Menopause Flashcards
Definition of menopause
The final menstrual period, can only be diagnosed after 12 consecutive months of amenorrhoea while not on any hormonal treatment
Definition of perimenopause
The symptoms experienced in the years preceding menopause while ovarian activity fluctuates
Definition of surgical menopause
Menopause occurring when functional ovaries are surgically removed
Definition of premature menopause
Menopause occurring before the age of 45
Average age of menopause in Western society
52 years (no change in last 150 years)
Iatrogenic causes of menopause
Surgical removal of functioning ovaries
Radiotherapy
Chemotherapy
Temporarily during GnRH analogue treatment
Causes of primary premature ovarian failure
Chromosome abnormalities (Turner's, Fragile X) Autoimmune: hypothyroidism, Addison's, Myasthenia Gravis Enzyme: galactosaemia, 17a-hydroxylase deficiency
Causes of secondary premature ovarian failure
Surgical menopause
Chemo or radiotherapy
Infectiosn (TB, mumps, malaria, varicella)
Endocrine changes in menopause
First change: fall in inhibin production (responsible for FSH production inhibition) - increased FSH
Reduces oestradiol levels- eventually insufficient to stimulate endometrial proliferation = menopause
Further decline in subsequent years - effects on all oestrogen-responsive tissues
GU effects of menopause
Vaginal atrophy - trauma, dryness, spontaneous bleeding, infection
Distal urethra + trigone bladder - similar atrophy - urinary symptoms without infection
Pelvic floor dysfunction - weakening of supporting ligaments and tissues - increased prolapse and stress incontinence
Osteoporosis mechanism in menopause
oestrogen = anti-resorptive agent on trabecular bone
Thus, dec. oestrogen - inc. bone resorption - dec. bone density
Oestrogen effects on CVS
inc. LDL, dec. HDL
direct effect on vessel wall - vasodilation via NO
thus increased risk of CVD after menopause
Short-term symptoms of menopause (0-5y)
Vasomotor: hot flushes, night sweats
Psychological: labile mood, anxiety, tearfulness
Cognitive: loss of concentration, poor memory
Joint aches and pains
Dry, itchy skin
Hair changes
Reduced libido
Intermediate effects of menopause (3-10 years)
vaginal dryness, soreness Dyspareunia Sensory urgency Urinary frequency Recurrent UTIs Urogenital prolapse
Long term effects of menopause (over 10y)
Osteoporosis
Cardiovascular disease
Dementia
Assessment of menopause:
frequency, severity and types of symptoms and impact on daily life
for most women, menopausal symptoms are relatively short lived and will settle within a few years
use as opportunity to raise awareness and practice preventative medicine
lifestyle management of menopause
Smoking cessation
Optimise diet
Regular, low-intensity exercise
Minimise weight gain (average weight gain of 1kg/year around menopause)
Alternative/complementary management of menopause
little is known about efficacy or safety:
Acupuncture, reflexology, magnetism
Herbal (black cohosh, evening primrose oil, st john’s wort, ginseng, ginko bilboa)
Bio-identical hormones (DHEA, natural progesterone gel, phytoestrogens - isoflavones, red clover)
Non-hormonal pharmaceutical management options for menopause
SSRIs and gabapentin:
- reduce hot flushes in short term
- significant side effect profile
Alpha-adrenergic agnoists (Clonidine)
- reduces hot flushes
- far less effective than HRT
Hormones to be given in HRT for menopause
Oestrogen - can only be given alone if no uterus is remaining (otherwise risk of endometrial cancer) + progesterone if uterus present
testosterone if surgical/chemo induced menopause
Time frame of HRT
Minimal effective dose for shortest duration
Ideally should be discontinued by 5 years
average woman will need symptomatic relief for 2-3 years
Routes of oestrogen administration
Oral - oestrone released into circulation, less expensive
Transdermal: avoids first-pass effect, reduced impact on haemostasis and coagulation (therefore better option in VTE/liver abnormalities)
+ more physiological (oestradiol released into circulation), logistically difficult to coadminister progesterone in unhysterectomised patients
Side effects related to oestrogen
fluid retention Nausea Headaches Breast enlargement Leg cramps Dyspepsia
Tend to settle within a few weeks
Progesterone addition in HRT
added for 10 days per calendar month (mimic menstrual cycle)
Cyclical regimen for perimenopauseal women
Continuous for post-menopausal women (no bleeding)
Side effects related to progestogens
Fluid retention Breast tenderness Headaches Acne Mood swings Depression Irritability Bloating Constipation Increased appetite
usually more trouble-some than oestrogen related side effects, especially in first few months
Switching dose or type of progestogen or to Mirena IUD may help
Symptoms of testosterone deficiency in a female
Loss of libido
Decreased sexual activity
Fatigue
Reduced feeling of physical well-being
Breast cancer risk with HRT
increases risk by 4 in 1000 (usually 15/1000)
No increase in risk if used for less than 5 years
more associated with progesterone than oestrogen
Endometrial cancer risk with HRT
only in unopposed oestrogen if woman still has uterus
Therefore always use progesterone unless no uterus
VTE risk with HRT
Increases risk 2- fold (overall impact small given that background risk is low)
- significantly increased risk in smokers, obese, underlying thrombophilia or history of VTE
Highest risk in first year of use
Absolute contraindications to HRT
Suspected pregnancy Breast cancer Endometrial cancer Active liver disease Uncontrolled HTN Known VTE Known thrombophilia Otosclerosis
relative contraindications to HRT
Uninvestigated abnormal bleeding Large uterine fibroids Past history of benign breast disease Unconfirmed personal history or strong family history of VTE Chronic stable liver disease Migraine with aura
Benefits of HRT
Most effective therapy for perimenopausal symptoms (vasomotor, urogenital, sexual function)
Treatment of osteoporosis
Reduced risk of ?CVD, colon cancer
Vaginal oestrogen
safe for those contraindicated for systemic HRT
useful only for urogenital symptoms
progesterone not required
daily for 2 weeks, then 1-2 times weekly for 12 months
Expected time for HRT to improve hot flush symptoms
4-6 weeks of treatment
Production of testosterone in women and effect of menopause
50% occurs in ovaries
other 50% in adrenals and adipose
Production not generally affected by natural menopause, but may become deficient if chemoradiation or surgical induced menopause
Regimens of HRT
Oestrogen only - post-hysterectomy
Cyclical progesterone + oestrogen - perimenopausal women (still will have period)
Continuous progesterone + oestrogen - postmenopausal women (will not have bleeding)
