Menopause

Question 1

Definition of menopause

Answer 1

12 consecutive months of amenorrhoea. Permanent cessation of follicular activity.

Question 2

Median age Menopause

Answer 2

51

Question 3

What is the Climacteric phase?

Answer 3

Phase in which decline of ovarian function. Decrease sex steroid, increase in anovulatory cycles and irregular menstruation.

Question 4

Define perimenopause

Answer 4

from the first onset of symptoms til 12m after last period

Question 5

What is Premature menopause?

Answer 5

<40 years. 1% women.

Question 6

Causes premature menopause

Answer 6

infection, bilateral oophorectomy, autoimmune, chemo, ovarian dysgenesis, metabolic disease, unknown.

Question 7

Causes of post menopausal bleeding

Answer 7

20% malignancy (endometrial, cervical, ovarian)
Endometrial hyperplasia, cervicitis, atrophic vaginitis
polyps

Question 8

Investigations for postmenopausal bleeding

Answer 8

bimanual, speculum, smear, TVUSS

if TVUSS shows endometrium >4mm and >1ep bleed -> endometrial biopsy with hysteroscopy

Question 9

sign that would indicate endometrial CA

Answer 9

purulent blood stained discharge

Question 10

atrophic vaginitis treatment

Answer 10

topical oestrogen or oral ospemifene (SERM) cream

Question 11

do you need to investigate regular withdrawal bleeds following sequential menopausal HRT?

Answer 11

No. Not if they are regular.

Question 12

symptoms of menopause

Answer 12

flushes and night sweats (70%, vasomotor -> tiredness, present <5yrs most), dyspareunia, dry, itch, urinary freq/urg/nocturia/infection (genitourinary syndrome of menopause), loss libido and sexual problems (50%), osteoporosis (1/3 >50 have osteoporotic fracture)

Question 13

proportion of deaths from CVD women

Answer 13

1/4

Question 14

how is osteoporosis measured

Answer 14

bone strength = density and quality. BMD scores (T score -2.5 or lower)

Question 15

common sites osteoporotic fractures

Answer 15

colles (wrist), spine, hip

Question 16

RF osteoporosis

Answer 16

• FHX (esp. 1st degree relationship with hip fracture)
• low BMI, early menopause
• smoking, alc, low ca, sedentary
• > 5mg pred or equivalent corticosteroids
• rheumatoid arth, NMD, CLD, hypogonadism, hyperparathyroidism, hyperthyroidism, malab syndromes

Question 17

what level of FSH is significant in menopause and explain

Answer 17

increase in serum FSH >30IU. show degree of ovarian reserve remaining. increase means fewer. helpful in prem ovarian failure. taken days 2-5. if had hysterectomy, 2 samples 2 weeks apart.

Question 18

what is AMH

Answer 18

Anti-mullerian hormone. direct measure ovarian reserve. low = failure. somewhat predict menopause depending on clinical context

Question 19

IX for Menopause (6)

Answer 19

• FSH (increase)
• AMH (decrease)
• TFTs
• LH, oestradiol, progesterone (low PG = an ovulation)
• bone profile (BMD, DEXA scan, biochem markers of turnover to monitor tx)
• catecholamines and 5-HIAA (increase pheochromocytoma and carcinoid syndrome)

Question 20

causes of falsely increased spine BDM

Answer 20

osteophytes from OA, Kyphosis, scoliosis, aortic calcification

Question 21

HRT principle for

a) hysterectomy
b) no hysterectomy

Answer 21

a) just oestrogen
b) oestrogen and progesterone (progesterone sequentially for 10-14 days every 4 weeks or 14 days every 13 weeks or continuously with oestrogen)

Question 22

how long do you give HRT for before review

Answer 22

5 yrs

If prem meno usually continue til normal median age menopause

Question 23

what tx can you give to perimenopausal women

Answer 23

sequential or cyclic therapy or IUS with oral/patch oestrogen if very heart menstrual bleed or need contraception

Question 24

post menopausal HRT regimen should be…

Answer 24

continuous due to lack of induced bleeding and reduced risk of endometrial CA. induces endometrial atrophy. SERM and oestrogen approved (eg if PG not appropriate).

Question 25

treatment for urogenital symptoms

Answer 25

topical oestrogen/ospemifene. oral ospemifene (SERM) can be used for mod-severe symptomatic vulvovaginal atrophy. cream or pessary.

Question 26

treatments for hot flushes and night sweats

Answer 26

SSRI/SNRI, clonidine (alpha ag), gabapentin, progestogens eg norethisterone or megestrol acetate

Question 27

complimentary therapies for menopause

Answer 27

phyto-oestrogens eg isoflavones, black cohosh, evening primrose

Question 28

list prevention and tx of osteoporosis

Answer 28

• bisphosphonates
• strontium ranelate (not used now?)
• raloxifene and bazedoxifene (SERMs)
• parathyroid hormone peptides
• denosumab
• calcium and vit D supplements

Question 29

3 Benefits of oestrogen based HRT

Answer 29

• ss control
• osteoporosis. fracture risk decrease. effective in at risk women under 60 or 10 yrs after menopause.
• colorectal cancer risk reduced

Question 30

risks oestrogen HRT (4)

Answer 30

• endometrial cancer if unopposed
• breast cancer. combined HRT slightly increases the risk.
• VTE increased risk 2 fold
• gall bladder disease

Question 31

treatment for libido

Answer 31

androgens (testosterone). not successful in all women.

Question 32

what are natural oestrogen and progestogens synthesised from

Answer 32

eg oestradiol, oestrone, oestriol. soy beans or yams. chemically identical to human.
can use mirena IUS

Question 33

what is ‘no bleed HRT’

Answer 33

For perimenopausal women who need contraception too. oestrogen HRT plus mirena coil

Question 34

what is tibolone and its use

Answer 34

synthetic steroid compound. inert but converted in vitro to metabolites with oestrogen, progestognenic and androgenic actions. used postmenopausal women who want amenorrhoea. tx vasomotor, psych and libido problems.