Menopause Flashcards
why is the menopause of medical significance
- More than a third of life spent in post menopause
- 8/10 women experience symptoms /problematic for 25% women / average duration 7 years
- Long term associated conditions – osteoporosis, CVD, stroke, urogenital atrophy and urinary incontinence
what is the peri-menopause
- Transition period
- From onset of symptoms until 1 yr after menopause
- Average age 45-55yr, timing of onset and duration variable
- period before the menopause when the endocrinological, biological, and clinical features of approaching menopause commence. It is characterized by irregular cycles of ovulation and menstruation and ends 12 months after the last menstrual period.
what is the menopause and what is the average age in UK?
- Single point in time
- Final menstrual period
- Average age 53 in UK (80% by 54 yrs)
- biological stage in a woman’s life when menstruation ceases permanently due to the loss of ovarian follicular activity. It occurs with the final menstrual period and is usually diagnosed clinically after 12 months of amenorrhoea. In the UK, the mean age of the natural menopause is 51 years, although this can vary between different ethnic groups.
what is post menopause?
- Rest of life after FMP
* Postmenopause is the time after a woman has not had a period for 12 consecutive months.
what is premature menopause
- FMP <40yrs or 45 yrs
* Premature menopause is usually defined as menopause occurring before the age of 40 years.
pathology of menopause?
- During late 40s FSH initially then LH concentration rise (dimished follicle supply)
- Oestrogen levels fall and cycle disrupted
- Irregular scanty periods over varibale period
- Menopausal pattern of low oestradil and elevated LH and FSH established
what advice should be given regarding contraception for women in the menopause?
- Continue until 2 years after last menstrual period (<50yr) / 1 year after last menstrual period (>50yrs)
- HRT is not contraceptive
- Consider; risk of STI, advice about safer sex
describe the role of FSH levels in diagnosing menopause
- Cessation of menses <45yrs
- Peri-menopausal symptoms <45yrs and iatrogenic amenorrhoea (hysterectomy, endometrial ablation or POC)
- Women on POC >50yrs and wishes to stop contraception
describe the role of serum estradiol in diagnosing menopause
- Not usually indicated
- <110picomol/L
- After menopause oestrone is derived form oestradial metabolism becomes dominant oestrogen
how should the diagnosis of menopause be made
In otherwise healthy women aged over 45 years with menopausal symptoms, the diagnosis of menopause should be based on the woman’s symptoms and age, without relying on laboratory investigations.
in what circumstances should FSH testing be used to diagnose menopause?
- Over 45 years with atypical symptoms.
- Between 40–45 years with menopausal symptoms, including a change in their menstrual cycle.
- Younger than 40 years if premature menopause is suspected.
- The FSH test should not be used to diagnose menopause in women using combined oestrogen and progestogen contraception or high-dose progestogen, as the diagnostic accuracy may be confounded by these treatments.
symptoms of menopause
menstrual cycle change vasomotor (hot flushes) MSK (joint and muscle pain) low mood urogenital (vaginal dryness) low sex drive
treatment of vasomotor symptoms (hot flushes, sweats)?
- HRT – oestrogen and progestogen (women with uterus) / oestrogen only (women with no uterus)
- SSRI’s and SNRI’s or clonidine not first line
- Isoflavines or black cohosh – consider safety, drug interactions
treatment of low mood in women during menopause?
- HRT
- CBT
- No evidence for SSRIs or SNRIs if not diagnosed with depression
treatment of vaginal dryness during the menopause
Vaginal oestrogen
• Consider in women where systemic HRT is contraindication
• May need ongoing treatment
• Adverse affects rare
• Report any unscheduled bleeding
• Vaginal moisturisers and lubricants can be used with vaginal oestrognes
• No need to monitor endometrial thickness
treatment of low sex drive in menopausal women
- HRT with or without testosterone
- Gel eg testogel
- Patch – intrinsa (withdrawn from UK)
- Implant 6-12 monthly
- tibolone
describe the impact of obesity of women during the menopause
- Increased vasomotor and menopausal symptoms
- Increased risk of CVD, independent of other factors
- Increased risk of VTE
- Increased risk of cancer
describe the impact of smoking on women during the menopause
- Increased menopausal symptoms (vasomotor, insomnia, psychological)
- Increased CVD risk
- Increased osteoporosis risk
- Mechanisms – toxicity to ovarian follicles, reduced oestrogen, earlier age of menopause
HRT
risk of VTE
- Risk increased with oral HRT
- Risk with transdermal no greater than baseline
- Consider transdermal in women with BMI >30
- Refer to haematology if strong FH or hereditary thrombophilia
HRT
risk of cardiovascular disease?
- HRT doesn’t increase CVD risk when started <60
- Does not affect risk of dying from CVD
- Presence of risk factors is not contraindication
- Oestrogen only HRT associated with no or reduced risk of CHD
- Combined HRT associated with little or no increased risk of CHD
- Oral (not transderal HRT) associatd with small increased risk of stroke
HRT
risk of breast cancer
- Risk varies depending on underlying risk factors
- Oestrogen only HRT – little or no change in incidence of breast cancer
- Combined HRT -increase in incidence of breast cancer
- Increase in risk of breast cancer related to duration and reduces after stopping HRT
- Avoid paroxetine and fluoxetine with tamoxifen
HRT
osteoporosis
- Give advice on bone health
- Risk of fragility fracturs is decreased while taking HRT
- Benefits maintained during treatment but decreases once stopped
HRT contraindications
- Current, past or suspected breast cancer
- Oestrogen sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- Previous or current VTE/DVT unless on anticoagulant
- Active/recent arterial disease eg angina/MI
- Uncontrolled BP
- Acute liver disease/abnormal LFT
- Porphyria
- Pregnancy
- Dubin-johnson/rotor (close monitoring)
HRT
oestrogen only
given when no uterus • Oral • Patch • Gel • Local oestrogen (vaginal ring, pessary, cream)
combined HRT
with uterus • Sequential • Continuous • Oral • Parenteral • Oestrogen and IUS • Tibolone
combined HRT
perimenopause
- Within 12 months of LMP
- Sequential HRT
- Monthly eg oestrogen daily and progestogen 10-14 days each cycle
- 3 monthly eg oestrogen daily and oestrogen 14 days every 13 weeks
- Switch to continuous combined after woman becomes postmenopausal
combined HRT
post menopause
- Continuous combined
- > 12 months since LMP
- May cause irregular bleeding in first 4-6 months
- Investigate if >6 months
- Tibolone
- Synthetic steroid with oestrogenic, progestogenic and androgenic activity
- No bleed
HRT
what medications can be used for women who are unable to have oestrogens
- Progestogens - Medroxy progesterone acetate 20mg dly, Norethisterone 5-10mg daily, Megestrol acetate 40-80mg daily
- Clonidine – 50-75mcg twice daily
- SSRI - Venlafaxine, Citalopram, Fluoxetine, Herbal remedies
what are the options for women unable or unwilling to use HRT to treat vasomotor symptoms?
a trial of fluoxetine, citalopram, or venlafaxine.
what are the options for women unable or unwilling to use HRT to treat vaginal dryness?
a vaginal lubricant or moisturizer
what are the options for women unable or unwilling to use HRT to treat psychological symptoms?
self-help groups, psychotherapy, counselling, or antidepressants, depending on the woman’s preferences.
HRT
describe some oestrogenic side effects?
• Fluid retention, bloating, breast tenderness, nausea, headaches, cramps, dyspepsia
HRT
describe some prostetogenic side effects?
Fluid retention, breast tenderness, migraine, mood swings, depression, acne, abdo pain, back pain
HRT
when should and how should HRT be stopped?
unscheduled vaginal bleeding common in first 3 months
report any unscheduled bleeding if after 3 months
when stopping
• can gradually reduce dose or can immediately stop
• gradually reducing may limit recurrence of symptoms
HRT
adverse effects
- Oestrogen-related adverse effects, such as fluid retention, bloating, breast tenderness, nausea, headaches, leg cramps, and dyspepsia.
- Progestogen-related adverse effects, such as fluid retention, breast tenderness, headaches or migraine, mood swings, depression, acne, and lower abdominal pain.
- Bleeding.
