Menopause

Question 1

DIAGNOSIS:

Answer 1

1. 12 months after LMP in women >50y

2. 24 months after LMP in women <50y

Question 2

SYMPTOMS:

Answer 2

1. Change in periods
   - change in length of menstrual cycles
   - dysfunctional uterine bleeding
2. Vasomotor symptoms
   - Hot flushes
   - Night sweats
3. Psychological
   - Anxiety and depression
   - Short-term memory impairment
4. Urogenital changes
   - Vaginal dryness and atrophy
   - Urinary frequency
   - Dyspareunia
   - Soreness
5. Longer term complications
   - Osteoporosis
   - Increased risk of ischaemic heart disease

Question 3

MANAGEMENT:

Answer 3

1. Lifestyle
   - regular exercise, avoid caffeine/spicy foods, lighter clothing
2. Hormonal
   - HRT
   - Tibolone: unsuitable for use within 12 months of LMP as can cause irregular bleeding
3. Non-hormonal methods for vasomotor symptoms:
   - SSRI
   - Clonidine(SE: dry mouth, dizziness, nausea)
   - progestogen ie norethisterone
   - Gabapentin
4. Vaginal Symptoms:
   - Topical oestrogens for vaginal atrophy
   - Vaginal lubricant/moisturizer if symptoms are predominantly vaginal dryness

Question 4

SIDE-EFFECTS:

Answer 4

1. Increased risk of breast cancer in women >50 taking HRT
   - increased further by addition of progestogen
   - no evidence of increased risk in women <50y
   - risk decreases and reaches baseline 5y after discontinuing HRT
2. Increased risk of VTE
   - increased by addition of progestogen
3. Slight increase risk of stroke
4. Increased risk of coronary heart disease for women starting combined HRT >10y after menopause
5. Caution in >65y
6. Nausea, breast tenderness, fluid retention and weight gain.
7. Increased risk of endometrial cancer
   - use of continuous progestogen eliminates this risk.

*Transdermal HRT has lower risk of VTE and stroke but more expensive

Question 5

BENEFITS:

Answer 5

1. Good treatment for vasomotor symptoms
2. Reduces risk of bowel cancer
3. Reduces risk of osteoporosis.

Question 6

CHOICE OF HRT:

1. Women who are still menstruating
2. Women no longer menstruating

Answer 6

1. Sequential HRT/Oestrogen only with Mirena
   - change to continuous combined at 54y
   - If periods are becoming infrequent, can use long cycle HRT(reduces frequency of bleeds but increases risk of endometrial hyperplasia)
2. Continuous combined
   - Oestrogen only with Miraena(licensed for 4y)
   - Tibalone: lowers risk of breast cancer but higher risk of cerebrovascular accident. Also helps with libido problems

Question 7

STOPPING HRT:

Answer 7

1. Do this gradually

2. Consider matrix patches and trimming to titrate dose

Question 8

LOCAL OESTROGEN TREATMENT:

Answer 8

1. Creams
2. Estring
   - lasts for 3/12
   - Does not help with flushes
3. Vaginal moisturizers