Menopause Flashcards
Menopause-symptoms
Vasomotor symptoms - hot flushes / night sweats
80% women affected 45% significant problem
usually last 2-5 yrs- but may be 10 years+
Vaginal dryness / soreness
Low libido
Muscle and joint aches
? Mood changes / poor memory – possibly related to vasomotor symptoms affecting sleep
menopause definition
The menopause is a woman’s last ever period
average age 51
1/3 of UK lifespan after menopause
perimenopause for approx 5 years before
premature menopause = 40 years or less affects 1% of women
Menopause-silent change- Osteoporosis
reduced bone mineral density DEXA scan bone density described as T score
Problems: fractured hip / vertebra 1% women 50-69 significant morbidity+mortality
what are risk factors of osteoporosis
Osteoporosis risk factors: thin/caucasian/smoker/ high EtOH/+ve FH esp male or younger age /malabsorption Vit D or Calcium / prolonged low oestrogen amenorrhoea /oral corticosteroids / hyperthyroid
how is osteoporosis prevented and treated
Prevention & treatment: wt bearing exercise , adequate calcium & Vit D, HRT, bisphosphonates, denosumab -monoclonal antibody to osteoclasts, calcitonin
Menopause- symptom treatment
Hormone replacement therapy (HRT)
1/ Local vaginal HRT oestrogen pessary/ring/cream
Local effects -minimal systemic absorption
Need to use longterm to maintain benefit
2/ Systemic oestrogen transdermal patch /gel or oral
transdermal avoids first pass- less risk VTE
a/oestrogen only if no uterus b/oestrogen + progestogen if uterus present progestogen oral , patch or LNG IUS progestogen prevents endometrial hyperplasia from unopposed oestrogen
Contraindications to Systemic HRT
NOT the same as contraindications to combined
hormonal contraception- very few CI
1/Current Hormone dependent cancer breast/endometrium
2/ Current active liver disease
3/ Uninvestigated abnormal vaginal bleeding
4/ seek advice if prev VTE, thrombophilia, FH VTE
5/ seek advice if previous breast cancer or BRCA carrier
Contraindications to Vaginal HRT
Avoid for women taking aromatase inhibitor treatment for breast cancer -but may choose to use if symptoms affecting quality of life.
No other CI as minimal systemic absorption
Menopause- symptom treatment (2)
Selective Estrogen Receptor Modulators (SERMs)
E effect on selected organs
eg tibolone has E effect on flushes, bones but not endometrium
clonidine or SSRI SNRI antidepressants eg venlafaxine NOT recommended for vasomotor symptoms. Frequent side effects & few women benefit
phytooestrogen herbs eg red clover/soya
hypnotherapy/ exercise / cognitive behavioural therapy
Non hormonal lubricants for vaginal dryness
Regular eg Replens TM or Pre sex ‘Sylk’ TM Yes! TM
HRT benefits
vasomotor
local genital symptoms
osteoporosis
HRT risks
breast and ovarian cancer
venous thrombosis
HRT use NICE guidance 2015
For treatment of severe vasomotor symptoms, review annually
For women with premature ovarian insufficiency
HRT benefits outweigh risks till age 50
Not as first line for osteoporosis prevention / treatment (bisphosphonates instead)
Use vaginal oestrogen if vaginal symptoms
No absolute upper age limit or maximum duration of HRT use
Andropause
Testosterone falls by 1% a year after 30
DHEAS falls
Fertility remains
No sudden change
? a medical disorder
( different from hypogonadism)
Primary amenorrhoea:
never had a period
affects 5% girls
delayed puberty if
>14yrs and no 2ndry sexual characteristics
>16 years if 2ndry sexual characteristics
( separate lecture)
Secondary amenorrhoea:
has had periods in past but none for 6 months
Secondary amenorrhoea : causes
Pregnancy / Breast feeding
Contraception related- current use or for 6-9 months after injectable
Polycystic ovary syndrome
Premature ovarian insufficiency
Hypothalamic- stress/ 10% wt change / excess exercise/ any severe illness
Thyroid disease/ Cushings
Raised prolactin- prolactinoma/ medication related
Congenital adrenal hyperplasia ( CAH)
Androgen secreting tumour- testosterone >5mg/l
Sheehans syndrome- pituitary failure
Ashermans syndrome- intrauterine adhesions
Secondary amenorrhoea: history
Possibility pregnancy ?
Breastfeeding ?
Medicines including contraception incl opiates/antipsychotics/metoclopramide
Galactorrhoea /visual change ( prolactin ↑)
Acne / hirsutism /voice change ( androgen↑)
Weight change
Exercise /stress
Significant illness
Secondary amenorrhoea: exam and tests
BMI, Cushingoid
Acne Hirsutism Virilised- enlarged clitoris/deep voice
Abdominal & bimanual exam ? Pelvic mass- pregnant uterus/ ovarian cyst
urine pregnancy test
bloods FSH oestradiol ( menopause)
prolactin
thyroid function
testosterone & SHBG – free androgen index
17 hydroxy progesterone ( CAH)
pelvic ultrasound- ?polycystic ovaries
Secondary amenorrhoea
treatment
Treat specific cause
BMI >20 <30 ideal for ovulation
Assume fertile and need contraception unless 2 yrs after confirmed menopause
If premature ovarian insufficiency offer HRT till 50
emotional support incl Daisy network
check for Fragile X relatives may wish testing
Polycystic ovary syndrome diagnosis
Diagnosis-Need 2 out of 3 of the following:
oligo/amenorrhoea
androgenic symptoms: excess hair/acne
Polycystic ovarian morphology on scan
( ie may have PCOS with normal looking ovaries)
Normal/high oestrogen levels
Increased androgens – acne/hirsutism
? Underlying cause is insulin resistance
US definition of polycystic ovaries
Small peripheral ovarian cysts x 10/0vary or
ovarian volume>12cm3
NB 20% women have this on scan but no other features ie not PCO syndrome
NB Multicystic ovaries common in adolescents and not associated with PCOS- don’t diagnose PCOS till late teens
management PCOS
Weight loss/exercise to BMI 20-25
can help all symptoms
increases SHBG so less free androgens
?increased NIDDM risk even if slim consider GTT
Support & information– Verity patient support group
Antiandrogen
- combined hormonal contraception if no CI
- spironolactone
- eflornithine cream reduces facial hair growth
Endometrial protection
CHC, Mirena IUS
Oral provera 10 days every 90 days if no period to cause withdrawal bleed
Fertility Rx clomiphene / metformin usually effective for ovulation induction
Underlying cause – insulin resistance Metformin- may encourage ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss
