Menopause Flashcards
What is the menopause?
Onset of the menopause is heralded by the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhoea
What is the average age for the menopause?
51 years
What is defined as early and premature menopause?
<45 years
<40 years
What is defined as late menopause?
> 54 years
What is the physiology of the menopause?
Reduced oestrogen due to lack of follicle production and lack of granulosa cells
Therefore FSH and LH will be raised due to a lack of negative feedback
What are the effects of oestrogen?
Secondary sexual characteristics Hair distribution, body shape and fat distribution Effects of collagen Bone growth Proliferates endometrium
What are the main categories of symptoms for the menopause?
Vasomotor
Irregular periods
Psychological
Sexual
Why should FSH and LH not be measured in perimenopausal woman over 45?
Released in a pulsatile fashion
Single raised or normal level does not confirm or rule out the menopause
What things are known to increase FSH and LH levels?
Raised just prior to ovulation
Raised with stopping COC or depo provera
Raised with breastfeeding or certain medications (SSRI)
What are the main physical symptoms of the menopause?
Hot flushes Night sweats Palpitations Insomnia Joint aches Headaches
What percentage of woman will have hot flushes?
60-80%
20% have severe symptoms
How long do hot flushes on average last?
Average is 2 years
10% for 15 years
Last for 3-5 mins
What psychological symptoms are associated with the menopause?
Mood swings Irritability Anxiety Difficulty concentrating Forgetfulness
What sexual symptoms are assoc with the menopause?
Vaginal dryness
Libido
What physiological change leads to vaginal dryness seen in the menopause?
Lack of collagen
What hormonal change leads to reduced libido seen in the menopause?
Testosterone
What are the later symptoms of menopause?
Urinary frequency Recurrent UTIs Dysuria Incontinence Dry hair and skin Atrophy of breast and genitals
Describe the perimenopausal dysfunctional uterine bleeding?
Irregular periods
Inter-menstrual bleeding
Post menopausal bleeding
What is the concern with post menopausal bleeding?
Endometrial cancer
What is the conservative management of the menopause?
Diet; phytoestrogens such as soy Wt loss Exercise Caffeine CBT Mindfulness
What are the treatment options for menorrhagia?
Mefenamic acid Tranexamic acid Progesterones Intrauterine system Endometrial ablation Hysterectomy
What are the mode of actions for mefenamic acid and tranexamic acid?
Mefenamic acid; NSAID, affects prostaglandins in uterus and decreases blood supply to womb
Tranexamic acid; anti fibrinolytic to stop body from breaking down clots
What are the different forms of HRT?
Oestrogen alone
Oestrogen and progesterone combined
Topical or oral
Continuous or sequential
When should woman with early menopause be advised to continue HRT?
Continue until at least the natural age of menopause (around 51)
Should FSH be measured in woman presenting with the menopause >45?
No
What is the 1st line treatment for women with vasomotor symptoms and low mood or anxiety?
HRT
What can be considered to alleviate low mood or anxiety?
CBT
When should transdermal instead of oral HRT be considered?
Increased risk of VTE
BMI over 30
Breast cancer risk
When should vaginal oestrogen be offered to post menopausal women?
Urogenital atrophy (including those on systemic HRT) but ONLY after examination to exclude other pathologies
Why is mirena IUS used in menopausal symptoms?
Does NOT help menopausal symptoms
Can be used for endometrial protection
Contraindications for HRT?
Breast ca Undiagnosed abnormal vaginal bleeding Endometrial cancer Pregnancy Active thromboembolism disease Recent myocardial infarction Active liver disease with abnormal LFT Porphyria cutanea tarda
What are the benefits of HRT?
Symptom control
Increased QOL
Reduced osteoporotic fracture
Reduced incidence of bowel cancer
Protective for alzheimer’s and parkinson’s
HRT <10 years after menopause fewer risks and less CV events
What are the risks assoc with HRT?
VTE CVA Breast ca Gallbladder disease HRT > 20 years after menopause greater risk of harm
Why can clonidine be given in menopausal women?
Regulates temperature at the level of the hypothalamus
What is the mode of regelle, yes and sylk in the menopause?
Vaginal lubricants
What is the referral criteria to the postmenopausal bleeding clinic?
Post menopausal women (>12 months after LMP)
Vaginal bleeding on continuous HRT more than 6 months after start of HRT
Vaginal bleeding persisting 6 weeks post stopping HRT
What are the benefits of systemic HRT?
Reduction of vasomotor symptoms
Improvement of low mood assoc with perimenopause
Prevention and treatemnt of vulovovaginal/ urogenital atrophy
Reduction of osteoporosis risk and fragility #
Improvement of sexual function
What are the recommended investigations for menopause below 40?
2 x FSH 4 to 6 weeks apart (menopausal levels >30) Testosterone Sex hormone binding globulin Prolactin TFT Autoimmune studies
Describe the HRT given to women with a hysterectomy?
Continuous oestrogen only HRT
Describe the HRT given to perimenopausal women with an intact uterus?
Sequential combined HRT
Describe the HRT given to postmenopausal women, aged 54 or after >4 years on sequential HRT?
Continuous combined HRT
Describe the general rules around contraception in the perimenopause?
Perimenopausal woman can get pregnant
HRT is NOT a contraceptive unless using IUS/ estradiol regimen
Contraception required for 2 years post LMP if <50 or 1 year if >50
Which contraceptive methods can be used in perimenopausal women?
CHC and DMPA may be stopped at 50 years but can be continued if benefits outweigh risks but NOT in conjunction with HRT
1st line CHC in women over 40 contains 30 mcg EE or less and a 2nd generation PG (LNG, NE) to lower VTE and CVD risk
POP, SDI or Cu-IUD can be used in conjunction with HRT
