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Obstetrics & Gynaecology > Menopause > Flashcards

Menopause Flashcards

1
Q

When is menopause recognised as having occurred?

A

After 12 months of consecutive amenorrhoea

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2
Q

What is the median age of menopause?

A

51

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3
Q

When is menopause considered premature?

A

When it occurs before the age of 40

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4
Q

Describe the period that is considered perimenopasual:

A

From the first features/signs indicative of the menopause to 12 consecutive months after the last menstrual period

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5
Q

What are the vasomotor Sx of menopause?

A

Hot flushes + night sweats (most commonly)

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6
Q

How do vasomotor Sx tend to effect a woman?

A

Sleep disturbance + irritability

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7
Q

Vasomotor Sx tend to be alleviated after how long on HRT?

A

4 weeks

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8
Q

List the Sx of menopause:

A

Vasomotor Sx
Psychological Sx
Skin atrophy
Osteoporosis/osteoporotic fractures
Cerebrovascular disease
Genital tract atrophy - dyspareunia, pruritus
Urinary tract atrophy - recurrent infection, freq/urgency/nocturia

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9
Q

What are the ‘early’ Sx of menopause?

A

Psychological + vasomotor

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10
Q

What are the ‘intermediate’ Sx of menopause?

A

Skin, genital tract and urinary tract atrophy

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11
Q

What are the ‘late’ Sx of menopause?

A

Osteoporosis + cerebrovascular disease + CHD

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12
Q

What investigations may be carried out?

A

FSH - useful as an indicator of premature menopause. Increased FSH indicates fewer oocytes. Unnecessary in women with menopausal Sx over the age of 45

AMH - indicator of ovarian reserve. Decreased AMH = low ovarian reserve

TFTs - hyperthyroidism may also cause hot flushes. Take to exclude

DEXA bone scan

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13
Q

When in the cycle should FSH be taken?

A

Days 2-5

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14
Q

When in the cycle should AMH be taken?

A

AMH is stable throughout a cycle, thus can be taken at any point

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15
Q

While FSH rises and AMH falls, levels of what other hormones may change at menopause?

A 
Oestrogen = decreased (menopause is an oestrogen withdrawal syndrome)
Inhibin = decreased
Progesterone = decreased
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16
Q

What determines the age at which a woman enters menopause?

A

Menopausal age of mother
Smoking - smokers entering earlier than non-smokers

(Age of menarche, race and parity likely to have no effect)

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17
Q

What proportion of menopausal women experience hot flushes/flashes?

A

75%

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18
Q

Describe the sensation of a hot flush/flash:

A

Pressure in the head, followed by a flush of heat/burning that begins in the head or neck and then passes over the entire body. Sweating tends to accompany.

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19
Q

What is the mechanism that brings about a hot flush/flash?

A

The initiating mechanism = unknown, but it brings about peripheral vasodilation

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20
Q

By how much does the core body temperature drop during a hot flush/flash?

A

0.2 oC

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21
Q

When does the most rapid bone loss occur after menopause?

A

3-4 years after menopause, occurring more quickly in smokers and thin women

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22
Q

What menopausal women are less likely to develop osteoporosis?

A

African-American women and those with fluoride-treated water

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23
Q

What is the most common site of a osteoporosis-related fracture?

A

Vertebral body - may lead to the development of back pain and a ‘dowager’s hump’

24
Q

How does oestrogen deficiency in menopausal women effect bone?

A

Osteoblast activity, forming bone = unaffected by oestrogen deficiency. Osteoclast activity, acting in the resorption of bone, is increased

25
Q

What type of been is affected first by osteoporosis?

A

Trabecular bone, followed by cortical bone

26
Q

What effect does oestrogen have upon the cardiovascular system?

A

Decreased vascular resistance + increased blood flow. This is thought to be because oestrogen decreases the production of endothelin, a vasoconstrictor, by the vascular endothelium

27
Q

Why is HRT then controversial with regard to CHD?

A

Women Health Initiative - largest randomised trial of HRT - has demonstrated untoward cardiovascular effects with regard to HRT (despite the supposed benefits of oestrogen on the cardiovascular system)

28
Q

Do menopausal women still produce oestrogen?

A

Yes, but its peripheral oestrogen, circulating androgens having been converted to oestrogen by aromatase produced by fat, the liver and kidneys. The oestrogen produced by peripheral conversion = estrone, and is weaker than estradiol

29
Q

Which women are more protected from the effects of the menopause?

A

Obese women, because fat is a rich source of aromatase, and so large quantities of estrone can be produced by peripheral conversion to partially compensate for the estradiol deficiency.

= at a cost, because the estrone, unopposed by progesterone post-menopasually, then increases the risk of endometrial hyperplasia and carcinoma

30
Q

How is menopause Dx?

A

Usually clinically, but FSH may be used in cases of uncertainty

31
Q

What are the causes of premature menopause?

A

Surgical
Autoimmune
Chemo/radiotherapy
Infection

32
Q

What do you prescribe for vasomotor symptoms?

A

HRT

33
Q

What do you prescribe for psychological symptoms in menopause?

A

HRT

34
Q

What do you prescribe for altered sexual function in menopause?

A

1st line = HRT

2nd line = ADD testosterone supplementation

35
Q

What do you prescribe for urogenital atrophy in menopause?

A

Vaginal oestrogen (whether or not they are already receiving HRT) +/- moisturisers/lubricants

36
Q

What are the contraindications of HRT?

A 
Undiagnosed PV bleeding
PMHx of breast cancer
PMHx of VTE
PMHx of MI
PMHx of stroke
At high risk of CVD
37
Q

What are the types of HRT?

A

1) Oestrogen-only regimen

2) Oestrogen and progesterone regimen (combined HRT)

38
Q

In whom should an oestrogen-only regimen be used?

A

Women without a uterus, e.g. post-hysterectomy

39
Q

In whom should combined HRT be used?

A

Women with a uterus, and women with a history of endometriosis even if they don’t have a uterus

40
Q

What are the different types of combined HRT?

A

1) Cyclical

2) Continuous

41
Q

Describe cyclical combined HRT:

A

Progesterone given at fixed intervals, e.g. for 10-14 days every 4 weeks will result in monthly bleeds. Or, given for 14 days every 13 weeks will result in bleeds every 3 months

42
Q

Describe continuous combined HRT:

A

Progesterone given continuously, resulting in amenorrhoea.

Should only be given once a woman is period-free for 12 months

43
Q

How may oestrogen be delivered in HRT?

A

Oral; transdermal; implant; vagina/topical

44
Q

How may progesterone be delivered in HRT?

A

Oral; transdermal; intrauterine

45
Q

What is a common S/E of HRT?

A

Unscheduled vaginal bleeding in the first 3 months of use

46
Q

What are the benefits of HRT?

A

Relief from menopausal Sx
Decreased risk of osteoporotic fractures
Decreased risk of colorectal cancer
No increased, or possibility a decreased, risk of CHD in oestrogen-only HRT, though there may possibly be a small increase in combined HRT

47
Q

What are the risks of HRT?

A

Increased risk of VTE
Increased risk of T2DM
Increased risk of breast cancer (combined HRT)
Increased risk of endometrial cancer (oestrogen-only HRT)
Increased risk of gallbladder disease (oral)

48
Q

Which women taking HRT are at the greatest risk of a VTE?

A

Users of oral HRT and obese women

49
Q

What advice should be given about coming off HRT?

A

Gradually reducing may limit Sx recurrence in the short-term, but will make no difference to their Sx in the long-term

50
Q

On coming off HRT, what alternative may a women use to treat/prevent osteoporosis?

A

Bisphosphonates

51
Q

What are the alternatives to HRT?

A

Isoflavones (found in soya beans, chick peas and black cohosh) may relive vasomotor Sx

52
Q

Describe a structure for HRT counselling:

A

1) Check if they have contraindications for HRT - i.e. can they even take it?
2) Talk though BENEFITS
3) Talk through RISKS
4) Which prep? Do they have a uterus? Yes - how long do they want to bleed/do they want to bleed?
5) “As with any medication there are S/E’s…”
6) Alternatives to HRT
7) F/U and reminder to re-book if new Sx develop post-F/U - “I will remind you again at F/U…”
8) Coming off HRT (take for up to 5 years, gradual reduction)

53
Q

Why do oestrogen levels fall peirimenopausally?

A

Depletion of ovarian follicles

54
Q

What causes the depression seen in menopause?

A

Serotonin and noradrenaline deficit - since oestrogen increases the level of these neurotransmitters

55
Q

What are the psychological Sx of menopause?

A

Poor memory and concentration
Depression/mood changes
Anxiety/irritability (may be sleep-related)

56
Q

Whom may transdermal HRT be better suited for?

A

Women with gallbladder disease (increased risk in oral preparations) and those with poor absorption

Obstetrics & Gynaecology (14 decks)

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