Menopause

Question 1

What is menopause

Answer 1

Permanent Cessation of Menstruation due to loss of Ovarian Follicular activity
o Recognised to have occurred after 12 consecutive months of Amenorrhoea without obvious pathological or physiological cause
o In late 40yrs, FSH initially then LH concentrations rise as Follicular supply diminishes; Oestrogen
levels fall, resulting in Cycle Variability

Question 2

Perimenopause

Answer 2

Begins with first Clinical, Biological and Endocrine features of approaching Menopause (e.g. Vasomotor symptoms, Menstrual Irregularity

Question 3

Menopausal Transition

Answer 3

Time prior to Final Menstrual Period, with increased cycle variability

Question 4

Climacteric

Answer 4

Transitioning from Reproductive to Non-Reproductive state

Question 5

Diagnosing/Confirming Menopause

Answer 5

FSH is helpful only if diagnosis is in doubt; LH, Oestradiol and Progesterone of no value for diagnosis of Ovarian failure
o TFTs to rule out; Thyroid disease can present similar to Menopausal symptoms

Question 6

Vasomotor Symptoms

Answer 6

Hot flushes and Night Sweats are common; Highest prevalence in first year; Typically settles after <5yrs

Question 7

Sexual Dysfunction

Answer 7

Multifactoral; Vaginal Dryness due to Oestrogen deficiency, Unknown if lower Androgen levels plays role
o Psychosocial Factors – Conflict, Life Stress, Depression; Male Sexual problems
o Classified based on Loss of Desire, Arousal, Orgasm or Dyspareunia

Question 8

Psychological Symptoms

Answer 8

Depression, Anxiety, Irritability and Mood Swings, Lethargy, Sleep disturbance, Loss of Concentration, Weight gain
Most women do not experience major changes; Psychological issues likely associated with other problems and life stressors

Question 9

Osteoporosis

Answer 9

Compromised Bone Strength predisposing to increased risk of fracture
o Rapid loss in Bone Density in 10yrs after; Reduced BMD and poorer Bone Quality
o Most common sites of Osteoporotic fractures are Colle’s, NOF, and Vertebral
o Additional Risk Factors include FH, Low BMI, Early Menopause, Smoking, ETOH, Low Calcium, Sedentary Lifestyle, Corticosteroid use (>5mg Pred daily), Aromatase Inhibitors, GnRH Analogues, Hyperthyroid and Parathyroid, Malabsorption

Question 10

Cardiovascular Risks

Answer 10

Higher risk of MI and Stroke

Question 11

Urogenital Atrophy

Answer 11

Oestrogen deficiency leads to atrophic changes; Frequency, Urgency, Nocturia, Incontinence and Recurrent Infection
May co-exist with Vaginal Atrophy – Dyspareunia, Itching, Burning, Dryness

Question 12

Premature Ovarian Failure

Answer 12

Loss of Ovarian Function before 40yrs; Triad of Amenorrhoea, Hypergonadotrophism (Loss of Negative Feedback raises FSH) and Low Oestrogen
o Associated with Hypothyroidism, Addison’s Disease and other Autoimmune
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o If occurs prior to Menarche = Primary Ovarian Failure

Question 13

Causes of POF

Answer 13

Mostly Idiopathic – Primary causes include Chromosomal Abnormalities, FSH receptor mutations, Inhibin B mutations, Enzyme deficiencies and Autoimmune
o Can also be secondary to Chemo, Radiotherapy, Oophorectomy, Hysterectomy (Reduced blood flow to Ovaries?), Infection

Question 14

Treating POF

Answer 14

Require Oestrogen Replacement until average age of Natural Menopause; HRT or back-to-back COCP; No evidence for Bisphosphonates and Bone protection

Question 15

How can HRT be given?

Answer 15

Can be given either Systemically (for Hot flushes and Osteoporosis) or Vaginally (for Local Symptoms like Vaginal Dryness)

Question 16

HRT for women without hysterectomy

Answer 16

Combined HRT is recommended (Mitigates risk of Endometrial Cancer from unopposed Oestrogen)

Question 17

Types of HRT available

Answer 17

Oestrogens – Oestradiol, Oestrone, Oestriol synthesized from plants but chemically similar
• Progestagens – Dydrogesterone, Medroxyprogesterone Acetate, Norethisterone, Levonorgestrel derived from Plant sources

Question 18

Local HRT

Answer 18

Cream or Pessaries/Rings; Long term treatment required; No Endometrial effects from using unopposed Oestrogens in Non-Hysterectomised women

Question 19

Alternatives to HRT

Answer 19

Alternatives to HRT for Symptomatic Relief – SSRI (Fluoxetine, Paroxetine) and SNRI (Venlafaxine) for Vasomotor Symptoms; Bone Protection and SERMS for Osteoporosis

Question 20

Benefits of HRT

Answer 20

Reduced Vasomotor symptoms, Urogenital symptoms, Sexuality, Reduced risk of Osteoporosis and Colorectal Ca

Question 21

HRT Risks

Answer 21

Increased risk of Ca Breast, Endometrial Ca, VTE; Unknown if increases Gallbladder Disease
Unopposed Oestrogen raises Endometrial Ca risk by RR2.3; Further to 9.5 if >10yrs use; Remains for >5yrs after stop; No increased risk with Continuous Combined HRT
o Increased VTE risk; Absolute risk remains small; More likely in first year of HRT
▪ Age, Obesity, Thrombophilia significantly increases risk
Breast Cancer – Similar risk to Late Natural Menopause; Dependent on Duration; Risk to baseline once HRT stopped; Dependent on regimen (Combined HRT > Unopposed)