Menopause and its abnormalities Flashcards
Define menopause.
Permanent cessation of menstruation resulting from loss of ovarian follicular activity.
At what age (average) do women experience menopause?
51 yrs
Define postmenopause.
Describes the period from 12 months after the final menstrual period onwards
Define perimenopause.
Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.
Define premature menopause.
Menopause before the age of 40 yrs. It results from premature ovarian insufficiency
What are the biochemical results in menopause?
- Low oestrogen and progesterone
- High FSH and LH (in response to absence of oestrogen)
Describe the physiology of menopause.
The process of the menopause begins with a decline in the development of the ovarian follicles. Without the growth of follicles, there is reduced production of oestrogen. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH.
The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). Lower levels of oestrogen also cause the perimenopausal symptoms.
What are perimenopausal symptoms?
A lack of oestrogen in the perimenopausal period leads to symptoms of:
- Vasomotor symptoms
- Hot flushes
- Night sweats
- Urogenital problems
- Vaginal dryness and atrophy
- Dyspareunia
- Itching burning dryness
- Sexual problems
- Reduced libido
- Emotional lability or low mood
- Premenstrual syndrome
- Irregular periods
- Joint pains
- Heavier or lighter periods
What are the risks of menopause?
- Osteoporosis
- CVD and stroke
- Pelvic organ prolapse
- Urinary incontinence
How to we diagnose menopause?
A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.
NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in:
- Women under 40 years with suspected premature menopause
- Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
What advice should we give regarding contraception in the peri and post menopausal period?
Women need to use effective contraception for:
- Two years after the last menstrual period in women under 50
- One year after the last menstrual period in women over 50
Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms. This can make diagnosing menopause in women on hormonal contraception more difficult.
What contraception would you offer women approaching menopause?
Good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause are:
- Barrier methods
- Mirena or copper coil
- Progesterone only pill
- Progesterone implant
- Progesterone depot injection (under 45 years - due to SEs: reduced bone mineral density)
- Sterilisation
The combined oral contraceptive pill is UKMEC 2 (the advantages generally outweigh the risks) after aged 40, and can be used up to age 50 years if there are no other contraindications. Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options.
What are the treatment options for perimenopausal symptoms?
- Hot flushes and night sweats
- Vaginal atrophy
- Osteoporosis
- Psychological
- Reduced libido
When are the vasomotor symptoms likely to resolve?
Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment. Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include:
- No treatment
- Hormone replacement therapy (HRT)
Hot flushes and night sweats
- HRT
- Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors
- Isoflavone or black cohosh - helpful but interactions with other medications noted and different preparations exist.
Vaginal atrophy
- Offer vaginal oestrogen to women with urogenital atrophy (including those on systemic HRT) and continue treatment for as long as needed to relieve symptoms.
- If vaginal oestrogen does not relieve symptoms of urogenital atrophy, consider increasing the dose after seeking advice from a healthcare professional with expertise in menopause.
- Counsel:
- Symptoms can come back when tx stopped
- Adverse effects rare
- Report any unscheduled bleeding to GP
- Moisturisers such as Sylk, Replens and YES and lubricants can be used alone or in addition to vaginal oestrogen.
Osteoporosis
- Explain to women that the baseline population risk of fragility fracture for women around menopausal age in the UK is low and varies from one woman to another.
- Explain to women that their risk of fragility fracture is decreased while taking HRT and that this benefit:
- is maintained during treatment but decreases once treatment stops
- may continue for longer in women who take HRT for longer
Psychological
- HRT
- Cognitive behavioural therapy (CBT)
- Only if evidence that they are depressed → SSRI antidepressants, such as fluoxetine or citalopram
Reduced libido:
Consider Testosterone (usually as a gel or cream) supplementation for menopausal women with low sexual desire if HRT alone is not effective
When should you review and refer for menopause?
Why is combined HRT used in women who have uteri?
Progesterone needs to be given (in addition to oestrogen) to women that have a uterus. The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen
What are the indications of HRT?
- Replacing hormones in premature ovarian insufficiency, even without symptoms
- Reducing vasomotor symptoms such as hot flushes and night sweats
- Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
- Reducing risk of osteoporosis in women under 60 years
What are the benefits of HRT?
In women under 60 years, the benefits of HRT generally outweigh the risks.
The key benefits to inform women of include:
- Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
- Improved quality of life
- Reduced the risk of osteoporosis and fractures
What are the risks of HRT?
Women may be concerned about the risks of HRT. It is crucial to put these into perspective. In women under 60 years, the benefits generally outweigh the risks. Specific treatment regimes significantly reduce the risks associated with HRT.
The risks of HRT are more significant in older women and increase with a longer duration of treatment. The principal risks of HRT are:
- Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
- Increased risk of endometrial cancer
- Increased risk of venous thromboembolism (2 – 3 times the background risk)
- Increased risk of stroke and coronary artery disease with long term use in older women
- The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
These risks do not apply to all women:
- The risks are not increased in women under 50 years compared with other women their age
- There is no risk of endometrial cancer in women without a uterus
- There is no increased risk of coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT)
Ways to reduce the risks:
- The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
- The risk of VTE is reduced by using patches rather than pills - Consider transdermal rather than oral HRT for menopausal women who are at increased risk of VTE, including those with a BMI over 30 kg/m2
What are contraindications of HRT?
- Undiagnosed abnormal bleeding
- Endometrial hyperplasia or cancer
- Breast cancer
- Uncontrolled hypertension
- Venous thromboembolism
- Liver disease
- Active angina or myocardial infarction
- Pregnancy
What ix do we need to do before starting a patient on HRT?
Before initiating HRT, there are a few things to check and consider:
- Take a full history to ensure there are no contraindications
- Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
- Check the body mass index (BMI) and blood pressure
- Ensure cervical and breast screening is up to date
- Encourage lifestyle changes that are likely to improve symptoms and reduce risks
What three steps do we need to go through when choosing what type of HRT a patient should get?
There are three steps to consider when choosing the HRT formulation:
Step 1: Do they have local or systemic symptoms?
- Local symptoms: use topical treatments such as topical oestrogen cream or tablets
- Systemic symptoms: use systemic treatment – go to step 2
Step 2: Does the woman have a uterus?
- No uterus: use continuous oestrogen-only HRT
- Has uterus: add progesterone (combined HRT) – go to step 3
Step 3: Have they had a period in the past 12 months?
- Perimenopausal: give cyclical combined HRT
- Postmenopausal (more than 12 months since last period): give continuous combined HRT
When should we offer oestrogen patches rather than pills?
Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches.
What is the difference between cyclical and continuous progesterone? Can you switch from one to another?
Cyclical progesterone, given for 10 – 14 days per month, is used for women that have had a period within the past 12 months. Cycling the progesterone allows patients to have a monthly breakthrough bleed during the oestrogen-only part of the cycle, similar to a period.
Continuous progesterone is used when the woman has not had a period in the past:
- 24 months if under 50 years
- 12 months if over 50 years
Using continuous combined HRT before postmenopause can lead to irregular breakthrough bleeding and investigation for other underlying causes of bleeding.
You can switch from cyclical to continuous HRT after at least 12 months of treatment in women over 50, and 24 months in women under 50. Switch from cyclical to continuous HRT during the withdrawal bleed. Continuous HRT has better endometrial protection than cyclical HRT.
What are the options for delivering progesterone?
There are three options for delivering progesterone for endometrial protection:
- Oral (tablets)
- Transdermal (patches)
- Intrauterine system (e.g. Mirena coil)
Cyclical combined HRT options include sequential tablets or patches containing continuous oestrogen with progesterone added for specific periods during the cycle.
The Mirena coil is licensed for four years for endometrial protection, after which time it needs replacing. The Mirena coil has the added benefits of contraception and treating heavy menstrual periods. It can cause irregular bleeding and spotting in the first few months after insertion. This usually settles with time and many women become amenorrhoeic.
