Menopause

Question 1

When does menopause usually occur?

Premature menopause age cut off

Answer 1

Average is 51

Premature menopause is considered <40

Question 2

What happens to estrogen and FSH

What happens in ovarian insufficiency? [4]

Answer 2

Estrogen falls
Excessive release of FSH and LH rises

· Lose sensitivity to GnRH
· Oocytes undergo atresia; resulting in decline of quality and number of eggs
· Anovulatory cycles occur
. Failure of LH surge

Question 3

What are the symptoms of menopause? [6]

Answer 3

Vasomotor (Hot flushes), night sweats
Low libido
Muscle, joint aches
Mood change, poor memory
Menstrual irregularity
Atrophy of estrogen dependent tissues - breasts, vagina
Osteoporosis

Question 4

Menopause causes osteoporosis due to the lack of oestrogen, what are the risk factors for this? [4]
Mechanism of bone loss in these women [3]

Answer 4

• Thin Caucasian women w FMH
• Smokers, alcohol, steroids
• Amenorrhoea, hyperthyroid
• Malabsorption

Loss of trabecular bone due to increased bone resorption and decreased bone formation

Question 5

How can we prevent and treat osteoporosis in menopausal women? [6]
Which one is first line treatment

Answer 5

• WB exercise
• Ca2+ supp, Vit D
• HRT
• Bisphosphonates*
• Denosumab (mAb to osteoclast)
• Teriparatide

Question 6

HRT is common treatment for peri-menopausal symptoms, how long is it used for?
Routes of administration: local [4] and systemic [2]
Pros of transdermal patch as opposed to oral [1]

Answer 6

For roughly 5 yrs, only used to treat peri-menopausal symptoms not long term

Local - Vaginal oestrogen pessary, ring or cream

Systemic - Transdermal patch or oral

Transdermal carries less risk of VTE as it bypasses first pass metabolism

Question 7

HRT also comes in various formulations and regimens, what are these? [4]
Which would you give to someone with some ovarian function in perimenopausal stage
Which would you give to someone with no ovarian function eg more than one year after menopause?

Answer 7

1) Oestrogen only
2) Oestrogen + Progestogen (combined)
(2a) Cyclical - 14 days E –> 14 days of E&P
• Indicated if still some ovarian function ie perimenopause
(2b) Continuous - 28 days E&P
• Indicated if no ovarian function eg more than one year after menopause or >54 yo
Mirena LNG IUS + daily E - any age

Question 8

When would we use Oestrogen only HRT? [2]

Answer 8

If the women had no uterus, e.g. her menopause was after a TAH and BSO

NO UTERUS = OESTROGEN ONLY
UTERUS = OESTROGEN AND PROGESTERONE

Question 9

What are the contraindications to HRT? [4]

Seek advice in 3 conditions…

Answer 9

• Current estrogen dependant breast/endometrial cancer
• Current liver disease (elevated LFTs)
• Uninvestigated PV bleed
• Past PE, phlebitis

You should also seek advice you’ve had previous:

• VTE
• Thrombophilia & Fh/o
• Breast Ca or carry BRCA genes

Question 10

How do different types of HRT affect bleeding?

Answer 10

Cyclical combined has a withdrawal bleed

Continuous combined HRT is bleed free after 3 months

Question 11

What are the pros [2] and cons [4] of HRT?

Answer 11

Pros = Works for vasomotor, local genital and osteoporosis symptoms
- Reduced risk of Colon ca

Cons

• Breast ca if combined HRT
• Ovarian ca
• Venous thrombosis if oral route - systemic
• CVA (cerebrovascular accident) if oral route

Question 12

Official NICE guidance on HRT use (indications) [3]

NB HRT benefits outweigh risks till age 50

Answer 12

• If they have severe vasomotor symptoms, and it should be reviewed annually
• For premature ovarian insufficiency (up to age 50)
• Vaginal symptoms > vaginal estrogen (safe and won’t increase breast ca risk indicated even in breast ca remission)

Question 13

Name some other non-HRT treatments for menopause? [4]

Answer 13

· SERMs - tibolone has estrogen positive effect on selected organs that helps with flushes, keeps bone strong, effects on breast eg pain.
· Non-hormonal lubricants for vaginal sxs eg replens, sylk
· Non-pharmacological methods
~ SSRI/SNRIs - antidepressants eg venlafaxine or clonidine

Question 14

Men have their own form of menopause called “andropause” what are the changes that occur? [2]

Answer 14

Testosterone falls by about 1%/yr after 30, DHEAS also falls.

Unlike menopause fertility remains and the changes are more gradual

Question 15

Jane, 48 yo woman has hot flushes and night sweats
Has periods 5/30 cycle but missed 2 periods in last year
Medical management [3] and diagnosis [1]
If these don’t work what herbal preparations can you sanction?

Answer 15

Lifestyle/herbal: red clover
HRT - which therapy?
Combined because Jane still has a uterus
Has some ovarian function so needs cyclical combined
OR can give Mirena + estrogen oral/transdermal route

Question 16

Describe 5 non-pharmacological methods to integrate into existing medical management

Answer 16

Phytoestrogen - soy
Herbs - red clover, black kohosh
Hypnotherapy
Exercise
CBT - for mood swings

Question 17

SE of HRT [5]

Answer 17

Fluid retention
Breast tenderness
Nausea, headache
Leg cramps
Dyspepsia, bloating

Question 18

Perimenopause - explain pathophysiology [4]

Answer 18

Increased number of anovulatory cycles
> less progesterone
> less endometrial secretory changes
> irregular menses