Menopause

Question 1

What does menopause mean?

Answer 1

Last ever period

Question 2

What is the average age of menopause?

Answer 2

51

Question 3

How long does perimenopause occur for?

Answer 3

approx. 5 years before menopause

Question 4

At what age is menopause considered premature?

Answer 4

40 or under

Question 5

What is the physiology behind menopause?

Answer 5

Ovarian insufficiency

• oestradiol falls
• FSH rises
• Still some oestradiol from peripheral conversion of adrenal androgens in fat

Question 6

What are some symptoms of menopause?

Answer 6

Vasomotor symptoms (hot flushes)
Vaginal dryness / dyspareunia
Low libido
Muscle and joint aches
Mood changes
Poor memory

Question 7

How can you prevent and treat menopausal osteoporosis?

Answer 7

Exercise
Adequate calcium and vitamin D
HRT
Bisphosphonates
Denosumab (monoclonal antibody to osteoclasts)
Teriparatide (PTH replacement)

Question 8

What are the different options for symptomatic treatment of menopause?

Answer 8

Systemic HRT
Local HRT
selective oestrogen receptor modulators (SERMs)
SSRI/SNRI antidepressants
Natural methods
Non hormonal vaginal lubricants

Question 9

What is the benefit of using a transdermal hormonal patch over gel or oral preparations?

Answer 9

Avoids first pass metabolism, less VTE risk

Question 10

If the patient has had a hysterectomy, which hormones do they need?

Answer 10

Oestrogen only

Question 11

If the patient still has their uterus, which hormones do they need?

Answer 11

Progestogen to prevent endometrial hyperplasia, as well as oestrogen

Question 12

What are the advantages of local HRT, i.e. vaginal pessary/ring/cream?

Answer 12

Minimal absorption - no increased VTE or breast cancer risk

Don’t need progestogen for endometrial protection

Question 13

What are the contraindications to systemic HRT, and when should you seek advice?

Answer 13

contrindications:

• current hormone dependent breast/endometrial cancer
• current active liver disease
• uninvestigated abnormal bleeding

seek advice if:

• previous VTE, thrombophilia, FH VTE
• previous breast cancer or BRCA carrier

Question 14

What is first line treatment for osteoporosis?

Answer 14

Bisphosphonates

Question 15

Jane is 48 and has hot flushes and night sweats. She has periods 5/30 cycle but has missed 2 periods in the last year. Which HRT should you recommend?

Answer 15

Vasomotor symptoms need oestrogen
Has a uterus so needs progestogen
Has some ovarian function so needs: Cyclical combined OR
Mirena + oestrogen oral/transdermal

Question 16

Sheila had a hysterectomy for menorrhagia when she was 36 for 18/40 size fibroids. Her ovaries were conserved. She is now 39 and has hot flushes - she wonders if she is menopausal. Which HRT would you recommend?

Answer 16

Premature menopause is frequent after hysterectomy even if ovaries are conserved
If symptomatic, needs oestrogen
Does not have uterus so does not need progestogen
Maybe vaginal HRT for vaginal symptoms

Question 17

Lucy is 55. Her periods stopped when she was 51. She attends for routine cervical cytology - which is more uncomfortable than before and mentions that she has vaginal dryness and dyspareunia. She has tried non hormonal vaginal moisturisers and lubricants but still has symptoms. Which HRT would you recommend?

Answer 17

If significant atrophy is likely to need oestrogen
Has uterus and is >2 years postmenopausal
Vaginal oestrogen - pessary/ring/cream