Menopause Flashcards by Arya Nedungadi

Define premenopause

Entire reproductive period up to final menses

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Define perimenopause

Time before menopause (3 to 5 years) but is associated with gradual endocrine changes

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Define Menopause

12 months or longer cessation of menstruation associated with reduced hormonal production

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Define climacteric

Ageing process of women during which transition from reprodcuctive to non-reproductive stage occurs

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What is the average age of menopause?

49 to 51

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What age does premature menopause occur at?

<40 yrs

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What age does early menopause occur

<45 years

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What is the physiology of menopause?

Ovarian follicles degenerate over time, remaning follicles have reduced sensitivity to FSH and LH

PERIMENOPAUSE: Few functional follicles leading to anovulatory cycles and therefore irregular periods.

Reduced functional follicles means reduced oestrogen and progesterone from granulosa and theca cells

This reduces inhibition on hypothalamus and pituitary causing high levels of GnRH and therefore FSH and LH

Erratic FSH and LH production results in clinical features of menopause and eventually 12 month cessation of menstrual period

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What are the factors causing early onset of menopause?

Family history
Smoking (2 years earlier) 
Blindness
Abnormal chromosome karyotype
Precocious puberty
Left-handedness
Poor nutrition
Nullipara
Low socio-economic status
Prior hysterectomy

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What factors cause late onset of menopause?

Obesity

High socio-economic status

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Why is obesity associated with later onset of menopause?

Peripheral adipocytes govern the conversion of androstenedione (from ovary and adrenals) into E1 and then to E2.

Thus, obese women produce more oestrone (E1).

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What is the risk of unopposed oestrogen?

Endometrial cancer

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List the phases of change during the climacteric

Phase I - hypothalamic and pituitary hyperactivity
Phase II - Ovulation and corpus luteum
Phase III - Ovarian follicular failure

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Which hormones are raised during phase I of climacteric

FSH and later LH

Increased follicular resistance to gonadotrophins

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Which phase of climacteric causes DUB, endometrial hyperplasia and Ca? Why?

Phase II

Infrequent, deficient/absent ovulation, Low progesterone

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Which hormone is deficient in Phase II of climacteric?

Oestrogen

What type of clinical manifestations occur during menopause?

Physical
Psychological
Sexual
Systemic (diseases, later on)

List the physical symptoms of menopause

hot flushes
Night sweats
Insomnia
Palpitation
Joint aches
Headaches
Vaginal atrophy
Skin atrophy

What is the pathophysiology of hot flushes in menopause?

Vasomotor effect

Result of increase in core temperature (in addition to sweating, peripheral vasodilation, increased pulse rate)

Develop upon oestrogen withdrawal after exposure to oestrogen

Which setting is more prone to hot flushes?

Warm environment

Night time

What are the psychological symptoms of menopause?

Depression
Anxiety
Irritability 
Mood swings
Difficulty concentrating
Forgetfulness

What is the pathophysiology of depression in menopause?

Decreased oestrogen leads to decreased metabolism of serotonin

What are the sexual symptoms of menopause?

Vaginal dryness

Reduced libido

What is the cardiovascular impact of menopause?

Rapid increase of ATH, MI, IHD, HTN and stroke in post menopausal women

Low E2 level, therefore:

low HDL
high LDL (increased oxidation of cholesterol)
loss of vasodilation
reduced CO and SV

Why does skin atrophy occur during menopause?

Low E2 level - thinning of the skin and collagen content (more lax skin which is easily bruised and heals poorly) Can be reversed by E2 replacement

Why does vaginal atrophy occur during menopause? What is the consequence?

Reduced vaginal epithelium and loss of vaginal rugae due to reduced E2. Consequence: atrophic vaginitis, dyspareunia

What are the later effects of menopause?

``` Increased frequency Recurrent UTI Dysuria Incontinence Dry hair and skin Osteoporosis Dementia Cancers ```

Why does incontinence occur during menopause?

Diminished support of the pelvic organs, including the bladder and urethra, leads to prolapse and poor urinary continence

Explain why frequency, urgency and nocturia occur during menopause?

Decreased elastic capacity of the bladder (even though no change in urine output)

Why is bone health commonly affected during menopause?

Osteoporosis is the most significant long-term sequelae of menopause Increases the risk of fracture in the absence of trauma

Why is there accelerated bone loss during menopause?

Increased frequency of new remodelling sites - calcitionin level is reduced in oestrogen deficiency Inadequate intestinal calcium reabsorption - conversion of Vit D to 1,25-dihydroxyvitamin D is oestrogen dependant Reduced oestrogen = reduced transforming growth factor-beta and insulin-like growth factor-1, both of which stimulate bone formation

Types of perimenopausal DUB

Irregular periods Intra-menstrual bleeding Post menopausal bleeding

Conservative management of menopause

``` Diet - increase Ca intake Weight loss Exercise Lifestyle Caffeine CBT Mindfulness ```

Management of menorrhagia

``` Mefenamic acid Tranexamic acid Progesterones Intra-uterine system Endometrial ablation Hysterectomy ```

Types of Hormone Replacement therapy in menopause

Oestrogen alone Oestrogen and progesterone Topical or oral

Risk of oestrogen therapy

Endometrial hyperplasia - cancer Breast cancer Increased coagulation factors (DVT, PE)

Contraindications of HRT

``` Pregnancy Abnormal vaginal bleeding Breast Ca Endometrial Ca Active thrombo-embolic disorder Recent MI Active liver disease with abnormal LFT Porphyria cutanea tarda ```