Menopause Flashcards
1
Q
Define normal, early
A
Cessation of menses for >12 months
Early is when <40 yo
2
Q
Average age of onset
A
Usually 45-55, average age is 50-51
3
Q
The four phases
A
- Phase 1 Premenopausal: up to 5 years before the last menstrual period.
- Phase 2 Perimenopausal: the presence of early menopausal symptoms with vaginal bleeding (usually irregular) 3. Phase
3 Menopausal: the last menstrual period
- Phase 4 Postmenopausal: approximately 5 years after the menopause
4
Q
During menopause, does the ovary produce must estrogen or androgens
A
- The ovary produces little estrogen 2. Produces ++androgens
5
Q
Symptoms overview
A
- Vasomotor
- Psychogenic
- Urogenital
- MSK
- Skin and other tissue changes
- Other
6
Q
Vasomotor symptoms
A
- Hot flushes
- Night sweats
- Palpitations
- Lightheadedness
- Migraine
7
Q
Psychogenic symptoms
A
- Depression
- Irritability
- Mood swings
- Anxiety
- Tearfullness
- Poor concentration
- Sleep disturbance
- Loss of self confendence
8
Q
Urogenital symptoms
A
- Atrophic vaginitis
- Vaginal dryness
- Dysparaneuria
- Decline in libido
- Bladder dusfunction
- Stress incontinence
9
Q
Musckuloskeletal symptoms
A
- Non-specific muscular aches
- Non-specific joint aches and pains
10
Q
Skin and other tissue symptoms
A
- Dry skin
- Fornicatioin
- New facial hair
- Breast glandular atrophy
11
Q
Other symptoms
A
- Unusual tiredness
- Headache
12
Q
History
A
- Symptoms of estrogen deficiency
- Gynaecological history
- Obstetric history
- Mental state symptoms
- Sexual history
- Contraception
- Micturition
- Social history
- Family history of osteoporosis, cancer, cardiovascular disease
13
Q
Examination
A
- BP, height, weight, waist
- Breast
- Abdomen
- Vaginal examination
- Pap smear
14
Q
Investigations
A
- Urinalysis
- FBC
- Fasting lipids, glucose
- LFTs
- Mammography
If in doubt, or early
- Serum FSH
- Serum estradiol
15
Q
Management
A
- Education and lifestyle Diet Obesity Relaxation Exercise Smoking Caffeine and alcohol reduction Pelvic floor
- Continue sexual relations->use lubricant
- Contraception for 12 months after last period
- OCP available until 50/51
- Consider HRT->allow 6 months to stabilise
- Estrogen pessary for vaginal dryness
- Consider non-hormonal: Paroxetine or venlafaxine
- Consider short term testosterone if loss of libido issue 9. Regular followup
16
Q
Important aspects of the women’s health initiative study
A
- first prospective, randomized, controlled clinical trial of hormone replacement therapy (HRT), it aimed to recruit more than 16,000 women and do follow-up on them for 8.5 years.
- A 37% reduction in colon cancer
- 34% decrease in hip fractures
- 2.11-fold increase in deep venous thromboses
- 26% increase in invasive breast cancer This finding was surprising, since a recent comprehensive review of previous epidemiologic studies had concluded that no convincing link between breast cancer and HRT was present.
- The big WHI surprises were the 29% increase in heart attacks and the 41% increase in strokes that were seen.
- A major problem is that HRT is the only potent therapy for vasomotor symptoms and genital atrophy in menopausal women
- In addition to increased adherence to dietary/lifestyle modifications, women concerned with osteoporosis might be better served by taking SERMs (eg, raloxifene hydrochloride) or bisphosphonates (alendronate sodium, risedronate sodium); either seems to give the same approximate fracture prevention as HRT
17
Q
Indications for HRT
A
- Relieving distressing symptoms of hot flushed, urogenital symptoms, sleepiness and joint
- Transdermal most favoured.
18
Q
Golden rule in HRT
A
- Progesterone must be give with estrogen in women who still have a uterus
19
Q
Tibolone
A
- SERM
- Alternative to traditional HRT
- Vasomotor, urogenital, BMD and fracture risk
- Not for perimenopausal
- Breakthrough bleeding and virilisation are the concerns
20
Q
Contraindications to HRT
A
- Estrogen dependent tumor
- Recurrent VTE
- Acute IHD
- CAD
- Cerebrovascular
- Uncontrolled HTN
- Undiagnosed vaginal bleeding
- Acute liver disease
- Active SLE
- Pregnancy
- Osteosclerosis
- Acute intermittent porphyria
21
Q
Complications
A
- Uterine enlargment->irregular bleeding
- Continued periods
- Maignancy? No increase in cervical or ovarian cancer Risk of endometrial Ca->relates to unopposed estrogen and duration of use: 3-6X risk after 5 years, 10X risk after 10 years. Breast cancer
- VTE
- MI
- Stroke
- Cholecystitis and cholelithiasis
22
Q
Side effects
A
- Generally well tolerated
- May have some breast tenderness, HA, breast fullness, often resolves after 3 months.
23
Q
Components of WHI to explain: end point, criticisms, conclusion
A
- Were older, had other risks, cannot extrapolate to younger, healthy women early in menopause wanting symptom releif
- End point- Breast Ca
Secondary end-points +Myocardial infarction +Cerebrovascular accidents +Pulmonary thrombosis
- ve Fracture of the hip
- ve Cancer of the colon
?Endometrial carcinoma
Stopped early as incidence of breast carcinoma increased, not mortality
- Concluded not suitable for primary prevention->relative risk of adverse effects +15% however, absolute risks not great.
