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
VTE risk
When is it highest
Who is it high for
what are the alternatives
Prev VTE is a contraindication to HRT
The risk of VTE and stroke increases with oral MHT but the absolute risk is rare before age 60
With combined MRT the risk increases 2 fold
The risk with oestrogen only is of borderline significance
Absolute risk is related to other risk factors
risk highest in the first year of use
the risk of VTE associated with HRT is greater for oral than transdermal preparations
the risk associated with transdermal HRT given at standard therapeutic doses is no greater than baseline population risk.
Tibolone has been found not to increase VTE risk
If woman have a personal or FHx of VTE screening and risk counselling is appropriate being treatment
When is the risk of stroke and MRT ?
Increased risk of stroke for woman over 60 or over 10 years from menopause using estrogen or combined therapy
Ischemic stroke, probably relates to thrombotic risk
No increased risk with transdermal 50ug or less were used (increased risk with oral and high dose transdermal)
Explain to women that taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke. Also explain that the baseline population risk of stroke in women aged under 60 years is very low
Migraine is not a contraindication to MHT use however low dose transdermal therapy may be preferable.
MRT and cardiovascular disease risk
HRT does not increase cardiovascular disease risk when started in women aged under 60 years (within 10 years of menopause)
HRT does not affect the risk of dying from cardiovascular disease.
Woman with a hx of cardiovascular disease initiating MHT may increase their risk - careful risk assessment and considering risk and benefits needs to occur and consult her physician
HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease
HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease.
for 50-59 year olds Risk significantly reduced for estrogen only and no difference for combined users
A recent Cochrane analysis concluded that, overall, MHT conferred no protective effect on all-cause mortality, cardiovascular death, non-fatal infarction, angina or revascularisation but did increase risk of stroke and VTE. However, in women who started MHT less than 10 years after the menopause there was lower mortality (RR0.70, 95%CI 0.520.95), and also a lower incidence of coronary heart disease
How does MRT affect T2DM
Explain to women that taking HRT (either orally or transdermally) is not associated with an increased risk of developing type 2 diabetes.
Ensure that women with type 2 diabetes and all healthcare professionals involved in their care are aware that HRT is not generally associated with an adverse effect on blood glucose control.
Consider HRT for menopausal symptoms in women with type 2 diabetes after taking comorbidities into account and seeking specialist advice if needed.
How does Breast cancer risk change of MRT
HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer
Increased risk with duration of use
HRT with oestrogen alone is associated with little or no change in the risk of breast cancer
any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT.
Combined MHT use for more than 5 years may be associated with an increased risk of breast cancer. This risk appears to be related to the use of a Progestogen and duration of therapy.
No increased risk less then 5 years
Estrogen alone does NOT increase breast cancer risk
Osteoporosis
and MRT
How is it affected ?
While randomised clinical trials have shown MHT to reduce fracture risk in low risk post-menopausal women, bone protection is not an approved primary indication for MHT.
MRT can be used if other treatments are inappropropriate AND they are symptomatic
HRT should be considered if they have low bone density and have not sustained a fracture
MHT is also effective and appropriate for the prevention of osteoporosis related fracture in at risk women within 10 years of the menopause
MHT is also effective and appropriate for the prevention of osteoporosis related fracture in at risk women within 10 years of the menopause
MRT and ovarian cancer
Associated is uncertain
A large metaanalysis supported an increase in ovarian cancer by 2.4:10 000
Increase in serous and endometrioid sybtypes - reduction in clear cell and mucinous types
One specifically designed study looked at this - no change
Gall bladder disease and MRT
Cholecystitis is increased with oral MHT amounting to an extra 12 cases per 1000 woman per 5 years
Transdermal therapy is likely to limit this
In women with abnormal liver function tests transdermal therapy should be preferred
What % of 85 year olds have vasomotor sx?
15%
40-70% of woman have ongoing sx through their lives
How to dx menopause + perimenopause in
woman Over 45
Diagnose over 45
perimenopause: based on vasomotor symptoms and irregular periods
menopause: in women who have not had a period for at least 12months and are not using hormonal contraception
menopause: based on symptoms in women without a uterus.
FSH on woman over 45 should not be performed
This is because FSH fluctuates considerably over short periods of time during the years leading up to menopause and so blood levels are not a helpful addition to what is a clinical diagnosis
If has had an ablation can Tx based on Sx of menopause (need progesterone)
If Progesterone IUD in situ can give oral estrogen if symptomatic
How to dx menopause in 40-45 year olds
Under 40 year olds
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
MRT and breast cancer risk
Combined MHT use for more them 5years may be associated with an increased risk of breast cancer - this is related to the progestogen use and duration of therapy
Estrogen only MHT does not increase risk of breast cancer.
How to help woman with breast cancer going through menopause
Quality of life issues should be discussed and assessed together with the risks of developing osteoporosis, cardiovascular disease, thromboembolism, and dementia.
Life style factors should be addressed including adequate exercise, calcium/ vitamin D intake, avoidance of smoking, excessive alcohol and caffeine intake, optimal weight maintenance and reduction of stress. Sexual counselling should be considered.
Evidence-based non-hormonal options should first be considered
(e.g. bisphosphonates or SERMs for osteoporosis, cholesterol lowering agents and aspirin for cardiovascular disease).
Some individual menopausal symptoms may be ameliorated with individual selected therapies eg venlafaxine, desvenlafaxine, escitalopram, citalopram and paroxetine, clonidine and gabapentin for vasomotor symptoms, vaginal lubricants for superficial dyspareunia, and anticholinergics for urinary urgency.
Please note that paroxetine and tamoxifen should not be prescribed together.
Can woman with a hx of breast cancer be given vaginal oestrogen?
A reasonable therapeutic option for the control of urogenital symptoms.
Oestriol preparations may have less systemic absorption than oestradiol preparations.
In women taking aromatase inhibitors oestriol preparations are preferred as local oestradiol preparations may transitory elevate serum E2 levels. When used according to instructions supplementary progestogen therapy is not required with either preparation.
What if woman with prev breast cancer choose to use MRT
Refer to a menopause specialist
In women who find HRT necessary for quality of life reasons, for a regimen to be developed with the lowest effective dose of estrogen combined with sequential progestogen, ideally dydrogesterone or micronized progesterone.
Evidence for the use of Mirena in these circumstances is lacking although small studies show reduced breast density with Mirena compared to oral norethisterone.
How to monitor for the risk of breast cancer?
Annual review including mammography is recommended for women on HT.
Diagnose premature ovarian insufficiency in women aged under 40 years based on:
Menopausal sx
FSH levels on 2 blood samples 4-6 weeks apart
Do not dx on a single blood test
Do not use AMH to dx POI
If there is doubt about the diagnosis of premature ovarian insufficiency, refer the woman to a specialist with expertise in menopause or reproductive medicine.
Management POI
Offer sex steroid replacement with a choice of HRT or a combined hormonal contraceptive to women with premature ovarian insufficiency, unless contraindicated (for example, in women with hormone-sensitive cancer).
POI increases the risk of CVD and osteoporosis and this is the indication for tx
Need higher dosing and need to be continued until 52
Give the replacement therapy as long as needed No set time
Risk of VTE or breast cancer is very low
that both HRT and combined oral contraceptives offer bone protection
that HRT is not a contraceptive
Give women with premature ovarian insufficiency and contraindications to hormonal treatments advice, including on bone and cardiovascular health, and symptom management
How to manage MRT with surgical menopause
Women experiencing premature or early menopause due to bilateral oophorectomy at the time of hysterectomy are different from women who reach menopause at the median age of 51 years, and data regarding the use of hormone therapy in naturally menopausal women should not be extrapolated to women who have surgical menopause at the time of hysterectomy
Observational data consistently indicate that several of the serious long-term health consequences of bilateral oophorectomy can be ameliorated by taking estrogen therapy until at least age 50 to 51 years
Women who are treated with hormone therapy after hysterectomy may take estrogen therapy alone since a progestogen for endometrial protection is not needed.
Some clinicians use androgen for sexual dysfunction bu long term safety data is lacking
