Menopause Flashcards
What factors contribute to earlier menopause?
Earlier
Smokers have earlier menopause, As does lower IQ, being single, Asian, living at an altitude above 2000m and having had a hysterectomy
Later menopause - higher BMI, OCP use, parity
What is ‘early’ menopause?
What is the age cut off for POI ?
early menopause is before 45
POI before 40
% of woman have early menopause
How long do menopausal sx last?
Sx typically last 4 years, 10% of woman can continue for 12 years
40-70% of woman have symptoms throughout their lives
15% 85 year olds still have VMS
Stages of menopause What is: the late reproductive phase Perimenopause early and late transition Menopause Post menopause
+ what are the hormones doing at each stage?
Late reproductive phase Change in flow cycle / length FSH and E2 variable AMH and inhibin B low Some woman have intermittent symptoms
Perimenopause is irregular cycles to 12 months after the last menstural period
Early menopause transition is persistent difference of 7 days or more in length of consecutive cycles
FSH increased
E2 variable
AMH / inhibin B low
Late menopause transition is marker by periods of 60 days of amenorrhoea or more, frequent anovulation and onset of perimenopausal sx
Menopause is the last menstrual period
Post menopausal is 12 months after the last menstrual period
FSH elevation
E2 AMH inhibin B low
Progesterone low
Vaso motor symptoms
When do they start
How do they present
For who are they more common
Most common reason for woman presenting for tx
Symptoms start during menopause transition and last 4-5 years
affects 80% of woman, 20% severely effected
10% of woman symptoms persist for more than a decade
More common in obese woman
More common in African American woman, less so in Asian woman
1/4 woman experience severe VMS
What are the 4 main groups of menopausal sx
Vasomotor psychological Genitourinary general physical - headaches, fatigue, joint and muscle stiffness
Who to perform hormone levels on?
in woman 40-45 with menopausal symptoms including a change in their menstrual cycle
(Elevated FSH / low estradiol
a low AMH is not a diagnostic test )
In woman under 40 whom menopause is suspected -
Ensure rule out pregnancy, hyperprolactinaemia, thyroid disease, hypothalamic anemorrhoea (anorexia) iron deficiency T2DM
Cannot use for woman on the OCP - only way to tell menopausal status is to cease usage
What is the effect of menopause on the systems of the body?
Metabolic
Increase in central fat deposition
Insulin resistance and increase in T2DM
Cardiovascular
Impaired endothelial function
Increased cholesterol
Skeletal
Accelerated bone loss
Increased fracture risk
Neurological
? mixed opinion about hormonal changes on cognitive performance
Urogential
Atrophic vaginitis
Urinary tract - frequency, cystitis, urge incontinence, dysuria
Contraindications to HRT (RANZCOG)
what conditions must you use with caution
Preexisting cardiovascular disease
Prev VTE
Breast cancer
Abnormal undiagnosed bleeding
Use with caution Endometrial cancer Active SLE Active cardiovascular disease Abnormal LFTs
How to manage vaginal bleeding on HRT
Explain to women with a uterus that unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3-month review appointment, or promptly if it occurs after the first 3 months
Any unexpected vaginal bleeding after 6 months required investigation
How often to FU woman on HRT ?
Initially 3-6 months (RANZCOG says 6 months) Then annually Assess for SEs changing CV risk profile Tx effect
What advice to give about complementary therapy
Explain to women that the efficacy and safety of unregulated compounded bioidentical hormones are unknown.
Explain to women who wish to try complementary therapies that the quality, purity and constituents of products may be unknown.
Advise women with a history of, or at high risk of, breast cancer that, although there is some evidence that St John’s wort may be of benefit in the relief of vasomotor symptoms, there is uncertainty about:
appropriate doses
persistence of effect
variation in the nature and potency of preparations
Potential serious interactions with other drugs including tamoxifen, anticoagulants, anticonvulsants
Ho w to manage altered sexual function
Not an indication alone for HRT
Consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective.
How to address the psychological sx of menopause
Psychological symptoms
Consider HRT to alleviate low mood that arises as a result of the menopause.
Consider CBT to alleviate low mood or anxiety that arise as a result of the menopause.
Ensure that menopausal women and healthcare professionals involved in their care understand that there is no clear evidence for SSRIs or SNRIs to ease low mood in menopausal women who have not been diagnosed with depression
What is the difference between immediately stopping and gradually stopping HRT
Offer women who are stopping HRT a choice of gradually reducing or immediately stopping treatment.
Gradually reducing HRT may limit recurrence of sx in the short term
gradually reducing or stopping HRT makes no difference to sx in the long term
Cessation of HRT leads to a recurrence in 50% of woman
Most guidelines recommend HRT 4-5 years
