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OBG: Functional Gynaecology > Menopause > Flashcards

Menopause Flashcards

1
Q

What is the literal definition of menopause?

A

Last menstrual period

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2
Q

What is a woman described has having gone through the menopause clinically?

A

12 months of absent menses in a woman with a uterus who is not pregnant or taking hormones that might induce amenorrhoea

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3
Q

What is the definition of perimenopause?

A

The years leading up to the menopause, associated with fluctuating levels of oestrogen due to declining ovarian function

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4
Q

How can the short-term symptoms of menopause be classified into 4 groups?

A
  1. Vasomotor symptoms
  2. Psychological
  3. Sexual problems
  4. Musculoskeletal
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5
Q

What are 4 vasomotor short-term problems associated with the menopause?

A
  1. Hot flushes
  2. Night sweats
  3. Headaches
  4. Palpitations
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6
Q

What are 7 short-term psychological symptoms of the menopause?

A
  1. Insomnia
  2. Irritability
  3. Poor concentration
  4. Poor short-term memory
  5. Depression/ low mood
  6. Lethargy
  7. Decreased self-confidence
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7
Q

What are 2 short-term sexual problems associated with the menopause?

A
  1. Decreased libido
  2. Dyspareunia
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8
Q

What is a short term musculoskeletal symptom associated with the menopause?

A

Joint aches

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9
Q

What intermediate term type of problem is commonly associated with the menopause?

A

Urogenital

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10
Q

What are 4 intermediate-term urogenital symptoms of the menopause?

A
  1. Atrophic vaginitis
  2. Vaginal dryness
  3. Urethral symptoms
  4. Urge incontinence/ frequency
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11
Q

What are 2 groups of long-term problems associated with the menopause?

A
  1. Circulation
  2. Skeletal
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12
Q

What are 2 long-term circulation problems associated with the menopause?

A
  1. Cardiovascular disease
  2. Cerebrovascular disease
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13
Q

What are 3 long-term skeletal problems which may be associated with the menopause?

A
  1. Osteoporosis
  2. Hip fracture
  3. Vertebral fracture
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14
Q

What is another term used to describe ‘peri-menopause’?

A

Climacteric

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15
Q

On average, when does the perimenopause (or climacteric) begin?

A

4 years before last menstrual period (may be months or year)

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16
Q

For how long can perimenopause symptoms last?

A

may last for years after last menstrual period

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17
Q

What is the median age at menopause in the UK?

A

50.8 years

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18
Q

What physiologically causes menopausal symptoms to occur?

A

when supply of oocytes becomes exhausted

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19
Q

How many oocytes is a newborn girl born with?

A

Over half a million

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20
Q

What happens to the 500 000+ oocytes between birth and the menopause in a woman?

A

over third disappear before puberty

most of the remainder lost during reproductive life

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21
Q

How many primordial follicles are involved in each menstrual cycle?

A

20-30 follicles begin to develop in each menstrual cycle and most become atretic

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22
Q

What is the average number of menstrual cycles which occur during a woman’s lifetime?

A

400 cycles

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23
Q

How are most oocytes lost during reproductive life (i.e. after puberty has occurred before the menopause)?

A

most lost spontaneously through ageing rather than through ovulation

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24
Q

What happens physiologically in the ovary as a woman becomes peri-menopausal?

A
  • premenopause, oestradiol produced by granulosa cells of developing follicle
  • production of oestradiol becomes variable as menopause approaches
  • proportion of anovulatory menstrual cycles increases, progesteone production declines
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25
Q

What happens to FSH and LH levels during the menopause and why?

A

Levels rise due to diminishing negative feedback from oestrogen and other ovarian hormones such as inhibin

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26
Q

What blood test can be used to clinically clarify a diagnosis of menopause?

A

serum FSH > 30IU/L (when associted with irregular or absent periods)

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27
Q

Why is it important to use FSH levels along with the clinical picture when suspecting menopause?

A

levels of FSH begin to rise significantly around age of 38 in normally cycling women

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28
Q

What is a better marker of follicular reserve than FSH and what can it be used for in particular?

A

Müllerian hormone: used particularly to assess response to ovarian stimulation during assisted conception

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29
Q

What is the predominant circulating oestrogen form after the menopause?

A

Oestrone: formed from androstenedione, mainly of adrenal origin which is converted to oestrone

This is a less potent form of oestrogen compared to ovarian oestrogens (oestradiol)

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30
Q

What causes irregular periods before the menopause?

A

usually result of anovulatory menstrual cycles

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31
Q

What should be done if irregular bleeding at the menopause persists?

A

Endometrial assessment to exclude endometrial carcinoma

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32
Q

What proportion of postmenopausal bleeding is due to gynaecological malignancy?

A

10%

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33
Q

What is a hot flush?

A

Uncomfortable subjective feeling of warmth in the upper part of the body

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34
Q

How long do hot flushes typically last for?

A

around 3 minutes

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35
Q

What proportion of menopausal women experience vasomotor symptoms (e.g. hot flushes) and what proportion seek medical advice?

A
  • 50-85% experience vasomotor symptoms
  • 10-20% seek medical advice
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36
Q

What are 4 features that may accompany hot flushes?

A
  1. Nausea
  2. Palpitations
  3. Sweating
  4. Particularly troublesome at night ► insomnia
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37
Q

What is thought to be the cause of hot flushes?

A

Thought to be of hypothalamic origin, may be in some way related to LH release. Thought a fall in oestrogen levels affect central neurotransmitters such as alpha-adrenergic or serotonergic systems which affect central thermoregulatory centres and LH-releasing neurons

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38
Q

What proportion of women begin experiencing flushes while still menstruating regularly?

A

20%

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39
Q

What is the prognosis of hot flushes associated with the menopause?

A

usually improve as body adjusts to new low oestrogen concentrations but in 25% of women, continue for >5 years - can impair quality of life, distressing

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40
Q

In what proportion of women is HRT (exogenous oestrogen) effective in relieving symptoms of hot flushes?

A

90%

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41
Q

What happens to the genitourinary tract in the menopause and why?

A

genital system, urethra and bladder trigone are oestrogen dependent, undergo gradual atrophy after the menopause

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42
Q

What can occur as a result of vaginal atrophy due to the menopause?

A

can cause dyspareunia and bleeding

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43
Q

Why can peri- or postmenopausal women experience more vaginal infections?

A

Loss of vaginal glycogen causes rise in pH

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44
Q

What urinary symptom is common following the menopause and why?

A

urgency of micturition due to atrophic change in the trigone

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45
Q

What is the prognosis of atrophic genitourinary symptoms following the menopause?

A

may appear years after menopause and do not improve spontaneously

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46
Q

What is an effective treatment for genitourinary atrophy?

A

short course of local or systemic oestrogen

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47
Q

What is thought to be an effective treatment for irritability and lethargy in the menopause?

A

hormone therapy thought to improve more effectively than placebo

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48
Q

What is thought to be effective treatment for low mood and depression associated with the menopause?

A

thought that HRT may relieve low mode but clinical depression might not be relieved, as not usually caused directly by oestrogen withdrawal

49
Q

What are 3 key diseases whih the menopause increases a woman’s susceptibility to?

A
  1. Breast cancer
  2. Cardiovascular disease
  3. Osteoporosis
50
Q

How is the relationship with breast cancer related to the menopause?

A

Risk reduced if premature menopause, increased if it occurs late (double risk if menopause in late 50s compared with early 40s)

51
Q

What is thought to be the effect of postmenopausal HRT on cardiovascular disease?

A

Unclear - HRT at start of natural menopause not associated with increased incidence of CVD events, may be associated with decrease

Impact in women over 60-65 when initiated is unclear

52
Q

How does the menopause affect bones physiologically?

A
  • Bone resorption by osteoclasts is accelerated by the menopause
  • Oestrogen receptors shown to be present on bone cells, and oestrogens stimulate osteoblasts directly
  • Calcitonin and prostaglandins may also be involved as intermediate factors in link between oestrogen and bone metabolism
53
Q

What is the rate of decline in bone mass following the menopause?

A

in first 4 years after menopause, annual loss of 1-3% of bone mass, falling to 0.6% per year thereafter

54
Q

What are 3 common areas for fractures following the menopause due to osteoporosis?

A
  1. Distal radius
  2. Vertebral body
  3. Upper femur
55
Q

What proportion of women over 65 years will be affected by one of the 3 commonest fractures secondary to osteoporosis (distal radius, vertebral body, upper femur)?

A

40%

56
Q

What is meant by ‘dowager’s hump’ and what proportion of women are affected?

A
  • wedge compression fractures of spine cause this
  • affects 25% of white women over 60 years of age
57
Q

How common are hip fractures following the menopause?

A

occur in 20% of women by age of 90

58
Q

What are 2 further risk factors for osteoporosis following the menopause?

A
  1. Underweight women
  2. White or Asian women have higher risk than Afro-Caribbean women who have greater in initial bone mass
59
Q

What proportion of women who suffer femoral fractures die in hospital?

A

17%

60
Q

What is the first line treatment for osteoporosis in women over 60? What are 3 further aspects of management?

A
  1. a bisphosphonate = first line
  2. oestrogen used only where bisphosphonate inappropriate
  3. elderly women: supplementation with calcium, calcitonin and vitamin D - reduces risk of hip fractures
  4. moderate exercise may slow rate of bone loss (but poor compliance with exercise programmes)
61
Q

What are 7 differentials for the menopause?

A
  1. Pre-menstrual syndrome
  2. Depression
  3. Thyroid dysfunction
  4. Pregnancy
  5. Phaeochromocytoma
  6. Carcinoid syndrome
  7. Vasomotor symptoms: calcium antagonists and tricyclic antidepressants
62
Q

How is the diagnosis of post-menopause made?

A

Clinical - can only be made in retrospect after 12 months of amenorrhoea (sometimes 6 in women under 40 years of age)

63
Q

What investigations can be performed to diagnose the menopause if there is confusion e.g. in younger woman?

A

serum FSH measured - >30IU/L postmenopausally

64
Q

What tests should be performed in women younger than 40 years with suspected menopause?

A

2 serum FSH levels, measured 6 weeks apart

often fluctuate considerably during perimenopause

65
Q

Why is FSH measured twice 6 weeks apart in women under 40 years?

A

FSH levels fluctuate so perimenopausally, level may be in premenopausal range - FSH leels peak physiologically mid cycle, so worth re-checking apparently high levels again

66
Q

When might you consider a therapeutic trial of HRT in cases of diagnostic doubt about the menopause? What does the result indicate?

A

women over 45 years

absence of satisfactory response suggests symptoms unrelated to low levels of oestrogen

67
Q

What hormonal therapy may be given to treat menopausal symptoms?

A
  1. Oestrogen supplementation is the basis
  2. Progestogen - small role in relieving vasomotor symptoms, but mainly added to protect endometrium from hyperplasia + malignancy
68
Q

What are 4 types of oestrogen replacement forms available?

A
  1. Daily oral tablets
  2. Twice-weekly or weekly transdermal patches
  3. Subcutaneous implants every 6-8 months
  4. Daily nasal sprays, skin creams, 3 monthly vaginal rings - some countries
69
Q

When must progestegen therapy be given with oestrogen and why?

A

women who have not undergone hysterectomy

to minimise risk of endometrial cancer associated with unopposed oestrogen therapy

also applies if have undergone endometrial resection

70
Q

What is a benefit of giving oestrogen replacement as oral tablets?

A

Beneficial effect on lipid profiles leading to higher HDL level (non-atherogenic) and lower LDL levels (atherogenic)

71
Q

What is a disadvantage of oral preparations of oestrogen replacement?

A

potentially more thrombotic than parenteral therapy

72
Q

In what 2 forms is oral oestrogen replacement available?

A
  1. Oestrogen only if have had hysterectomy
  2. Oestrogen-progestogen if have not undergone hysterectomy
73
Q

What are 2 ways that oral combined oestrogen and progestogen tablets can be taken?

A
  1. Cyclically
  2. Continuously
74
Q

When are cyclical and continuous preparations of combined oral oestrogen and progestogen used?

A
  1. Cyclical - cause monthly withdrawal bleeds - used perimenopausally
  2. Continuous - no period - option from more than 2 years after LMP
75
Q

Why is continuous combined oral HRT useful for many patients?

A

more convenient for the majority who do not suffer unscheduled bleeding

(erratic bleeding beyond first 6 months of treatment warrants further investigation)

76
Q

What are 2 alternatives to oestrogen-progesterone preparations as oral HRT?

A
  1. Tibolone
  2. Raloxifene
77
Q

What is tibolone?

A

synthetic steroid with weak oestrogenic, progestogenic and androgenic effects

78
Q

How many tibolone be used to treat menopausal symptoms?

A

oral drug, may be started 2 years after periods have ceased (similar to continuous combined preparations)

79
Q

What is raloxifene?

A

synthetic selective oestrogen receptor modulator (SERM) used to treat menopausal symptoms: has oestrogenic effects on bone and lipid metabolism, but minimal effect on uterine and breast tissue

80
Q

What is and isn’t raloxifene used for treating in terms of menopausal symptoms?

A
  1. Bone and lipid metabolism - good effects, useful in protecting against osteoporosis, doesn’t cause vaginal bleeding
  2. Uterine and breast tissue -minimal effect, ineffective for controlling perimenopausal symptoms
81
Q

What types of new preparations for oral treatments of menopausal symptoms are being developed?

A

combination of oestrogens and SERM bazedoxifene - recently reached market

82
Q

What 2 types of transcutaneous administration of HRT can be used?

A
  1. transdermal patches available as unopposed oestrogen form, or as cyclical or continuoous oestrogen-progestogen combinations
  2. percutaneous oestrogen gels
83
Q

How are transdermal patches containing replacement hormone usually used?

A

applied to buttock, each patch lasts for between 3 and 7 days, depending on formulation

84
Q

What is a type of adverse reaction that sometimes occurs in transcutaneous administration of HRT?

A

skin reactions, from hyperaemia to blisters, affect small percentage of users

85
Q

What are 3 potential advantages of transcutaneous administration of HRT?

A
  1. No increase in risk of thrombosis - minimised effect on hepatic production of coagulation factors
  2. May avoid GI side effects
  3. May also avoid change sin lipoprotein levels
86
Q

What different types of transdermal HRT patches are available?

A

available as unopposed oestrogen form, or as cyclical or continuoous oestrogen-progestogen

87
Q

How are percutaneous oestrogen gels used for HRT? What is an advantage of the gels?

A

measured dose rubbed into skin, avoids prolonged skin contact of patches

88
Q

What is present in subcutaneous implants for HRT symptoms? 2 types

A
  1. oestradiol
  2. testosterone implants if low libido
89
Q

Where are subcutaneous implants for HRT inserted?

A

lower abdomen

90
Q

For how long can subcutaneous HRT implants be inserted?

A

no less than 5 or 6 months

91
Q

What are 2 disadvantages of subcutaneous oestrogen implants?

A
  1. Oestradiol level doesn’t always fall away to baseline before symptoms recur
  2. Risk of tachyphylaxis (persistent symptoms despite ever-increasing oestradiol levels) unless strict dose control observed
92
Q

How can the risk of tachyphylaxis from subcutaneous oestrogen implants be minimised?

A

pre-implant oestradiol levels should be monitored

93
Q

What are 4 types of vaginal preparations that can be used to treat vaginal symptoms of menopause?

A
  1. Oestradiol tablets
  2. Low-dose oestradiol-releasing silastic ring pessaries
  3. Oestriol vaginal pessaries
  4. Vaginal cream
94
Q

In what form are vaginal preparations useful for menopausal symptoms and what are they good for?

A

Low-dose preparations - useful to treat atrophic vaginitis, since systemic absorption very small after first few weeks of administration

95
Q

What are 4 side-effects associated with HRT?

A
  1. Nausea
  2. Breast-tenderness
  3. Uterine bleeding (investigate irregular bleeding)
  4. Cholelithiasis
96
Q

What proportion of patients taking HRT do nausea and breast tenderness occur in?

A

5-10%

97
Q

With what regimens of HRT does uterine bleeding commonly occur in?

A

low dose regimens

98
Q

With what HRT preparations is there a slight risk of cholelithiasis?

A

oral

99
Q

What endocrine disease may improve/ the risk of be reduced with HRT?

A

Diabetes - control improved, incidence lowered

100
Q

What are 4 major things that the risk of is increased with HRT?

A
  1. Breast cancer
  2. Endometrial carcinoma
  3. Venous thromboembolic disease
  4. Stroke
101
Q

By what factor is the risk of endometrial carcinoma increased with 1) unopposed oestrogen therapy and 2) opposed therapy with progesterone for at least 10 days per cycle?

A
  1. 4x
  2. RR <1.0
102
Q

What is an effective way of protecting the endometrium effectively when using oestrogen-only HRT in postmenopausal women?

A

Levonorgestrel-releasing intra-uterine system (Mirena)

103
Q

What is believed to cause the increase in the incidence of breast cancer in menopausal women using HRT?

A

progesterone - no increase in incidence observed when using oestrogen-only therapy in women who have had hysterectomy

104
Q

When is the increased risk of breast cancer from HRT eliminated?

A

no increased risk in those who stopped taking HRT more than 5 years previously

105
Q

What type of cancer has reduced incidence in women taking HRT?

A

colorectal cancer

106
Q

When is the risk of venous thromboembolic disease with HRT present?

A

largely confined to first year of use, only oral HRT (no increased risk for transdermal)

107
Q

When should pre-screening for thrombophilia be carried out in someone who may start taking HRT?

A

if personal or family history of venous thromboembolic disease

108
Q

What is the relative risk of VTE with HRT?

A

4.0 in first 6 months, 3 in second 6 months

109
Q

What effect is there on stroke with HRT?

A

significant increase in likelihood of stroke in all age groups with oral HRT, but impact small in younger menopausal women as baseline risk low

110
Q

What are 5 contraindications to hormone treatment?

A
  1. Pregnancy
  2. Venous thromboembolic disease
  3. History of recurrent thromboembolism
  4. Liver disease
  5. Undiagnosed vaginal bleeding
  6. History of breast carcinoma and advanced endometrial carcinoma
111
Q

Are hypertension/ cardiovascular risk factors contraindications for HRT?

A

not if effectively managed

112
Q

How long are oestrogens given for vasomotor symptoms usually continued?

A

2 or 3 years then stopped

113
Q

How should you decide whether to continue oestrogen therapy for vasomotor symptoms beyond 2-3 years?

A

whether symptoms recur, weighing up risks of osteoporosis against potential side-effects, including breast cancer, for particular individual

114
Q

What are 2 types of non-hormonal treatment for menopausal symptoms?

A
  1. Drugs
  2. Psychological support
115
Q

What are 8 drug treatments for symptoms of the menopause?

A
  1. Clonidine - vasomotor symptoms
  2. SSRIs - vasomotor symptoms
  3. Beta-blockers - palpitations, tachycardia
  4. Sedatives - non-vasomotor
  5. Hypnotic - non-vasomotor
  6. Antidepressants - non-vasomotor
  7. Bisphosphante - osteoporosis
  8. Calcium, calcitonin, vitamin D - hip fractures
116
Q

How does clonidine act to treat vasomotor symptoms of menopause?

A

acts directly on hypothalamus (no more effective than placebo in RCTs)

is an alpha-agonist hypotensive

117
Q

What suggests that psychological support is very important to treat menopausal symptoms?

A

marked placebo benefits in various studies - shows psychological support and sympathetic ear needed

118
Q

What type of psychological support may be needed in menopausal women?

A

as many symptoms resolve with time, reassurance important

others may have particular stresses e.g. children leaving home - may accentuate symptoms

OBG: Functional Gynaecology (7 decks)

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