Menopause Flashcards
Menopause:
What criteria categorise a woman as postmenopausal?
1) if over 50yo not on hormonal contraception and amenorrhoeic for 12 months
2) under 56yo and no period for 12 months or more
3) over 56yo (unless they get symptoms on treatment free week if they are taking medication)
4) ovaries have been removed
5) under 56yo
AND
-have symptoms after removal of uterus, IUD or ablation
OR
-have not been aware of menstrual cycle for over 51 years
Menopause:
When is contraception required?
1) over 50yo but last period was less than 12 months ago
2) under 50yo but last period was less than 24months ago
Menopause:
Do withdrawal bleeds on COCP occur in post menopausal women?
yes, they will happen regardless of menopausal status
Menopause:
How long to continue progestogen only contraception?
Until 55yo if no contraindications.
Menopause:
What test is most useful to assist in postmenopausal diagnosis?
single FSH > 30UI/L in a 50 or older woman with 12 months of amenorrhoea who has only been taking progestogen only contraception
if <30UI/L continue for 12 months and re-test
Menopause:
Does Depot progestogen over 50yo have a role?
Case by case basis.
Only if no CVD risk factors who would benefit from amenorrhoea or hot flushes being managed.
depot associated with reduced bone density and also negatively alters lipid metabolism
Menopause:
Is the implanon or minipill useful for endometrial protection in women on oestrogen for menopause?
No. Another Progestogen source is required.
Menopause:
Aims of management?
1) Symptom control
2) Preventative health (OSA, HTN, DM, IHD, OP, renal function, breast screening, mental health)
Menopause:
Who gets symptoms:
60% some 20% none 20% severe Average length is 5 years 25% of women will have symptoms into 60's - 10% of these will become lifelong
Menopause:
Standard basics of management?
- Quit smoking (because smoking worsens symptoms and OP risk)
- avoid triggers (alcohol, hot drinks, spicy foods)
- consider natural oestrogen diet (no evidence as yet - soy, chickpeas, lentils, flaxseed)
- DO NOT USE NOT Red clover, dong quai, gingko, yam vitex agus castus, black cohosh (?evidence for this but associated with GIT side effects and liver failure)
Menopause:
Common symptoms that require investigations?
- hot flushes (24hr metanephrines, 24hr 5HAA [carcinoid], TSH, FT4)
- sweats (CBE, node biopsy, CXR, serum/protein electrophoresis)
- palpitations (ECG)
- formication (scabies/skin exam)
- myalgia/arthralgia (ESR, CRP, ANA, ENA, X-ray)
- headaches (CT/MRI)
- vaginal bleeding (CBE, coags, TSH, iron studies, TV USS, gynae biopsy)
- lack of vaginal bleeding (TSH, prolactin, FSH/LH, TV USS, pituitary MRI, pregnancy test)
- low libido (SHBG, calculated free testosterone [mane on day 7]
Menopause:
What is the true representation of breast cancer risks associated with HRT?
5 year breast cancer risk for women 50 - 59yo = 2.3%
Risk reduction with:
-oestrogen only HRT = 1.9%
-2.5hrs moderate activity per week = 1.6%
Risk increased with:
-smoking = 2.6%
-COCP/combined HRT = 2.7%
-2 or more standard drinks per day = 2.8%
-BMI > 30 = 4.7%
Menopause:
Medication management principles?
Uterus intact:
*at least 10 days per month of progestogen (cyclical [best for first 12 months post last menses], continuous (best if no periods for 12months) or mirena)
1) combined patch (best for high risk - Elevated BMI and triglycerides)
a] cyclical - Estalis sequi
b] continuous - Estalis
2) Transdermal/oral oestrogen with oral (Provera) or mirena progestogen
3) Tibolone (oestrogen/progestogen/androgenic activity - half the dose in elderly)
-use if >1yr since LMP as can cause breakthrough bleeding
-does not change mammographic density
4) Oestrogen and SERM (bazedoxifene)
No uterus:
- oestrogen only is required UNLESS severe endometriosis pain then consider very low dose combination with Tibolone so progestogen component assists with pain)
1) Transdermal oestrogen (Climara)
2) Oral oestrogen (premarin)
3) Tibolone
Non hormonal Hot flush management:
1) SSRI (quarter to half the Antidepressant dose - reduces symptoms by 60%)
- Agomelatine particularly helpful if depressive symptoms combined with vasomotor symptoms
- any SSRI will help
- best evidence for SNRIs (venlafaxine or desvenlafaxine)
2) clonidine (not particularly helpful cons > Pros According to Dr Amy Moten)
3) gapapentin or pregabalin
Primary vaginal symptoms: Vaginal oestrogen (tablets better tolerated than cream) - vagifem (10microg - but can be doubled if desired response not achieved) or ovestin
*Always try for lowest oestrogen dose possible (review 12 monthly)
*Trial HRT forms for 2 months before adjusting dose or delivery options
*Intolerance of medication symptoms (mood
changes, bloating, headache, and mastalgia) are typically related to progestogen being used (change type or mode of delivery)
*irregular bleeding is common in the first 3-6 months of HRT
Menopause:
What is the truth about VTE risk with HRT?
- baseline VTE risk is greatest in women over 60years (1/1000)
- HRT doubles a womans baseline risk of VTE (2/1000)
- there is no risk of VTE on transdermal preparation
- HRT can be transiently ceased if upcoming high risk time (eg travel, surgery, injury)
Menopause:
Contraindications to hormonal treatment?
- oestrogen dependent cancer
- thrombophillia or high VTE risk
- undiagnosed vaginal bleeding
- un treated HTN
- CVD
- severe liver disease
