Menopause and POI, Postmenopausal bleeding

Question 1

Menopause
-what is it
-presentation

Answer 1

Permanent cessation of menstruation due to loss of follicular activity in 40-50s

Clinical diagnosis made if no period for 1 year

Change in cycle length
Hot flushes, night sweats
Vaginal dryness, atrophy
Increased urinary frequency
A+D

Symptoms generally last 2-5 years

Question 2

Menopause
-management

Answer 2

Lifestyle
-regular exercise
-weight loss
-stress reduction
-sleep hygiene

HRT
Has uterus => PO/TD combined HRT
-endo cancer risk increased if O alone
No uterus => PO/TD O

Cyclical HRT if amenorrhea U1year
Continuous HRT if amenorrhea 1year+

Non-HRT
Hot flushes/night sweats - fluoxetine/citalopram/venlafaxine
Vaginal dryness - lubricant
Psychological symptoms - self help, CBT, antidepressants

Stopping HRT
-can occur when menopausal symptoms stop
-to be done gradually
-symptoms may return in the short term, but they do pass

Question 3

Premature ovarian insufficiency
-causes
-presentation
-investigations

Answer 3

Most common - idiopathic
Bilateral oopherectomy
RT, chemo
Infection - mumps
AI

Menopausal symptoms
Infertility
2ndary amenorrhea
High FSH (2 samples 4-6 weeks apart), LH
Low O

HRT or COCP until age of average menopause

Question 4

HRT
-side effects
-complications

Answer 4

SE
-nausea
-breast tenderness
-fluid retention, weight gain

Breast and ovarian cancer - OP
Endometrial cancer - O only, risk reduced with P
VTE - OP, risk reduced with patch
Stroke

Question 5

HRT
-contraindications

Answer 5

Current/past breast cancer
Oestrogen sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

Question 6

HRT
-use of contraception

Answer 6

50+ - 12 months after last period
U50 - 24 months after last period

Question 7

Postmenopausal bleeding
-causes
-investigations
-management

Answer 7

VAGINAL ATROPHY - most common
-thinning, drying, inflammation of walls => bleed
-topical O and lubrication/HRT

HRT
-no pathological cause
-can occur with unopposed O
-can change to different HRT

Endometrial hyperplasia
-obesity, unopposed O/tamoxifen use, PCOS, DM
-dilation and curettage to remove excess tissue

Endo cancer - must be ruled out urgently

Cervical cancer - look at smear attendance

Ovarian cancer

55+ with postmenopausal bleeding => 2w TVUS for endometrial cancer
-even if on HRT, must be investigated

Question 8

HRT
-indication
-types

Answer 8

Indications
-vasomotor symptoms - flushing, insomnia, headaches
-premature menopause (U50) => prevent development of osetoporosis

Oestrogen

Progestogen - given for uterine protection

Tibolone - estrogenic+progestogenic+androgenic activity

PO
Transdermal (patch/gel)
-preferred if at increased risk of VTE