Menopause

Question 1

Menopause can be defined by which of the following?

1 - symptoms associated with menopause such as brain fog and hot flushes beyond >45 y/o
2 - no menstrual cycle beyond >45 y/o
3 - no menstrual cycle for >12 months whilst not using contraception
4 - all of the above

Answer 1

3 - no menstrual cycle for >12 months whilst not using contraception

Essentially causes a drop in oestrogen

Question 2

What is the mean age that menopause occurs?

1 - 40
2 - 45
3 - 48
4 - 51

Answer 2

4 - 51
- typically occurs between 45-55 y/o

Question 3

Premature menopause typically occurs in those under what age?

1 - 40
2 - 45
3 - 48
4 - 51

Answer 3

1 - 40
- can be caused by a myriad of reasons, including chemotherapy and surgery

Question 4

Menopause is defined as having no menstrual cycle for >12 months whilst whilst not using contraception. What is the definition of peri-menopause, also called premature ovarian insufficiency?

1 - symptoms associated with menopause such as brain fog and hot flushes beyond >45 y/o
2 - no menstrual cycle beyond >45 y/o
3 - symptoms associated with menopause such as brain fog and hot flushes alongside irregular menstrual cycles and bleeding
4 - all of the above

Answer 4

3 - symptoms associated with menopause such as brain fog and hot flushes alongside irregular menstrual cycles and intermenstrual/postcoital bleeding

Question 5

Although the diagnosis of menopause and peri-menopause, also called premature ovarian insufficiency is a clinical diagnosis, which hormone can be measured in women:

• aged 40-45 with menopause symptoms
• with change in menstrual cycle
• aged <40 with suspected menopause

1 - LH
2 - FSH
3 - oestrogen
4 - progesterone

Answer 5

2 - FSH
- need 2 separate samples 4-6 weeks apart

Low FSH can lead to low oestrogen, and body thinks it is going through menopause

Question 6

Women who are peri-menopausal, also called premature ovarian insufficiency should be advised to go on HRT therapy until the age of natural menopause.

True or False?

Answer 6

• True

Question 7

What % of women in menopause experience symptoms of menopause?

1 - 10-15%
2 - 20-30%
3 - 50-60%
4 - 80-90%

Answer 7

4 - 80-90%

Symptoms typically last 7 years

25% of patients have debilitating symptoms

Question 8

Patients who are peri-menopausal, also called premature ovarian insufficiency or menopausal can experience a variety of vasomotor symptoms. But which 2 of the following is by far the most common?

1 - hot flushes and night sweats
2 - mood disturbances
3 - brain fog
4 - vaginal/urethra atrophy
5 - osteoporosis
6 - cardiovascular disease

Answer 8

1 - hot flushes and night sweats
- 70-80% of women experience this

3 - brain fog
- become more aware of in primary care

Question 9

Osteoporosis is commonly linked with menopause and ageing in women. Low levels of which hormone has been identified as the cause of this?

1 - leutenising hormone
2 - progesterone
3 - estrogen
4 - follicular stimulating hormone

Answer 9

3 - estrogen

Low estrogen is also linked with increased CVD and dementia risk

Question 10

In addition to estrogen, which hormone is important for maintaining a healthy endometrium and reducing the risk of endometrial cancer?

1 - testosterone]
2 - growth hormone
3 - progesterone
4 - all of the above

Answer 10

3 - progesterone

Testosterone can be useful in treating loss of libido, low mood or energy levels.
It is currently not licensed in the UK but is often still prescribed especially in HRT clinics

Question 11

Although menopause or peri-menopause may be the most likely diagnoses, it is important to rule out other differentials. Which 2 of the following should be performed if a patient has a low impact fracture or family history of osteoporosis?

1 - FBC
2 - renal function
3 - X-ray
4 - DEXA

Answer 11

3 - X-ray
4 - DEXA

Question 12

Women who are experiencing menopause can experience significant mood swings. This is linked to low estrogen, which has been linked to causing low levels of which neurotransmitter?

1 - glutamate
2 - serotonin
3 - dopamine
4 - GABA

Answer 12

2 - serotonin
- linked to insomnia, mood swings, anxiety, poor concentration and loss of libido

Question 13

Vaginal/urethra atrophy can be a common symptom that occurs in women going through peri-menopause or menopause. Which of the following can subsequently occur?

1 - dysparuria
2 - dysuria
3 - vaginal bleeding
4 - polyuria
5 - urge incontenance
6 - all of the above

Answer 13

6 - all of the above

Question 14

As women age the number of oocytes declines and by the time women are >45 only a few thousand remain. Does the oocytes sensitivity increase or decrease in response to FSH and LH >45 y/o?

Answer 14

• decreases
• leads to amenorrhea

Question 15

In menopause, beyond 45, oocytes have less sensitivity to FSH and LH. Does this then increase or decrease the levels of estrogen, progesterone and testosterone?

Answer 15

• decreases levels of all 3

Question 16

In menopause, beyond 45, oocytes have less sensitivity to FSH and LH. Reduced sensitivity casues estrogen, progesterone and testosterone levels to reduce. Do the low levels of these hormones then cause an increase or decrease in FSH and LH?

Answer 16

• LH and FSH increase
• NO negative feedback loop to inhibit the hypothalamus and pituitary gland

Question 17

Although menopause or peri-menopause may be the most likely diagnoses, it is important to rule out other differentials. If a patient presents with urinary symptoms such as polyuria, dysuria and urgency, which of the following is least important?

1 - urine pregnancy test
2 - urine dipstick
3 - urine microscopy
4 - urodynamic testing

Answer 17

1 - urine pregnancy test
- all others are associated with the patients immediate symptoms

Question 18

If a patient presents with urogenital atrophy, which of the following is most appropriate to relieve the symptoms?

1 - oral combined HRT
2 - transdermal oestrogen
3 - oestrogen pessary
4 - Mirena intrauterine device

Answer 18

3 - oestrogen pessary
- low absorption, but can help with vaginal symptoms

Question 19

Although menopause or peri-menopause may be the most likely diagnoses, it is important to rule out other differentials. If a patient presents with intermenstrual and/or post-coital bleeding, which of the following is the least important?

1 - STI test
2 - cervical smear test
3 - X-ray
4 - colposcopy

Answer 19

3 - X-ray

Question 20

Managing menopause can be classified into

• hormonal replacement therapy (HRT)
• non-hormonal treatments
• non-pharmaceutical treatments.

Which of these 3 options is most common?

Answer 20

• hormonal replacement therapy (HRT)

Can come as:
- estrogen and progesterone
- estrogen only

Question 21

Why is estrogen alone a bad HRT treatment in women with a uterus?

1 - increases risk of breast cancer
2 - increases risk of ectopic pregnancy
3 - increased risk of pregnancy
4 - increase risk of endometrial hyperplasia

Answer 21

4 - increase risk of endometrial hyperplasia
- this could lead to endometrial cancer

• only those without uterus should be given estrogen only

Question 22

HRT can be administered in a variety of forms. Which of the following is NOT one of them?

1 - suppository
2 - vaginal (pessary)
3 - transdermal patch
4 - oral
5 - uterine

Answer 22

1 - suppository

uterine = Mirena coil provides progesterone arm of HRT

Question 23

HRT can have a number of benefits. Which of the following is NOT one of these?

1 - reduce menopause symptoms and ADL
2 - reduce risk of stroke
3 - increased BMD
4 - reduce risk of CHD, Alzheimer’s, colorectal cancer and T2DM

Answer 23

2 - reduce risk of stroke
- HRT has been linked with a small increase in the risk of stroke

Question 24

HRT can have a number of detrimental effects. Which of the following is NOT one of these?

1 - increased risk of DBVT/PE
2 - increased risk of stroke
3 - increased breast cancer
4 - increased risk of osteoporosis
5 - increased ovarian cancer

Answer 24

4 - increased risk of osteoporosis

HRT containn oestrogen and therefore increases BMD and therefore reduces risk of osteoporosis

Question 25

Which of the following is NOT a contraindication to HRT?

1 - endometrial cancer
2 - current, past or present breast cancer
3 - undiagnosed vaginal bleeding
4 - T2DM
5 - pregnancy
6 - undiagnosed breast lumps
7 - undiagnosed vaginal bleeding
8 - personal history of VTE

Answer 25

4 - T2DM
- may be protective of this, so not a contraindication

Question 26

Which of the following are adverse events of HRT?

1 - fluid retention and bloating
2 - tender breasts
3 - nausea
4 - headaches and mood swings
5 - unscheduled vaginal bleeding
6 - all of the above

Answer 26

6 - all of the above
- unscheduled vaginal bleeding is only for first 3 months

Healthy diet and exercise can reduce side effects

Also need to increase Ca2+ and vitamin D

Question 27

How often should patients have their HRT therapy reviewed?

1 - 12 weekly
2 - 6 monthly
3 - yearly
4 - every 2 years

Answer 27

3 - yearly

Question 28

Which form of hormone therapy can be offered to women with low libido due to menopause?

1 - estrogen and progesterone
2 - testosterone and estrogen
3 - testosterone
4 - estrogen only

Answer 28

3 - testosterone

Question 29

Women with menopause are typically rates on the severity of their symptoms, as mild, moderate and severe. Which of these severities would typically be offered lifestyle changes (weight loss, exercise, dietary) and complimentary therapy (CBT, reflexology)?

Answer 29

• mild and moderate
• if these dont work, HRT can be tried
• women with severe symptoms are put straight on HRT

Question 30

When prescribing HRT to patients, is there a standard dose, or should all patients be placed on the lowest dose possible?

Answer 30

• lowest dose possible

Question 31

Which of the following complimentary treatments has been shown to have an attenuating effect on vasomotor symptoms?

1 - St johns warts
2 - CBT
3 - exercise and weight loss
4 - all of the above

Answer 31

1 - St johns warts
- contains hypericin and hyperforin, which are thought to affect mood.

Question 32

Women >50y/o should remain on some form of effective contraception until when?

1 - 12 months after the last period
2 - as long as they like
3 - 24 months after the last period
4 - 36 months after last period

Answer 32

1 - 12 months after the last period

Question 33

Women <50y/o should remain on some form of effective contraception until when?

1 - 12 months after the last period
2 - as long as they like
3 - 24 months after the last period
4 - 36 months after last period

Answer 33

3 - 24 months after the last period

Question 34

Which of the following patients would be suitable for estrogen only HRT?

1 - hysterectomy with bilateral salpingo-oophorectomy
2 - Copper coil
3 - Mirena coil
4 - Combined oral contraception

Answer 34

1 - hysterectomy with bilateral salpingo-oophorectomy
- she doesnt need progesterone if she has no uterus

Question 35

In a post-menopasual women who still has her uterus and fallopian tubes required HRT. Should she be given sequential HRT or continuous combined HRT?

• sequential = 2weeks estrogen alone
  2 weeks oestrogen and
  progesterone
• continuous = estrogen and progesterone given together all the time

Answer 35

• continuous = estrogen and progesterone given together all the time

Sequential therapy is given to patients who are peri-menopausal

BOTH of these can be transdermal or oral, but typically Evorel patches are used

Question 36

How often are transdermal patches changed?

1 - every 24h
2 - every week
3 - every 2 weeks
4 - every month

Answer 36

3 - every 2 weeks

Vaginal gel, given as a cream can be given as a gel, pessary or cream called estriol cream

Question 37

Which 2 of the following HRT therapies provide systemic estrogen only?

1 - Estrogel (2 pumps OD)
2 - Utrogestan tablets
3 - Evorel 50 patch
4 - Evorel sequential

Answer 37

1 - Estrogel (2 pumps OD)
3 - Evorel 50 patch

Question 38

Anne comes to see you in clinic. She is struggling with vaginal dryness and loss of libido. She is worried about the effect it is having on her marriage and is starting to feel down. She has been amenorrhoeic for 3 years. Which 2 of the following would be useful non-hormonal treatments?

1 - anti-cholinergics
2 - vaginal lubricant
3 - vaginal moisturiser
4 - Mirena intrauterine system

Answer 38

2 - vaginal lubricant
3 - vaginal moisturiser

Question 39

Anne comes to see you in clinic. She is struggling with vaginal dryness and loss of libido. She is worried about the effect it is having on her marriage and is starting to feel down. She has been amenorrhoeic for 3 years. Should this patient be on estrogen only or combined oestrogen and progesterone?

Answer 39

Combined oestrogen and progesterone

Should be given continuous as she is post-menopausal

Question 40

A patient is keen to consider HRT for her menopausal symptoms of hot flushes and brain fog. You measure her BP as part of your work up and find out that it is 153/95. She is an ex-smoker. She had a hysterectomy aged 47 for HMB. Which of the following is most appropriate for this patient?

1 - Combined oestrogen and progesterone HRT
2 - Estrogen only HRT
3 - Combined oral contraception pill
4 - Mirena intrauterine system

Answer 40

2 - Estrogen only HRT

She has no uterus, so this is safe

However, her BP needs to be addressed