Menopause Flashcards
what is menopause?
Cessation of menses for >12/12
Age of menopause?
Western women between 45-55 with average of 50-51y
What is early menopause?
Menopause before 45y
What is surgical menopause?
Bilateral oophorectomy
What are the phases of menopause?
- Premenopausal: 5y before LMP
- Perimenopausal: presence of early menopausal symptoms with vaginal bleeding (usu irregular)
- Menopausal: LMP
- Postmenopausal: ~5y after the menopause
Outline physiological changes of menopause
- Ovarian follicles decline rapidly
- FSH and LH increase (15x; 3x) that of the follicular phase ==> ovary doesn’t secrete oestrogen but continues to secrete androgens
Urogenital aspects of oestrogen withdrawal?
- Epithelium of vagina, vulva, urethra and base of bladder becomes thin and dry
- can lead to dysuria, frequency, itching, dyspareunia and atrophic bleeding
How can the urogenital aspects of menopause be managed?
HRT can ameliorate urogenital dysfunction of menopause
What are the vasomotor symptoms of menopause?
- Hot flushes
- Night sweats
- Palpitations
- Lightheadedness / dizziness
- Migraine
- Formication (ants crawling under skin)
What are the psychogenic aspects of menopause?
- Irritability
- Depression / anxiety
- Tearfulness
- Loss of concentration
- Unloved feelings
- Sleep disturbance
- Mood changes
- Decreased self confidence
What are the urogenital symptoms of menopause?
- Atrophic vaginitis
- Vaginal dryness
- Dyspareunia
- Decline in libido
- Bladder dysfunction (e.g. dysuria)
- Stress incontinence / prolapse
Skin/tissue changes of menopause?
- Dryness
- Formication
- New facial hair
- Breast gland atrophy
Hx to elicit in menopause evaluation?
- Menstrual Hx
- Other Sx related to oestrogen deficiency (esp hot flushes, mental state)
- Sexual Hx (contraception, microturition, relationships)
- FHx: osteoporosis, CVD, Ca
PEx in menopause evaluation?
- BP, height and weight
- Breast exam
- Abdo exam
- Vaginal exam
- Pap smear
Ix to consider in menopause work up?
- Urinalysis
- FBE
- Lipids
- LFTs
- Mammography (better 3/12 pre or post HRT)
- Diagnostic hysteroscopy and endometrial Bx IF undiagnosed vaginal bleeding
- Bone density (if RFx)
What is the role of hormone Ix? What are they?
If diagnosis is in doubt (e.g.
Ddx of menopausal Sx?
- depression
- anaemia
- thyroid dysfunction
- Hyperparathyroidism
- Gynae d/o (e.g. dysfunctional bleeding)
Mx of menopause?
-Importance healthy lifestyle >diet, exercise >smoking, caffeine >pelvic floor exercise -Sexual activity + lubricant -Discuss HRT -Osteoporosis screen, Vit C and D
Points to emphasise when discussing HRT?
- HRT pros: decreases symptoms, enhances QoL, reduces risk of bowel Ca, osteoporosis and fractures
- HRT negs: increased risk of endometrial hyperplasia, breast Ca and VTE
-no firm evidence of increased risk of breast Ca
What are the hormones for consideration in HRT?
- Oestrogen
- Progesterone
- Testosterone
Methods of oestrogen delivery?
-Oral
-Patches (most used worldwide)
-Implants
-Topical
(also injectable but rarely used)
What is the role of topical oestrogen?
Usually restricted to women with mild symptoms seeking management of urogenital aspects who cannot tolerate oral
What are the oral oestrogens in common use?
- Premarin
- Ogen
- Progynova
What is the role of progesterone in HRT?
Given to women with a uterus; prevents hyperplasia of uterus 2” unopposed oestrogen therapy (increases risk of Ca)
Progesterone cyclical or continuous?
If cyclical, D1-12 of calendar month but gives withdrawal bleed so many prefer continuous.
What is the golden rule of HRT?
Progestogens must be given with oestrogen in a woman with a uterus
Testosterone in HRT?
For women whose libido does not improve with HRT: use cautiously, little data re AEx
- always give with oestrogen
- given as implant
What is tibolone?
Selective tissue oestrogen activity regulator (combined oest, prog and androgen properties): alternative to conventional HRT.
Adverse effects of breakthrough bleeding and virilisation are concnerning
Contraindications to HRT?
- Oestrogen dependent tumour
- Recurrent VTE
- IHD acutely (absolute)
- Hx of CAD (relative)
- Stroke
- Uncontrolled HTN
- Undiagnosed vaginal bleeding
- Active liver disease
- Active SLE
- Pregnancy
- Otosclerosis
- Acute intermittent porphyria
AEx HRT?
- PMS: decrease dose progestogen or change
- Nausea/breast d/os: initial sensitivity to oestrogen. Reduce to starting dose or change to intravaginally
- Bleeding problems: heavy (dec oestrogen) / breakthrough (increase progestogen) / irregular (Ix and endometrial sampling) / intolerance (continuous regime of progestogen)
Duration of treatment?
Variable.
Useful rule: aim for Rx max 2y, r/v and plan for up to 5y use.
What is THE menopause?
the final menstrual period
What is the average age of menopause?
51 years
What are the perimenpausal hormonal changes?
- Gradual rise in FSH
- Fluctuations in oestradiol and progesterone
- Dec ovarian inhibin B from ovarian granulosa cells
- androgen mostly unchanged
Which days is it occasionally useful to measure hormonal levels? When?
D2-6 in younger women or when diagnosis uncertain
Normal FSH in normal cycling women D2-6?
How does smoking affect age of menopause?
Menopause 1-2y earlier in smokers cf non smokers
What is the aetiology of menopause?
- ovarian primordial follicle stores are exhausted by atresia and ovulation
- follicles progressively more resistant to gonadotrophins; Graafian follicles that do develop may not secrete enough estradiol and progesterone to produce menstruation
Why does endometrial hyperplasia and cancer risk increase around the menopuase?
Irregular anovulatory cycles lead to prolonged unnopposed E2 (estradiol)
Percentage women experiencing hot flushes?
Up to 80%
How does E2 (estradiol) deficiency affect bone?
- E2 suppresses bone resoprtion by suppressing osteoclast activity (i.e. deficiency increases resorption)
- Directly impairs gut calcium absorption
- Directly increases renal calcium excretion
What is premature menopause?
Menopause occurring before 40y of age
What is the aetiology of premature menopause?
- Idiopathic (karyotypically normal, spontaneous POF)
- Iatrogenic (surg, chemo, RT)
- Rare (galactosemia)
- Genetic (Turner’s syndrome, Fragile X syndrome)
- Auto immune
How is premature menopause diagnosed?
- > 4 months amenorrhoea before 40y
- FSH >40IU/mL on 2 occasions at least one month apart; E2
- Karytoype and Fragile X if POF under 40y
- Exclude out flow obstruction
- Exclusion of all secondary causes of amenorrhoea
Investigations following diagnosis of premature menopause?
- Thyroid and adrenal auto antibodies
- Fasting glucose
- Bone density 2yrly
- Serum B12, gastric parietal cell antibodies
What are the implications of premature menopause?
- Menopausal symptoms
- Increased risk CVD
- Increased risk osteoporosis
- Loss of fertility
- Altered body image
- Increased depression
Risk of HRT oestrogen alone?
- Increased risk stroke, VTE, PE
- Cholecystitis
Risks of HRT combined oestrogen and progesterone?
- Inc risk stroke, VTE, PE
- Increased breast density and abnormal MMG
- Increased risk breast Ca with >5y use
- Increased incidence stroke and CAD
- Unscheduled bleeding
- Cholecystitis
Method of delivery if CVD risk in woman having HRT?
Transdermal therapy may be preferable:
- no effect on renin substrates
- no effect on antithrombin III
- no effect / reduction in TG
When does HRT reduce fracture risk?
If started
Non hormonal therapies for menopause?
- Gabapentin
- SSRI/SNRI
- Clonidine
