptoms:
= selective serotonin reuptake inhibitors (SSRIs) (e.g. fluoxetine),
= selective noradrenaline reuptake inhibitors (e.g. venlafaxine), clonidine, gabapentin,
- cognitive behaviour therapy (CBT)

Question 14

Lifestyle advice

Answer 14

• Avoid possible triggers for hot flushes, including spicy foods, caffeine, alcohol, smoking
• Regular exercise
• Weight loss if appropriate
• Stress management
• Contraception :
  = Women <50 years old: advise contraception until 2 years after the last menstrual period
  = Women >50 years old: advise contraception until 1 year after the last menstrual period

Question 15

Complications

Answer 15

Postmenopausal women are at increased risk of:
- Osteoporosis and fracture
- Cardiovascular disease and stroke
- Genitourinary syndrome of menopause: i.e. vulvovaginal and urinary symptoms causing by reducing oestrogen levels

Premature or early menopause may be associated with an increased risk of:
- Osteoporosis and fracture
- Cardiovascular disease
- Type 2 diabetes
- Depression