Menopause

Question 1

Contraindications for HRT

Answer 1

Breast cancer
Thrombophilia or past VTE
Undiagnosed vaginal bleeding
Active liver disease
Uncontrolled HTN
CVD risk or disease

Question 2

Symptoms of Menopause

Answer 2

Features due to oestrogen deficiency
Vasomotor instability - tend to dissipate with time.
- Hot flushes/flashes, 
- night sweats, 
- sleep disturbances, 
- formication, 
- nausea, 
- palpitations
urogenital trophy involving vagina, urethra, bladder
- Dyspareunia,
- Pruritus
- vaginal dryness
- bleeding
- urinary frequency
- urgency
- incontinence
Skeletal
- Osteoporosis
- Joint and muscle pain
- back pain
Skin and soft tissue
- decreased breast size
- skin thinning/loss of elasticity
Psychological 
- mood disturbance
- Irritability 
- fatigue
- decreased libido
- Memory loss

Question 3

Phases of menopause

Answer 3

Regular cycles
 ‘premenopause’
• Change in cycle frequency  ‘early perimenopause’
• Cycles up to 3-12 months apart  ‘late perimenopause’
• No menstrual cycles for >12 months  ‘menopause’ average age 51 years

Question 4

Tx for Menopause

Answer 4

Screening for Heart disease, Osteoporosis, central adiposity, mood disorders.
Tx Hot flushes by reducing layers, natural fibres, reduce wt, reduce Etoh, increase activity, reduce caffei

Question 5

Definition of menopasuse

Answer 5

lack of menses for 1yr

Question 6

Causes of menopause

Answer 6

Physiological: average age 51 yr Folicular atresia
Premature ovarian failure: before 40 due to autoimmune disorder, infection, turner’s syndrome
Iatrogenic e.g. surgical, radiation/ chemotherapy

Question 7

Ix for menopause

Answer 7

Increased levels of FSH and LH (FSH>LH) on day 3
Diagnosed on absence of menses for 1 yr
Later - decreased levels of estradiol

Question 8

Define preimenopause

Answer 8

Period of time surrounding menopause
2-8 yr preceding + 1 yr after last menses.
characterised by fluctuating hormone levels, irregular menstrual cycles and symptoms onset.

Question 9

Tx of vasomotor instability e.g. Hot flushes/flashes,

• night sweats,
• sleep disturbances,
• formication,
• nausea,
• palpitations

Answer 9

1st line - HRT
SSRIs, 
venlafaxine
gabapentin
propranolol
Clonidine
Acupuncture

Question 10

Tx of vaginal atrophy

Answer 10

oestrogen cream, suppository, ring, lubricants

Question 11

Tx for urogenital health

Answer 11

Lifestyle changes e.g. wt loss, bladder retraining
Local oestrogen replacement
surgery

Question 12

Tx of osteoporosis

Answer 12

Calcium
Vitamin D
wt bearing exercise
cease smoking
bisphosphonates
Selective oestrogen receptor modifiers - mini oestrogen's affect on bone. Tibolone.
2rd line HRT

Question 13

Tx of decreased libido

Answer 13

Vaginal lubrication
Counseling
Androgen replacement e.g. cream or oral

Question 14

Tx of cardiovascular disease

Answer 14

Mx RF

Question 15

Tx of mood and memory

Answer 15

antidepressant

HRT

Question 16

Non evidence based tx of osteoporosis

Answer 16

Black cohosh
phytoestrogens
St John's wart
gingko biloba
Valerian
Evening primrose oil
Ginseng
Don Quai

Question 17

Discuss the risk HRT

Answer 17

Increased risk of breast cancer is associated with oestrogen and progesterone HRT but not with oestrogen only
All women taking HRT should have periodic surveillance and counselling regarding its benefits and risks.
VTE
Stroke
increase risk of breast and ovarian Endometrial Ca
withdrawal bleeds
Risk reduces in oestrogen only but can only give if no uterus.

Question 18

Absolute contraindications for HRT

Answer 18

ABCD
Acute liver disease
Undiagnosed vaginal bleeding
Cancer, Cardiovascular disease
DVT

Question 19

Side effect of HRT

Answer 19

abnormal uterine bleeding
Mastrodynia - breast tenderness
Edema, bloating, heartburn, nausea
Mood changes due to progesterone
can be worse in progesterone phase of combined therapy

Question 20

Benefits of HRT

Answer 20

Reduces osteoporosis and fracture
reduce colorectal Ca
reduces symptoms and pay