Menopause Flashcards
Define menopause
Cessation of menstruation
Average onset 51yrs, normal range = 45-55; 40-45yrs = early menopause; >40yrs = premature ovarian failure
Diagnosed after 12 months of amenorrhoea
If person has had hysterectomy: diagnosed on basis of perimenopausal symptoms (hot flushes, vaginal dryness, mood swings etc)
What are perimenopausal symptoms and why do they occur?
Central effects of decreased oestrogen levels:
Vasomotor symptoms - hot flushes (can last 2-7yrs) and sweats - with the withdrawal of oestrogen, the set point of the thermoregulation centre becomes very narrow - overly sensitive to small fluctuations in internal body temp and subsequent overreactive response
MSK symptoms - joint and muscle pain
Low mood and sexual differences - low sexual desire, poor memory/concentration/confidence/energy
Local effects of decreased oestrogen:
Urogenital symptoms (vaginal dryness due to vaginal atrophy)
Why do women come to menopause?
Genetic and personal factors
Even if you have an ovary removed - still occurs at the same time
Born with all the follicles you will have, reduce before puberty (?) to about 500 - which will be with you for life
What are short term effects of the menopause?
Vasomotor symptoms
Mood/memory/confidence/energy
Headache
Skin+joint changes/pains
What are medium term effects of menopause?
Urogenital atrophy: (no oestrogen means decrease in collagen content of skin and connective tissues)
Dyspareunia
Recurrent UTI
Post menopausal bleeding (PMB)
Peak incidence of urinary incontinence and prolapse is 55-65yrs
What are the long term effects of menopause?
Osteoporosis - effects reliably reversible with oestrogens
Cardiovascular effects - risks increase with early onset
Dementia - risks increase with early onset
Risk reduction should start at the time of the menopause
What are some benefits and risks associated with giving women HRT for menopause?
Benefits:
Relief of menopause symptoms
Bone mineral density protection
Possibly prevent long term morbidity
Risks:
Breast cancer - risk is variable between women; oestrogen alone is a reduced risk; with oestrogen and progesterone is only a slightly increased risk (23/1000 in general population, 27/1000 in this population), but this disappears when woman stops taking HRT; women with current or Hx of BC then don’t prescribe and discontinue if develop BC
VTE - increased risk by oral HRT compared to transdermal (due to first past metabolism - oestrogen increases production of clotting factors, same a pregnancy); transdermal is no increased risk in normal BMI, but increased risk in BMI >30; if FHx or Hx refer to haematology before starting
CV disease - only increased risk of HRT started after the age of 60; reduced risk if oestrogen alone, slightly increased risk for combined
Stroke - slight increase by oral, not increased with transdermal
HRT not related to glycaemic control so fine in DM (though think CV/stroke risks too in this population)
What are some non-medical ways to help manage the menopause? (or other health problems associated with it or its treatment)
Lifestyle advice - smoking cessation, weight reduction, exercise, diet, drinking etc.
Reduce modifiable risk factors - again stuff regarding weight loss; manage urinary incontinence etc; Calcium and vitamin D supplementation for osteoporosis prevention etc
Psychological support - CBT - about how to relate to new state of being
Sometimes this will be enough for people
When do you treat with HRT?
Goes according to the woman’s wants
Who needs combined HRT?
Progesterone + oestrogen needed in women who haven’t had a hysterectomy:
This protects the endometrial lining from the stimulatory effects of unopposed oestrogen which would otherwise lead to a massive proliferation of endometrium and an increased risk of endometrial cancers
No progesterone needed if women has no uterus
How is HRT prescribed?
Uterus present:
Sequential - Progesterone should be used for 12-14 days every 14wks sequentially with oestrogen
perimenopausally (within first 12m) - prevent irregular bleeding - then switch to…
Continuous combined - Tibolone - doesn’t have oestrogen activity on the uterus (does on bone, brain etc) - commonly used; not used within 12m of LMP
ALTERNATIVELY:
Can use the MIRENA coil for the progesterone part of HRT then prescribe oestrogen only (Estradiol)
Route: (depends on preferences and other risk factors)
PO
Transdermally - patch Vs gel Vs intravaginally (for urogenital atrophy)
Dose:
lowest effective dose - lots of different doses though…
Who should have transdermal oestrogens?
Gastric upset - e.g. Crohn’s
Need for steady absorption - migraine, epilepsy (want to avoid big spikes in oestrogen that occur with oral as can trigger episodes)
High risk of VTE
Older women staring HRT
HTN
Patient choice
How do you manage low sexual desire?
Consider testosterone supplements
What is premature ovarian insufficiency? (POI)
Menopause <40yrs
Natural (e.g. genetics/chromosomal abnormalities) or iatrogenic (e.g. surgery, radiotherapy)
Majority are idiopathic
Primary (never produce follicles e.g. in some genetic conditions) Vs Secondary (some follicles but depleted quickly)
How do you treat POI?
HRT up to the age of 51yrs to minimise risks of hypo-oestrogens (osteoporosis etc)
If primary - will need to be given during puberty to develop secondary sexual characteristics
