Menopause

Question 1

List three obstetrical complications that increase the risk of cardiovascular disease in the post-menopausal woman.

Answer 1

Preeclampsia or gestational hypertension
Gestational diabetes
Placental abruption
Preterm delivery
IUGR

Question 2

What are the three main causes of illness and disability for post-menopausal women?

Answer 2

Cardiovascular disease
Cancer
Osteoporosis-associated fractures

Question 3

What effect does combined HRT have on the following health risks:

Adverse cardiac events
Stroke
VTE
DM
Breast cancer

Answer 3

Adverse cardiac events - women who start combined HRT shortly after menopause are at low risk/possibly reduced risk for the first few years, women who start combined HRT > 10 years after menopause are at increased risk

Stroke - increased risk in general, less so in younger women & with lower doses

VTE - increased risk, more so with oral vs transdermal preparations, more so with combined HRT vs estrogen alone

DM - decreased risk

Breast cancer - unclear (HRT may encourage growth of existing tumours but does not cause new tumours to develop)

Question 4

Describe the concept of the critical window and how it relates to cardiovascular disease & HRT.

Answer 4

Critical window refers to the timing of initiating HRT
HRT may have anti-atherogenic effects for younger women with healthy coronaries
HRT may have pro-thrombotic/plaque-destabilizing effects in older women with established CAD

Question 5

Is HRT contraindicated in women with a family history of breast cancer? Why or why not?

Answer 5

No - with a single affected family member > 50 years old, risk is barely increased over population baseline and therefore HRT is reasonable. With more or younger affected family members, the risk is so significantly increased that the effect of HRT is negligible.

Question 6

Which of the following cannot be effectively treated with vaginal estrogen?

A. Urge incontinence
B. Stress incontinence
C. Vaginal atrophy
D. Recurrent UTIs
E. A & B

Answer 6

B. Stress incontinence

Question 7

List three contraindications to estrogen-containing HRT.

Answer 7

Unexplained vaginal bleeding
Acute liver dysfunction
Estrogen-dependent cancer
Coronary heart disease
Previous stroke
Active thromboembolic disease

Question 8

List two contraindications to progesterone-containing HRT.

Answer 8

Unexplained vaginal bleeding
Breast cancer
(Caution in women with liver disease)

Question 9

Your patient is on continuous HRT for bothersome vasomotor symptoms. She has an episode of bleeding and you perform an endometrial biopsy. The pathology comes back as “proliferative endometrium.” How should you manage this? What if the pathology shows “atrophic endometrium?”

Answer 9

Proliferative: Increase progesterone dose
Atrophic: Decrease progesterone dose

If either persists, consider D&C/hysteroscopy

Question 10

Your patient discontinues her HRT, but finds herself again bothered by vasomotor symptoms. She decides to restart her HRT. After how long would she be considered a new user of HRT (ie. you should revisit the risks associated with HRT in light of her current age)?

Answer 10

6 months

Question 11

What is the mechanism by which estrogen protects against osteoporosis?

Answer 11

Estrogen decreases maturation of osteoclast precursors & activity of mature osteoclasts, thereby decreasing bone resorption

Question 12

What is the difference between the T & Z scores for bone mineral density?

Answer 12

T score - number of standard deviations from expected BMD for a person of the same sex at peak bone mass

Z score - number of standard deviations from average BMD for a person of the same age & weight

Question 13

How is osteoporosis diagnosed in post-menopausal women? What about in pre-menopausal women?

Answer 13

Post-menopause: T score < -2.5

Pre-menopause: Z score < -2 AND fragility fracture

Question 14

What role do the following tests play in working up osteoporosis:

• PTH
• Creatinine
• TSH
• 25dihydroxy vitamin D

Answer 14

PTH - r/o primary hyperparathyroidism
Creatinine - r/o secondary hyperparathyroidism due to renal failure
TSH - r/o hyperthyroidism
25dihydroxy vitamin D - r/o osteomalacia

Question 15

List four categories of medications that can be used to prevent & treat osteoporosis.

Answer 15

Supplements (calcium, vitamin D)
HRT
SERMs
Bisphosphonates
Denosumab (antibody to RANK ligand, which activates osteoclast maturation & function)
Teriparatide (recombinant PTH)

Question 16

What is the average interval between first missed or irregular period and menopause?

Answer 16

4 years
(However, the earlier the first irregularity occurs, the longer the transition period may last)

Question 17

Why are FSH levels elevated in perimenopausal women?

Answer 17

Follicle loss leads to decreased inhibin production, which results in a loss of restraint on FSH secretion

Question 18

Before perimenopause and menstrual irregularity, cycles often become shorter. Explain why this occurs.

Answer 18

Less inhibin production leads to increased FSH secretion
Consequently, luteal recruitment of follicles may occur, resulting in a shorter follicular phase
(Dominant follicles develop, but are often smaller at the time of ovulation than earlier on in the reproductive years - this also results in a shorter follicular phase)

Question 19

A patient comes to you requesting you check her hormones to see whether she is menopausal. How do you respond?

Answer 19

No value to measuring hormones - not diagnostic of menopause

No level of FSH predicts irreversible amenorrhea

Question 20

What two medications can be used for primary prevention of breast cancer in post-menopausal women?

Answer 20

Raloxifene

Tamoxifen

Question 21

List three risk factors for difficulty weaning HRT.

Answer 21

Surgical menopause
Severe symptoms prior to starting HRT
Symptoms lasting > 10 years
Early age at symptom onset

Question 22

Your patient has debilitating hot flushes but is adamant that she will not use hormones. What other medications can you offer her?

Answer 22

SSRIs
SNRIs
Gabapentin

(Paroxetine & gabapentin are the most effective)