Menopause Flashcards
When is menopause recognised as having occurred?
After 12 months of consecutive amenorrhoea
What is the median age of menopause?
51
When is menopause considered premature?
When it occurs before the age of 40
Describe the period that is considered perimenopasual:
From the first features/signs indicative of the menopause to 12 consecutive months after the last menstrual period
What are the vasomotor Sx of menopause?
Hot flushes + night sweats (most commonly)
How do vasomotor Sx tend to effect a woman?
Sleep disturbance + irritability
Vasomotor Sx tend to be alleviated after how long on HRT?
4 weeks
List the Sx of menopause:
Vasomotor Sx
Psychological Sx
Skin atrophy
Osteoporosis/osteoporotic fractures
Cerebrovascular disease
Genital tract atrophy - dyspareunia, pruritus
Urinary tract atrophy - recurrent infection, freq/urgency/nocturia
What are the ‘early’ Sx of menopause?
Psychological + vasomotor
What are the ‘intermediate’ Sx of menopause?
Skin, genital tract and urinary tract atrophy
What are the ‘late’ Sx of menopause?
Osteoporosis + cerebrovascular disease + CHD
What investigations may be carried out?
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
When in the cycle should FSH be taken?
Days 2-5
When in the cycle should AMH be taken?
AMH is stable throughout a cycle, thus can be taken at any point
While FSH rises and AMH falls, levels of what other hormones may change at menopause?
Oestrogen = decreased (menopause is an oestrogen withdrawal syndrome) Inhibin = decreased Progesterone = decreased
What determines the age at which a woman enters menopause?
Menopausal age of mother
Smoking - smokers entering earlier than non-smokers
(Age of menarche, race and parity likely to have no effect)
What proportion of menopausal women experience hot flushes/flashes?
75%
Describe the sensation of a hot flush/flash:
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.
What is the mechanism that brings about a hot flush/flash?
The initiating mechanism = unknown, but it brings about peripheral vasodilation
By how much does the core body temperature drop during a hot flush/flash?
0.2 oC
When does the most rapid bone loss occur after menopause?
3-4 years after menopause, occurring more quickly in smokers and thin women
What menopausal women are less likely to develop osteoporosis?
African-American women and those with fluoride-treated water
What is the most common site of a osteoporosis-related fracture?
Vertebral body - may lead to the development of back pain and a ‘dowager’s hump’
How does oestrogen deficiency in menopausal women effect bone?
Osteoblast activity, forming bone = unaffected by oestrogen deficiency. Osteoclast activity, acting in the resorption of bone, is increased
What type of been is affected first by osteoporosis?
Trabecular bone, followed by cortical bone
What effect does oestrogen have upon the cardiovascular system?
Decreased vascular resistance + increased blood flow. This is thought to be because oestrogen decreases the production of endothelin, a vasoconstrictor, by the vascular endothelium
Why is HRT then controversial with regard to CHD?
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)
Do menopausal women still produce oestrogen?
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
Which women are more protected from the effects of the menopause?
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
How is menopause Dx?
Usually clinically, but FSH may be used in cases of uncertainty
What are the causes of premature menopause?
Surgical
Autoimmune
Chemo/radiotherapy
Infection
What do you prescribe for vasomotor symptoms?
HRT
What do you prescribe for psychological symptoms in menopause?
HRT
What do you prescribe for altered sexual function in menopause?
1st line = HRT
2nd line = ADD testosterone supplementation
What do you prescribe for urogenital atrophy in menopause?
Vaginal oestrogen (whether or not they are already receiving HRT) +/- moisturisers/lubricants
What are the contraindications of HRT?
Undiagnosed PV bleeding PMHx of breast cancer PMHx of VTE PMHx of MI PMHx of stroke At high risk of CVD
What are the types of HRT?
1) Oestrogen-only regimen
2) Oestrogen and progesterone regimen (combined HRT)
In whom should an oestrogen-only regimen be used?
Women without a uterus, e.g. post-hysterectomy
In whom should combined HRT be used?
Women with a uterus, and women with a history of endometriosis even if they don’t have a uterus
What are the different types of combined HRT?
1) Cyclical
2) Continuous
Describe cyclical combined HRT:
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
Describe continuous combined HRT:
Progesterone given continuously, resulting in amenorrhoea.
Should only be given once a woman is period-free for 12 months
How may oestrogen be delivered in HRT?
Oral; transdermal; implant; vagina/topical
How may progesterone be delivered in HRT?
Oral; transdermal; intrauterine
What is a common S/E of HRT?
Unscheduled vaginal bleeding in the first 3 months of use
What are the benefits of HRT?
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
What are the risks of HRT?
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)
Which women taking HRT are at the greatest risk of a VTE?
Users of oral HRT and obese women
What advice should be given about coming off HRT?
Gradually reducing may limit Sx recurrence in the short-term, but will make no difference to their Sx in the long-term
On coming off HRT, what alternative may a women use to treat/prevent osteoporosis?
Bisphosphonates
What are the alternatives to HRT?
Isoflavones (found in soya beans, chick peas and black cohosh) may relive vasomotor Sx
Describe a structure for HRT counselling:
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)
Why do oestrogen levels fall peirimenopausally?
Depletion of ovarian follicles
What causes the depression seen in menopause?
Serotonin and noradrenaline deficit - since oestrogen increases the level of these neurotransmitters
What are the psychological Sx of menopause?
Poor memory and concentration
Depression/mood changes
Anxiety/irritability (may be sleep-related)
Whom may transdermal HRT be better suited for?
Women with gallbladder disease (increased risk in oral preparations) and those with poor absorption
