Menopause

Question 1

What is menopause? What is the average age?

Answer 1

• final menstrual period
• average age is 51 (range 45-55) - not associated with menarche.
  
  • cigarette smoking
  • genetic factors
  • hysterectomy may decrease age

Question 2

Perimenopause vs menopause vs post-menopause?

Answer 2

• perimenopause - ovarian function declines, symptoms appear
• menopause = 12 months after final menstrual period
• post-menopause = whole of a women’s life after menopause

Question 3

What are the consequences of menopause?

Answer 3

Short term:

• vasomotor symptoms (hot flushes, night sweats, formication)
• vaginal dryness
• atrophic vaginitis
• sleep disturbance
• mood disturbance

Long term:

• decreased bone density
• increase OP risk
• AD/Dementia

Question 4

What is the endocrine changes in menopause and what is the cause?

Answer 4

• graudal increase in FSH due to lack of negative feedback from ovarian inhibin B
• fluctuations in oestradiol and progesterone
• follicles become progressively more resistant to gonadotropins, irregular anovulatory cycles, follicles exhausted.

Question 5

Premature menopause and Early definitions? Causes and important differentials?

Answer 5

• premature <40
• early between 40-45
• causes:
  
  • iatrogenic most common
  • primary ovarian insufficiency
  • idiopathic
  • rare
  • auto-immune
  • genetic = turners, FXS
• DDx:
  
  • FSH levels >40mlu/ml on >2 occassions >1mth apart
  • >4mths amenorrhoea
  • Prolactin
  • TFTs
  • pregnancy test
  • karyotyping
• consequences:
  
  • increase risk of OP, CVD, loss of fertility, change in body image, increased risk in depression.

Question 6

What works in terms of treatment for vasomotor symptoms?

Answer 6

Don’t know cause, little for targeted therapy

New approaches:

• CBT - RCT data - reduces problem rating
• Gabapention
• SSRIs/SNRIs
• clonidine

HRT works best still:

• oestrogen 85%

Question 7

What is HRT? How is it given?

Answer 7

• only for mod-severe symptoms - review regularly, for as short as possible. Individualised care.
• oestrogen + progesterone - to oppose effects on endometrium (if uterus present)
  
  • tablets
  • patches
  • gel
  • intrauterine
• transdermal = best (lowest risk of TE)
• sequentially or continually applied
• most effective for menopause sys:
  
  • improves vaginal dryness
  • improves bone density and decreases fracture risks
  • improve QOL
  • decreased DM risk
• obligation to explain evidence/lack of evidence for other things.

Question 8

What are some of the risks of HRT?

Answer 8

• breast cancer - only with combined HRT
• oestrogen alone:
  
  • stroke
  • VTE/PE
  • cholecystisis
• combined:
  
  • >5years cancer
  • CVD - relationship unknown

Contraindicated in:

• hormone responsive cancers
• smoking >40 years
• migraines with aura
• uncontrolled HTN
• personal hx TE disease
• undiagnosed irregular uterine bleeding

Question 9

What are the indications to do a DXA scan?

Answer 9

• lifestyle RF
  
  • reduced calcium intake
  • reduced body weight
  • eating disorders
  • immobilization
  • excess alcohol
  • smoking/caffeine
• PMHx:
  
  • prolonged corticosteroids
  • premature menopause
  • malabsorption
  • CLD
  • hyperparathyroidism

Question 10

What is the treatment for vaginal dryness?

Answer 10

• topical vaginal estrogen
• topical lubricants or anaethetics (lignocaine on vulva)
• treat menopause symptoms systemically

Question 11

A 53 year old women with symptoms of menopause. No relevant MHx aside from hysterectomy at age 35 due to fibroids. Her GP discussed HRT options, which is most appropriate?

1. continous oestrogen alone
2. continous progesterone alone
3. continous progesterone and testosterone
4. continous oestrogen with cyclical progesterone
5. COCP

Answer 11

A - continous oestrogen

• aim of HRT is provide enough oestrogen equivalent to premenopausal midfollicular range
• unopposed oestrogen therapy is recommended for women after hysterectomy
  
  • ​in women with a uterus it is associated with 4-8x increased risk of endometrial carcinoma. Risk negated by montly progestogen for 12 days.
  • medroxyprogesterone acetate standard - little effect on lipid and CHO metabolism.
  • testosterone with lack of libido.
  • if unopposed oestrogen is used then endometrial review 12 monthly.

Question 12

A women presents with post-menopausal bleeding, what are some differentials? What are some features on history?

Answer 12

• ENDOMETRIAL CANCER (RF age, nulliparity, >70)
• atrophic vaginitis (intracavity friction - dyspareunia, pale/dry epithelium)
• post-radiation therapy
• anticoagulation therapy

Premenopausal that might happen:

• polyps (if early postmenopause)
• adenomyosis (uncommon unless hormone secreting tumour)

Question 13

What is the treatment ranking scale you use for HRT?

Answer 13

1. nothing - mammogram/OP screen and send away
2. conservative + observation
   
   • lubricants for dryness
   • advice for flushes (advice about room temp, taking off layers, cold drinks, fans)
3. CBT (less evidence for mindfullness)
   
   • hot flushes and night sweats
4. HRT
   
   • oestrogen and progesterone if there is a uterus
     
     • patch (with mirena for progesterone - make clear its for progesterone)
     • gel - skin sensitivity problem for patch
     • tablet (increased DVT risk with oral oestrogen)
   • contraindications to HRT:
     
     • hormone responsive cancers
     • smoking >40 years
     • migraines with aura
     • uncontrolled HTN
     • personal hx TE disease
     • undiagnosed irregular uterine bleeding
       Medical
   • SSRI/SNRI - help with flushes, other mood stuff use it first
   • gabapentin - nocturnal (effect of drowsiness), start 300 and go up slow.
   • clonidine (not used in practice)
5. surgical
   
   • cervical ganglion block - significant risk.

Question 14

What are the hormonal findings for menopause?

Answer 14

• changes are decrease in ovarian follicle number:
  
  • causes inhibin B and anti-mullerian hormone levels to decrease
  • rising FSH
• Post menopause:
  
  • FSH raised
  • oestradiol (E2) low
  • Inhibin/AMH undetectable