Menopause

Question 1

Average age of menopause

Answer 1

51 - Jean Hailes tool
Early (<45 years)
Premature (<40 years)

Question 2

Symptoms of menopause

Answer 2

• Hot flushes
• Night sweats
• Muscle/joint pains
• Anxiety
• Irritability
• Sleep disturbance
• Fatigue
• Crawling sensations on skin
• Overall diminished wellbeing
• Low libido
• Lessened concentration
• Vaginal dryness
• Painful intercourse

Question 3

Routine screening at menopause consultation

Answer 3

• Thyroid
• Diabetes
• Cardiovascular health
• Iron deficiency
• Weight
• Lifestyle
• Medications
• Contraception
• Cervical screening and mammogram

Question 4

Conservative management

Answer 4

Hot flushes:
- Dress in layers
- Natural fibres
- Reduce alcohol, caffeine, weight
- Active lifestyle
Dry vagina:
- Topical oestrogen
- Vaginal lubrication (aim for similar pH to vagina)
Emotional health
Stress management
Black cohosh - mixed results, monitor for liver toxicity

Question 5

Contraindications to MHT

Answer 5

• Breast cancer (hormonally sensitive)
• Thrombophilia/past VTE
• Undiagnosed vaginal bleeding
• Active liver disease
• Uncontrolled hypertension (controlled is okay)
• CVD risk or disease

Question 6

MHT alternatives

Answer 6

• Escitalopram 10-20mgs daily
• Venlafaxine 37.5-75mgs daily
• Desvenlafaxine 50-100mgs daily
• Paroxetine (reduces Tamoxifen efficacy) 7.5-10mgs daily
• Gabapentin 300-900mgs daily
• Clonidine 50-150mcg daily

Question 7

MHT for early/premature menopause with intact uterus

Answer 7

Continue HRT/MHT until 50 years unless contraindicated. Higher doses usually required.
Options:
1. Continuous oestrogen (high dose oestrogen due to age) + cyclical or continuous progestogen
2. Combined contraceptive
3. Tibolone

Question 8

MHT for perimenopause with intact uterus

Answer 8

Dosage: lowest effective dose monitored by self-reported symptom control
Options:
1. Low dose combined contraceptive (if low CVD risk & <50 years)
2. Continuous oestrogen + cyclical progestogen 10-14 days each month + contraception (including barrier, sterilisation)
3. Continuous oestrogen + levonorgestrel IUD for progestogen and contraception

Question 9

MHT post-menopause with intact uterus

Answer 9

Dosage: lowest effective dose monitored by self-reported symptom control
Options:
1. Continuous oestrogen + continuous progestogen
(if menopause >1-2 years ago)
2. Continuous oestrogen + cyclical progestogen
(if menopause <1 year ago) or levonorgestrel IUD
3. Tibolone (if menopause is >1-2 years ago)
4. Tissue-selective oestrogen complex (TSEC

Question 10

Tibolone

Answer 10

Tibolone is a type of hormone therapy (HT) designed to relieve menopausal symptoms and prevent osteoporosis (thinning of the bones) in post-menopausal women.

Tibolone acts as a combined oral hormone therapy for treating menopausal symptoms.
It has not been researched as extensively as some other forms of HT.
Risks vs benefits for an individual need to take into account their co-morbidities.
It is contraindicated in women who have had breast cancer.

Tibolone is a synthetic steroid hormone derived from the Mexican yam
The metabolites of tibolone have estrogenic, androgenic and progestogenic effects [1,2].
Tibolone has oestrogen-like effects in the brain (preventing flushes), bone (preventing bone loss) and vaginal tissue (preventing dryness and soreness) [3,4].
Tibolone also has progesterone-like effects at the uterus to prevent endometrial thickening and subsequent bleeding. A woman who has not had a hysterectomy does not need to take a progestogen if she is taking tibolone.
Tibolone has testosterone-like activity that appears to play a role in enhancing women’s mood and libido, although response is variable.

Side-effects are uncommon but may include headache, dizziness, nausea, abdominal pain, swollen feet and itching. Breast tenderness is also uncommon..
Slight bleeding or spotting may commonly occur initially but tends to subside after a few months. Amenorrhea is achieved by about 80% of women after the first month of treatment with tibolone and over 90% after the third month of therapy

Long-term health

Tibolone prevents bone loss and reduces spinal fractures [5].
One uncontrolled English study has suggested that tibolone increases breast cancer risk but better quality placebo controlled randomised trials do not show that breast cancer rates in healthy women are changed by tibolone [5].
Tibolone does not increase breast density [6].
Tibolone may interfere with the effectiveness of breast cancer therapies and its use is contraindicated in women with breast cancer [7].
Regular mammograms and breast examination are advisable for all women.
Tibolone decreases total and LDL cholesterol and triglyceride levels. However, it also decreases HDL cholesterol. The impact of these changes are not clear.
Recent research suggests that Tibolone increases the risk of stroke [5]. This risk is mainly seen in women over 60 years of age. The increase among women in their 50s is 4 extra cases per 1000 and among women in their 60s, an extra 13 cases per 1000 women.
Tibolone should not be used for cardiovascular protection.
Few data are available with regard to thrombosis risk are available and the outcomes are inconclusive.