Menopause

Question 1

Sx and consequences of menopause (9)

Answer 1

CVD

vasomotor disturbance: hot flushes, sweating, palps

atrophy of oestrogen-dependant tissues, atrophic vaginitis, vaginal dryness

osteoporosis

irritability/depression

memory loss

loss of libido

stress incontinence

prolapse

Question 2

Ix for menopause

Answer 2

2 FSH readings >30 indicate menopause

if uncertainty in cause of Sx:

• TFTs
• urinary 5-HIAA

Question 3

Rx of menopausal Sx (4)

Answer 3

HRT is mainstay

if uterus absent: oestrogen replacement only

if uterus present: add progestogen e.g. levonorgestrel, norethisterone:

• continuous therapy if post menopausal
• cyclical therapy if still having periods

can use tibolone alone: not HRT, has both oestrogenic and progestogenic properties

Raloxifene is given to protect bones and reduce risk of endometrial and cervical ca.

Question 4

criteria for HRT (3)

Answer 4

early menopause-prevent osteoporosis

severe Sx

high risk of osteoporosis: parkinson’s, depression, CHD

Question 5

SEs of HRT (5)

Answer 5

wt. gain, bloating, mood swings, vomitting

cholestasis

cancers: breast, ovarian, endometrial

increased risk of VTE

PMS

bleeding common in 1st 4mo of use, if bleeding after 8mo do endometrial biopsy

Question 6

HRT CIs (6)

Answer 6

PMHx of oestrogen-dependant cancers: breast, ovarian, endometrial

PMHx of VTE

liver disease: risk of cholestasis

unexplained PV bleeding

breastfeeding

phlebitis

(avoid/monitor in Dubin-Johnson/Rotor syndromes: hepatic jaundice)

Question 7

monitoring while on HRT (2)

Answer 7

annually monitor:

• breasts
• BP

(menopausal Sx last on average for 4yrs but can be longer. Risks of HRT increase over time so annual monitoring required to assess risks vs benefits)

Question 8

Other Mx for menopausal Sx (4)

Answer 8

bisphosphonates for osteoporosis

for vasomotor Sx:

• SSRIs 1st line: paroxetine
• clonidine, tibolone

topical oestrogens for vaginal dryness and urinary incontinence/frequency

lifestyle modification:

• good diet
• wt. loss
• wt.-bearing exercises
• quite smoking
• more vit D

Question 9

Causes of post-menopausal bleeding (3)

Answer 9

most important: endometrial ca.

most common: atrophic vaginitis

others:
- cervical polyps
- cervicitis
- endometrial hypoplasia

Question 10

Mx of PMB (4)

Answer 10

bimanual+speculum

smear if not recently done

TV USS:
-if endometrial thickness <4mm and one episode of bleeding, do nothing

if >4mm or multiple bleeds do biopsy+/-hysteroscopy

Question 11

definition of premature ovarian failure

Answer 11

onset of menopausal Sx <40yrs

Question 12

Causes of premature ovarian failure (4)

Answer 12

idiopathic

autoimmune

chemotherapy

radiation

(features similar to menopause and often preceded by irregular cycles)

Question 13

Mx of premature ovarian failure

Answer 13

HRT