Menopause

Question 1

When does menopause usually occur?

Answer 1

Average is 51

Premature menopause is considered <40

Question 2

Is menopause instant?

Answer 2

No it takes ~5yrs prior to the actual date of menopause for the body to change. This is known as perimenopause and is when you get the symptoms of menopause

Question 3

What is happening during menopause?

Answer 3

Ovarian insufficiency. Oestradiol starts to fall and FSH rises

Question 4

What are the symptoms of menopause?

Answer 4

Altered periods (perimenopause)
Vasomotor (Hot flushes)
Vaginal dryness & soreness
Low Libido
Muscle & joint aches
Mood change & forgetfulness

Question 5

Menoapuse also causes osteoporosis due to the lack of oestrogen, what are the risk factors for this?

Answer 5

• Thin women
• Caucasians
• Smokers
• Alcohol
• FH
• Amenorrhoea
• Malabsorption
• Steroids
• Hyperthyroid

Question 6

How can we prevent and treat osteoporosis in menopausal women?

Answer 6

• Exercise
• Ca2+ & Vit D
• HRT
• Bisphosphonates
• Denosumab
• Teriparatide

Question 7

What is denosumab?

Answer 7

A monoclonal antibody to osteoclasts

Mechanism - RANKL inhibition

Question 8

What is the normal 1st line treatment for osteoporosis?

Answer 8

Bisphosphonates (if its not due to menopause) - eg Zoledronic acid

Question 9

HRT is common treatment for peri-menopausal symptoms, how long is it used for?

Answer 9

For roughly 5 yrs, only used to treat peri-menopausal symptoms not forever

Question 10

How can we deliver HRT?

Answer 10

Local - Vaginal oestrogen pessary, ring or cream

Systemic - Transdermal patch or oral

Question 11

Why would you choose transdermal vs oral HRT?

Answer 11

Transdermal carries less risk of VTE

Question 12

HRT also comes in various formulations and regimens, what are these?

Answer 12

1) Oestrogen only
2) Oestrogen/Progestogen (aka combined)
- (2a) Cyclical - 14 days E –> 14 days of E&P
- (2b) Continuous - 28 days E & P

Question 13

When would we use Oestrogen only HRT?

Answer 13

If the women had no uterus, e.g. her menopause was after a TAH & BSO

if a woman still has a uterus - use combined HRT

Question 14

When would we use Cyclical combined HRT vs continuous?

Answer 14

Cyclical is used if theres still some ovarian function i.e. still perimenopausal

Continuous is used if there’s no ovarian function i.e. its >1yr since menopause or they’re >54

Question 15

There is another option for HRT delivery that can be used at any age, whats that?

Answer 15

Mirena Levonorgestrel Intra-uterine system (LNG IUS)

Along with daily E either oral or transdermal

Question 16

What are the contraindications to HRT?

Answer 16

• Current hormone dependant breast/endometrial cancer
• Current liver disease
• Uninvestigated abnormal bleed

You should also seek advice you’ve had previous:

• VTE
• Thrombophilia & Fh/o
• Breast Ca
• Or carry BRCA genes

Question 17

How do different types of HRT affect bleeding?

Answer 17

Cyclical combined has a withdrawal bleed

Continuous combined HRT is bleed free after 3 months

Question 18

What are the pros & cons of HRT?

Answer 18

Pros = Works for vasomotor, local genital & osteoporosis symptoms

Cons = Increases risk of breast/ovarian cancer as well as VTE & stroke if taken orally

Question 19

Heres some common misconceptions about HRT which patients may believe or ask about?

Answer 19

• It helps alzheimers
• It increases risk of CVD (doesn’t if started <60)
• High risk of breast cancer (goes from 1/100000 to 2/100000, actually less than if you were obese or drank a lot)

Question 20

Whne should we give HRT?

Answer 20

• If they have severe vasomotor symptoms, and it should be reviewed annually
• For premature ovarian insufficiency (up to age 50)
• Vaginal oestrogen if they have vaginal symptoms

Don’t give it for someone just cos they have osteoporosis, treat that with bisphosphonates

Question 21

Name some other non-HRT treatments for menopause?

Answer 21

• Selective Oestrogen Receptor Modulators (SERMS)
• SSRI & SNRI antidepressants e.g. venlafaxine
• Natural methods e.g. red clover & hypnotherapy
• Non-hormonal lubricants e.g. Sylk

Question 22

How effective are antidepressants for menopause?

Answer 22

Pretty crap and they have lots of side effects

Question 23

How effective are natural methods of treating menopause?

Answer 23

They have a high placebo effect and can be very costly. Some work some don’t its not really worth it.

Question 24

Men have their own form of menopause called “andropause” how does this work?

Answer 24

Testosterone falls by about 1%/yr after 30, DHEAS also falls.

Unlike menopause fertility remains and the changes are more gradual