Menopause

Question 1

How is the menopause defined?

Answer 1

Last menstrual period. In practice, thought, difficult to know when this is. So in practice, this is defined as amenorrhoea for 1 yr with other causes excluded.

Question 2

What is the average age of occurrence of menopause?

Answer 2

Average age is around 52, with a span of around 45 to 55. Menopause before the age of 40 is referred to as premature ovarian failure.

Question 3

What are they symptoms of menopause?

Answer 3

Hot flushes, vaginal dryness, night sweats, palpations, insomnia. Can occur up to 5 years before final menstrual period. Very bad for some, not too bad for others.Other features include change in mood, irritability, depression,loss of concentration, and formication.

Question 4

How long do menstrual symptoms last?

Answer 4

Vasomotor symptoms typically decrease 2 yrs after the final menstrual period, but psychological features may last longer.

Question 5

What are the long term problems of menopause? And why?

Answer 5

Osteoporosis (lack of oestrogen).Cardiovascular risk increased.Urinary incontinence, esp. stress incontinence. Also bladder outflow obstruction leading to overactive bladder. (This is due to lack of oestrogen meaning degradation of connective tissue esp. in overweight people - pelvic floor disruption).Increased UTI (change in vaginal bacteria + atrophy).Sometimes skin dryness, thinness, and poor skin healing.Related to this dyspareunea –> loss of libido.

Question 6

What different reasons might a woman want to check if she is menopausal?

Answer 6

1) Seeing if pregnancy still possible.2) Explain symptoms/just to know.

Question 7

What is the test for “ovarian reserve” i.e., to see if someone is approaching the menopause in context of wanting to get pregnant?

Answer 7

FSH, taken on day 2-3 of a cycle.<15 - can still produce viable eggs.15-30 - perimenopausal.30+ usually post menopausal.However, not totally reliable. Anti-mullarian hormone can also be used, but though this is more accurate, it is generally not done in primary care.

Question 8

What is a good first line way to check if someone is peri-menopausal?

Answer 8

Can try one month of HRT (assuming right age group + symptoms fit). If symptoms disappear, then this is highly suggestive of menopause, and can discount other causes.If no change in symptoms, have to start looking for other causes. E.g., routine bloods, note diabetes can mimic some symptoms.

Question 9

How does the efficiency of contraception change as menopause is approached?

Answer 9

All forms become much more efficient.

Question 10

What is contraceptive advice for women who enter menopause and whose periods stop?

Answer 10

FPA recommend women under 50 should continue contraception for 2 years; women over 50, for 1 year.

Question 11

How many percentage of women in the UK use oral contraception?

Answer 11

Oral contraception is used by 25 - 30% of couples in the UK.

Question 12

What are the reasons for using oral contraception?

Answer 12

1) Contraception!2) To manage irregular menstrual cycles.3) To ameliorate dysmenorrhoea .4) To manage endometriosis (preparations with relatively low oestrogen and high progesterone).5) sometimes to manage acne.

Question 13

What factors should be considered when deciding which oral contraceptive to offer?

Answer 13

Loads! Age, smoking habits, BMI, cardiovascular risk, pre-existing acne/hirsuitism…

Question 14

What hormones do COC and POP contain?

Answer 14

COC contains both an oestrogen and progesterone; POP just progesterone.

Question 15

What is the maximum age that COC can be given to?

Answer 15

50If they smoke, then 35.If they have a BMI >30, risk of DVT is high and they should be counselled about an alternative.

Question 16

What contraindicates the use of COC?

Answer 16

1) over 502) smoker over 353) focal migraines, severe or crescendo migraines, TIA’s.4) BP >140/905) VTE in first degree relative (not absolute - thrombophilia screen should be performed first though)6) Existing pregnancy (you could get into all kinds of legal ho water here by causing an abortion!)7) multiple risk factors for arterial disease.8)Liver disease (gallstones, adenoma, porphyria, hepatitis, disorders of hepatic excretion).9) Personal Hx of VTE or thrombotic disease.10)Valvular heart disease with risk of thrombus or pulmonary hpt11) Varicose veins during sclerosing treatment.12)Undiagnosed vaginal bleeding.13) Breast or genital tract cancer14) Breast feeding15) Hydatiform mole until gonadotrophins normal16) If in a prev pregnancy had: pruritus, pemphigoid, chorea, cholestatic jaundice, osteosclerotic deterioration.

Question 17

COC also reduces the risk of certain cancers - which ones?

Answer 17

Ovarian and endometrial.Also less risk of ovarian cyst.

Question 18

Does COC use increase the risk of any cancers?

Answer 18

If taken for longer than 5 years, then the risk of cervical cancer is increased.Breast cancer in some sub groups of women.

Question 19

What group of drugs make the COC less effective?

Answer 19

Liver enzyme inducers. (Additional barrier methods should be used until 4 weeks after the liver enzyme inducer is stopped!)

Question 20

What is the relative risk of VTE in a “normal” woman taking the COC?

Answer 20

It is x5! BUT in absolute terms this is still relatively low, and less than in pregnancy.

Question 21

What are the risks of taking COC?

Answer 21

1) failure 2) VTE3) ischaemic stroke4) ischamic heart disease (BUT only in unhealthy smokers!)5) unpredictable breakthrough bleeding (though this is more common with POP)

Question 22

Do women who take COC put on weight?

Answer 22

No evidence for this.

Question 23

How is the COC effective?

Answer 23

It inhibits ovulation via inhibiting GnRH. Also has effects on cervical mucous (less penetrable to sperm) and endometrium (making it more atrophic and less conductive to implantation), and interfering with transport of ova down fallopian tube (if ovulation does occur, that is!).

Question 24

How effective is COC?

Answer 24

> 99% (when used correctly)

Question 25

When should COC be started in terms of the cycle?

Answer 25

Day 1 (i.e., the first day of bleeding) but can be started unto day 5 (otherwise additional contraception needed for first 7 days; and it can only be started then if there is no chance of pregnancy).

Question 26

Can oral contraceptives be taken by breastfeeding women? If so, when?

Answer 26

COC - no!POP - yes!If they are not breastfeeding, COC can be started day 21 post partum.

Question 27

How consistently does the COC need to be taken?

Answer 27

Within 12 hours of the same time each day (cf POP).

Question 28

How many days in a month does a women take COC?

Answer 28

21 days. Then 7 days off (or placebo pills) during which a withdrawal bleed occurs.They are still contraceptively covered during those 7 days off/placebo.

Question 29

When should women taking the COC be advised to come to the practice for a pregnancy test?

Answer 29

If they have missed or late pills, vomiting or diarrhoea, or use a new drug (as it might be an enzyme inducer) AND there is then either no withdrawal bleed or only a very light bleed.

Question 30

Are women taking broad spectrum (but not enzyme inducing) abx contraceptively covered by the COC?

Answer 30

No! They should be advised to use additional barrier methods during the course of the abc and for 7 days afterwards!

Question 31

Are women who are taking rifampicin covered contraceptively by the COC?

Answer 31

No! Not while taking it, and not for 4 weeks afterwards!

Question 32

What are the two common progesterones used at low dose in COC?

Answer 32

Norethistrone and levonorgestrel.

Question 33

Focusing more on arterial risk factors and the COC, what does the BNF say?

Answer 33

Use with caution if one risk factor, contraindicated if two.1) Smoking (>40/day = contraindication)2) Diabetes mellitus (if complications, then contraindicated).3) Over 35.4) BMI >30 (contraindicated if BMI >39)5) Fx of MI or CVA in 1st degree relative 30 - contraindicated

Question 34

Is the POP or COC more effective?

Answer 34

COC - >99%POP is less effective, with a failure rate of 2-6 per 100 women years.

Question 35

How does the POP work?

Answer 35

Does NOT inhibit ovulationIncreases viscosity of cervical mucous, “sperm cannot pass!”Changes in the endometrium inhibit implantation.Interfere with tubal transport of ova.: cerezette does sometimes inhibit ovulation.

Question 36

What are the advantages of POP over COC?

Answer 36

No increased risk of VTE.Do not inhibit lactation - so can take while breastfeeding.Suitable for diabetics.Useful when the COC is contraindicated.

Question 37

What s/e’s of POP?

Answer 37

Irregular low grade uterine bleeding, but this often settles into a regular cycle after 6-9/12.Skin reactions.Breast fullness.Depression.Increased risk of ectopic.Slight increase in breast Ca risk.

Question 38

On how many days of the cycle are the POP taken?

Answer 38

Continuously, every day.

Question 39

Does the POP increase risk of CVD?

Answer 39

Current evidence seems to suggest not, as opposed to the COC.

Question 40

Does the POP affect BP?

Answer 40

Again, NICE are being cautious! It seems that it does not increase the BP of women taking POP. But NICE warn caution. In fact, newer POP’s (e.g., drosperenone) have a anti-mineraliocorticoid effect, meaning they can actually lower BP very slightly!

Question 41

When should the POP be started?

Answer 41

Generally on the first day of the cycle, i.e., day 1 of bleeding. If switching from COC, then take POP immediately after the last COC - i.e., no withdrawal bleed period.

Question 42

How forgiving is the POP in terms of when it is taken?

Answer 42

Less than the COC! Should be taken within 3 hours of the same time each day. EXCEPT cerazette, which has a 12 hour window and often inhibits ovulation.NOTE - this does not make it a better contraceptive than other POP’s.

Question 43

Do enzyme inducers affect POP?

Answer 43

Yes! They continue to reduce POP efficiency for 8 weeks after discontinuation - extra protection advised!

Question 44

Does taking abx affect the efficacy of POP?

Answer 44

Generally it does not! However, enzyme inducers (e.g., rifampicin) do, and women should be warned of this.

Question 45

What morning after pills are there? Is there another option?

Answer 45

1) Levonorgestrel pill 1.5mg taken up to 3 days after intercourse.
2) Ulipristal (ellaOne) (SERM) may be used up to 120 hours after unprotected sex, taken as a single dose. (For these two pills, the earlier they are taken, the more likely they are to work).
3) Also copper IUD - failure rate of 0.1% (i.e., the best) and can be implanted up to 5 days after sex.In all cases, follow up is essential and should occur 3-4 weeks later.

Question 46

Are there any contraindications to the morning after pill?

Answer 46

1. Hx of thrombosis2. Active acute porphyria3) Current severe liver disease4) Focal migraine at time of presentation.

Question 47

What are the current British Menopause Society guidelines one HRT? (This comes from GP update - comes from a systematic review of available evidence and looking again at the million women study. The guidance is supported by RCOG, but not worldwide!)

Answer 47

1)The decision whether to use HRT should be made by each woman having been given sufficient information to make a fully informed choice.2)HRT dosage, regimen and duration should be individualised and reviewed annually.3)Arbitrary limits should not be placed on the duration of usage; if symptoms persist, the benefits of HRT usually outweigh the risks (this statement is not referenced by the BMS!).4)HRT prescribed before the age of 60y has a favourable benefit/risk profile.5) Encourage women with premature ovarian failure to use HRT at least to the average age of menopause.6) If HRT is to be used over the age of 60y, lower doses should be started preferably with transdermal route, because of its lower VTE risk.

Question 48

What is the cause of the menopause, and what effect does it have? What, then, is given as HRT?

Answer 48

Caused by falling levels of oestrogen. This causes the vasomotor effects (hot flushes, dry vaginas and dyparaunea, urinary infections, etc); but unopposed oestrogen causes proliferation in an intact uterus; thus, women who have a uterus and have HRT are given progesterone, too.

Question 49

What are the three main types of HRT?

Answer 49

1) Oestrogen only – for women who have had a hysterectomy.
2) Cyclical HRT (oestrogen and progesterone added sequentially to trigger a bleed) – minimises irregular bleeding in perimenopausal women.
3) Continuous combined HRT (daily dose of oestrogen and progesterone) – use only once women are a year or more from their last period otherwise spotting and erratic bleeding is likely.

Question 50

Although there are three main types of HRT, there are other approaches - what are the three?

Answer 50

1) The progesterone component can be delivered as a Mirena IUS, with oral or topical oestrogen used alongside this.2) Transdermal patches of oestrogen alone and combined HRT are also available.3) In perimenopausal women who also need contraception, if there are no contraindications, the COCP will treat hot flushes.

Question 51

What are the indications for HRT? (There are 2, but there is a third reason which is NOT an indication, for which it is often given!)

Answer 51

1) For control of vasomotor symptoms impacting on quality of life in perimenopausal and menopausal women.
2) HRT is recommended for women with premature (<45y) menopause until the age of 50y for symptom control and bone protection.
3) Bone protection, low libido, low mood and vaginal symptoms are not indications for oral HRT though they may be helped by taking it!

Question 52

How effective is HRT?

Answer 52

It is the most effective available treatment for vasomotor symptoms:Reduces frequency of flushes by on average 18 per week!Reduces severity by 87%.There is also evidence that it reduces fracture risk, improves vaginal dryness and sexual function and may improve sleep and muscle aches and pains.

Question 53

What are the two main risks of HRT?What other risks?

Answer 53

VTE and breast cancer.Slight increase in risk of cholecystitis (lower in transdermal HRT).Increase in risk of endometrial cancer IF the woman has a uterus and IF she does not take progesterone as well as oestrogen.Increased risk of stroke, especially over 60yrs.

Question 54

What is the relationship between HRT and VTE?

Answer 54

-All oral forms of HRT increase the risk of DVT, PE and stroke.-This risk increases with age and is highest in the first year of use.-In prescribing HRT other risk factors such as obesity, smoking and immobility should be considered.-Previous VTE or high risk of VTE (e.g. thrombophilia) are both absolute contraindications.-Routine screening for thrombophilia is not indicated.-It is uncertain if transdermal HRT carries the same risk – it is probably lower.

Question 55

What is the relationship between HRT and breast cancer?

Answer 55

-Combined HRT increases the risk of breast cancer diagnosis and breast cancer mortality.-Combined HRT increases breast density and the risk of an abnormal mammogram.-The data for oestrogen-only HRT are conflicting, however: The Women’s Health Initiative study did not show an increased risk taking oestrogen-only HRT for 7y. BUT the Million Women Study showed a small increased risk.-The starting age for HRT matters. Starting HRT before or soon after menopause (cessation of menses) was associated with a higher risk of breast cancer than starting some time later. Also, longer duration of use increases risk of breast cancer (J Natl Cancer Inst 2011;103:296).

Question 56

Can you summarise the relative risk of breast cancer with either oestrogen-only HRT and with combined HRT for women who start 5yr after the menopause?

Answer 56

If started early, i.e., 5yr after the menopause, then the RR is 2.04 (1.97-2.12)If started late, i.e., >5yrs after menopause, RR of breast cancer is 1.05 (0.89-1.23) in oestrogen only HRT, or 1.53 (1.38-1.69) with combined HRT.So there is an increased risk, but it is not huge, it is higher if it is started early, and it is lower with oestrogen only HRT.

Question 57

What about the relative risks of women who use HRT (oestrogen only Vs combined) by total duration of < or > than 5yrs (i.e., not when it is started?

Answer 57

If the total duration is less than 5yrs, the RR of breast Ca is 1.24 (1.14-1.35) in oestrogen only HRT and 1.62 (1.54-1.71) in combined HRT.If the total duration of HRT is > 5yrs, the RR of breast Ca is 1.44 (1.37 - 1.52) in oestrogen only HRT, and 2.19 (2.10-2.27) in combined HRT.So, again, longer use, and use of combined HRT increases the risk of breast Ca, though the RR is not huge.

Question 58

What about HRT and stroke?

Answer 58

-HRT increases the risk of stroke and this becomes a greater risk with age and duration of use, particularly over age 60y.-Avoid HRT and tibolone (basically an oestrogen) in women at high risk of stroke.(This comes from Cochrane data).

Question 59

What about HRT and cardiovascular disease?

Answer 59

-There are conflicting data depending on age of starting HRT and whether there is pre-existing cardiovascular disease.-HRT should generally be avoided in women over the age 60y where pre-existing cardiovascular disease is more likely.-Cochrane also concluded that we should NOT prescribe HRT for the primary or secondary PREVENTION of cardiovascular disease. (!!)

Question 60

Does HRT protect against dementia?

Answer 60

No! But some people think it does, despite a complete lack of evidence. Disabuse them of their ignorance!

Question 61

Looking at the BENEFITS of HRT - consider 100 0 women who suffer from hot flushes, vaginal atrophy, fractures, diabetes, and colorectal cancer. How many of those 1000 women would NOT suffer from these things, both with oestrogen HRT and combined HRT?

Answer 61

Benefit Oestrogen CombinedHot flushes 900 820Vaginal atrophy 800 870Fractures 6 5Diabetes 11 11Colo Ca 0 1

Question 62

In summary, what are the benefits of HRT?

Answer 62

Used for as short a time as possible, massive symptom control when it comes to hot flushes and vaginal atrophy, but less good at preventing osteoporosis, especially when risks considered.

Question 63

But haven’t studies shown that HRY=T actually DECREASES CVD risk? This is really confusing!

Answer 63

A small Danish study (open label RCT BMJ 2012;345;e6409) SEEMED to show a reduced rate of death from MI over 10 years in women taking HRT - but the general feeling from the sum of existing evidence is that HRT does NOT improve CVD risk (and if anything, it makes it worse) and larger RCT’s are needed.

Question 64

What are the precautions and contraindications to the COC? (Amazingly, no absolute consensus on this 0 Red Whale suggests the following 7 points…)

Answer 64

1) Avoid HRT and tibolone in women with breast cancer or a history of breast cancer.
2) Seek advice before starting HRT in women with a history of endometrial or ovarian cancer.
3) Exclude or investigate breast symptoms before starting HRT.
4) Avoid HRT in a women with a personal history of VTE or arterial thrombotic disease.
5) Avoid HRT in uncontrolled hypertension.
6) Ix abnormal vaginal bleeding before starting HRT.
7) Migraines do not seem to be exacerbated by low dose HRT, but transdermal preparations may be helpful.

Question 65

What about monitoring in HRT?

Answer 65

1) Women on HRT should be monitored annually - discuss symptom control, Ongoing indication, Side effects.
2) Monitor BMI and BP.
3) Do a CVD risk assessment and offer appropriate lifestyle advice.
4) Check if cervical and breast screening are up to date.
5) Ask about bleeding pattern - with combined preparations, unscheduled bleeding may occur in the first 6 months of use, but if it persists beyond 6 months of use, it should be investigated.
6) Consider whether anxiety or depression may be contributing to the somatic symptoms of menopause.