Menopause

Question 1

What is menopause?

Answer 1

Is permanent cessation of menustration resulting from loss of ovarian follicular activity.

Menopause is recognised to have occurred when there has been 12 consecutive months of amenorrhoea.

Question 2

What is the peri-menopausal period?

Answer 2

When women first start to experience symptoms of menopause up until after they been amenorrhoeic for 12 months.

Question 3

What is post menopause?

Answer 3

It is from the date of the last period however it cannot be determined until the women has gone through 12 months of spontaneous amenorrhoea.

Question 4

What are the symptoms of menopause?

Answer 4

Vasomotor:
Hot flushes and night sweats

Urogenital:
Vaginal atrophy, causing itchiness, dyspareunia and burning.
Urinary symptoms: frequency and urgency.

Sexual dysfunction:
Loss of libido

Osteoporosis

Mood disturbances

Question 5

What are some of the longer term complications of menopause?

Answer 5

Increases CVD risk.

Osteoporosis

Question 6

What are the different types of oestrogen which are found in the body?

Answer 6

Esterone (converted from androstenedione)

Estradiol-17B (converted from testosterone) most prevalent oestrogen in the body

Question 7

What is early menopause?

Answer 7

Menopause before the age of 40.

Average age of menopause is 51yo

Question 8

What are the causes of early menopause?

Answer 8

Idiopathic (50%)
Iatrogenic (surgery or chemo for haem malignancies)
Neoplastic
Post mumps
Turner's

Question 9

What investigations should be done if you think a women may have gone through early menopause?

Answer 9

Hormone profile (FSH should be raised)
Pelvic USS (rule out any obvious masses)
Endometrial assessment
DEXA scan (spine and hips)

Question 10

Which women can have HRT and what are the contraindications?

Answer 10

If they are symptomatic and do not have contraindications.

Absolute contraindications:

• Active liver disease
• Thromboembolic disease

Relative contraindications:

• Breast/endometrial cancer
• Chronic liver disease
• Familial breast ca

Note: if contraindicated SSRI’s can be used to help with hot flushes.

Question 11

What are the different types of HRT?

Answer 11

Oestrogen alone (only for post hysterectomy women)*

Combined oestrogen and progesterone (cyclical or continuously)

If the women is perimenopausal should use cyclical not continuous.

*as unopposed oestrogen increases endometrial Ca risk

Question 12

What are the risks of HRT?

Answer 12

Unopposed oestrogen increases risk of endometrial Ca.

Combined increases risk of breast cancer (4 extra cases per 1000 users over 5 years)

Increased risk of VTE

Question 13

What are the benefits of HRT?

Answer 13

Symptomatic relief + decreases risk of osteoporosis and colorectal Ca

Question 14

How are the risks of HRT minimised?

Answer 14

Oestrogen only is not given to women with a uterus due the endometrial Ca risk.

Lowest effective dose is used.

HRT is not used after 60 yo

Is only used for up 5 years as breast Ca risk is duration related.

Question 15

What is the significance of post menopausal bleeding?

Answer 15

10% will have endometrial Ca

Question 16

How should post menopausal bleeding be investigated?

Answer 16

Speculum and cervical smear.

Transvaginal USS to measure endometrial thickness.

If less than 4mm and only one episode of bleeding biopsy NOT indicated.

If more than one episode of bleeding (at least 7 days apart) or thickness greater than 4mm. Hysteroscopy + biopsy.

If not endometrial Ca likely it is due to atrophic vaginitis.