Menopause Flashcards
Definition of menopause
The permanent cessation of menstruation that results from loss of ovarian follicular activity
- average age 51 years
- natural menopause considered to happen after 12 consecutive months of amenorrhoea, for which no other obvious cause is present
Define the climacteric
Phase encompassing the transition from the reproductive state to the non-reproductive state
The menopause itself thus is a specific event that occurs during the climacteric, just as the menarche is a specific event that happens during puberty
The symptoms are brought on by a drop in progesterone and oestrogen levels
Define premature ovarian insufficiency
A loss of normal function of the ovaries before the age of 40
- ovarian failure means sub-optimal amounts of oestrogen is produced, or eggs aren’t released regularly
- subfertility is a common result
Different from premature menopause because women with POI, can have periods for several years, and sometimes can become pregnanct
HPO-axis changes during menopause
Ovarian failure occurs, causing a drop in oestrogen production, therefore decreasing the negative feedback loop to the hypothalamus and pituitary.
- increased levels of FSH and LH are seen
- diagnostic of menopause
Causes of menopause and associated risk factors
Normal
Premature ovarian insufficiency
- primary (X-chromosome deletion 46XO, FSH receptor gene polymorphism, enzyme deficiencies and autoimmune disease)
- secondary (hysterectomy without oopherectomy, radio/chemotherapy, surgical menopause and infection)
Smoking
Primary ovarian insufficiency
Diagnostic criteria for menopause in women >45 years
Women who have not had a period for 12 consecutive months and are not using hormonal contraception
Menopause is based on symptoms in women without a uterus
Diagnostic criteria for menopause in women <45 years
Women who have menopausal symptoms, including a change in their menstrual cycle for 4 consecutive months + FSH increased (>30IU/L on 2 samples, 6 weeks apart)
Can’t interpret results if on COCP or high dose progesterone
Effect of menopause on vasomotor symptoms
Hot flushes Night sweats Palpitations Headaches Dizziness - most commonly reported symptoms during (peri)menopause - median duration of 7 years Palpitations
Effect of menopause on the pelvic floor
Effect - decreased blood supply - decreased tone - increased relaxation Consequence - uterovaginal prolapse
Effect of menopause on the vagina
Effect - vaginal epithelium becomes thinner and less rugose - intermediate cells are replaced by superficial cells - secretions diminish Consequences - atrophic vaginitis - dryness - painful sex/sexual dysfunction - relationship breakdown - general discomfort - trauma and bleeding
Effect of menopause the urinary tract
Effect - urethral mucosa atrophies Consequence - atrophic bladder - increased frequency - dysuria - incontinence - recurrent UTIs
Effect of menopause on the uterus, ovaries and uterine tubes
Ovaries and uterine tubes become atrophic
The muscle in the uterus become fibrous tissue
- fibroids in the uterus become smaller
Effect of menopause on the external genitalia
The external genitalia becomes atrophic and loses fat
Effect of menopause on mood and sleep
Depression Irritability Anxiety Memory Sleep disturbance Mood swings Poor concentration Decreased libido - due to mood/atrophic vaginitis
Effect of menopause on bone health + factors relating to early fracture
Factors contributing to an early presentation of osteoporosis related fractures - smoking - low BMI - long episodes of amenorrhoea - early age of menopause - FH of osteoporosis - systemic disease (e.g. renal) - drug usage e.g. steroids/chemotherapy Use FRAX risk assessment tool
Effect of menopause on cardiovascular disease and stroke risk
CVD is most common cause of death in women over 60
HRT use in CHD management is associated with higher risk of stroke
However, CHD risk reduced by 50% if HRT commenced within 10 years of the menopause
Effect of menopause on lipido
Female sexual dysfunction (88% of women during late menopause)
Causes
- vaginal dryness (caused by decreasing oestrogen levels) causing dyspareunia
- conflict with partner due to mood disturbance and life stress
Categories
- loss of sexual desire
- loss of sexual arousal
- problems with orgasm
- painful sex
Indications for HRT use in menopause
Most effective treatment for vasomotor symptoms associated with menopause at any age HOWEVER, benefits outweigh risks for symptomatic women <60 years, or within 10 years of menopause
- relief of short term symptoms
- prevention/treatment of osteoporosis
- management of premature ovarian failure
Contraindications for HRT
Pregnancy History of recent thromboembolism Acute/chronic liver disease Undiagnosed uterine bleeding Diabetic Suspected/active breast or endometrial cancer
Types of HRT available
Oestrodiol
- tablet, pessary or patch
- pessaries preferred if the main complaint is atrophic vaginitis
- requires progesterone if uterus in situ (risk of endometrial cancer)
- unopposed oestrogen causes uncontrolled endometrial proliferation
- give cyclical if <54 years or bleed in last year (causing bleeding to occur once a month)
HRT ‘rules’
Minimum effective dose, used for the shortest duration
Treatment reviewed at least annually
Limited experience treating women >65 years
Benefits for treating short-term symptoms outweigh the risks in women <60 years
Adverse effects of HRT
Oestrogen-related - fluid retention - bloating - breast tenderness - nausea - headaches/migraine - leg cramps - dyspepsia Progesterone related - fluid retention - breast tenderness - headaches/migraine - mood swings - depression - acne - lower abdominal pain
Risk of HRT therapy
Endometrium - risk of unopposed oestrogen - progesterone can be given via mirena Breast - no increase with oestrogen alone - small increase with progesterone, that decreases back to normal after cessation VTE - increased risk in first year of use - increased risk only associated with oral HRT Stroke - small increase
Where to access figures on risk of HRT when counseling women
NICE guideleines
NHS online HRT information pages
Fertility in the perimenopausal woman
HRT doesn’t provide contraception
A woman is considered potentially fertile
- for 2 years after LMP if under 50
- for 1 year after LMP is over 50
How is fertility managed in the perimenopausal woman?
Under 50 and free or risk factors
- COCP for relief of menopausal symptoms and contraception
- stop at 50 due to better alternatives
Over 50 that requires HRT
- non-hormonal contraceptive measures such as condoms, or the mirena coil
Prescribed non-hormonal HRT for managing vasomotor symptoms
Clonidine - can reduce symptoms of flushing - use is hampered by extensive side effects SSRI - can reduce flushing Gabapentin - some evidence of reduced flushing - side effects
Phytoestrogens as alternatives for hormonal HRT
Found in food e.g. soy, soya and milk Weak oestrogen agonist and antagonist properties Some improvement in symptoms - underpowered - low quality - >50% placebo response
Black cohosh as an alternative for hormonal HRT
Weak oestrogen agonist and antagonist properties
Trend toward reducing hot flushes only in mild to moderate symptoms
- no benefit in comparison to placebo
What non-hormonal methods of HRT are there?
Prescribed - clonidine - SSRI - gabapentin Non-prescribed - vitamin E - evening primrose oil (placebo better results) - phytoestrogens - block cohosh Alternative - acupuncture - lifestyle - stellate ganglion blockade
