Menopause and post reproductive health Flashcards
Define the terms menopause, perimenopause and postmenopause.
The menopause is defined as the woman’s final menstrual period.
This is confirmed by the absence of a period for ≥1 year; the woman is then post-menopausal.
Menopause is caused by cessation of regular ovarian function.
The perimenopause is the time of onset of ovarian dysfunction until 1 year after the last period.
Postmenopause is the time after 1 year of amenorrhoea.
What is the normal age for the menopause?
What is it called when menopause happens earlier?
The meduan age is 51-52.
95% of woman will reach menopause between 45 and 55.
Menopause before the age of 45 is called early, and before the age of 40 is alled premature ovarian insufficiency.
What is the currently accepted pathophysiology behind menopause?
It is currently thought that menopause occurse at the time of depeltion of oocytes fromt he ovary.
In the perimenopause, decreased number of follicles lead to decreased inhibin B production, which in turn increases FSH levels (which leads to recruitment of the last remianing follicles).
Eventually, steroid hormone production decreases, including oestrogen, until the amount is so low that it is no longer sufficient to stimulate endometrial proliferation and subsequently menstruation.
Describe the hormonal changes in a woman during perimenopause, early menopause and late menopause.
Hormones
Perimenopause
Early menopause
Late menopause and elderly
GnRH
Increased pulsatility
Progressive decline in pulsatility
Reduction in overall levels
LH and FSH
Increased
Increased
Progressive decline
Oestrogen
Slight decline
Rapid decline in levels
Sustained in very low levels
Inhibin
Slight decline
Significant decline
Undetectable
Testosterone
Progressive decline
Progressive decline
Sustained low levels
How is the diagnosis of menopause made?
It is largely a clinical diagnosis. Symptoms include:
- Oligo/amnorrhoea
- Oestrogen deficiency symptoms:
- Vasomotor symptoms (hot flushes, night sweats)
- Psychological symptoms (labile mood, anxiety, tearfulness)
- Decreased libido, loss of concentration/poor memory
- Dry and itchy skin, Hair changes
- Joint aches and pains
Blood tests looking at the hormone levels are of littel value, as the natural variations are large and can occur as part of a normal menstrual cycle.
Always exclude pregnancy!
What are the short, medium and long term symptoms of the menopause?
What is your apporach to managing a woman that is menopausal?
The treatment apporach needs to be tailored to the woman’s presentation and wishes.
In addition to the menopausal symptoms, you also need to take into account the associated cardiovascular and osteoporotic risk factors.
Conservative:
- Lifestyle: Exercise, weight loss and healthy diet (can help with symptoms, as well as with CV risk and bone health)
- Avoid spicy foods, caffeine and warm environments (all make the hot flushes worse)
- Wear layered clothing to be able to respond to onset of hot flushes
- Vitamin D (+ Ca supplementation)
- Herbal remidies (isoflavones, Black cohosh) (these are mentioned in NICE)
Medical:
- Hormonal:
- Combined (oestrogen + progesterone). Either continous (if amenorrhoea for >12 months) or cyclical (if <1 year since LMP)
- Oestrogen alone (only if the woman had hysterecotmy, otherwise risk of endometrial cancer)
- Non-hormonal:
- SSRIs/SNRIs (e.g. Fluoxetine, escitalopram) (can help with vasomotor symptoms)
- Gabapentin (can help with hot flushes)
- Clonidine (an anti-adenergic antihypertensive. Can reduce hot flushes)
- In addition, vaginal oestrogen creme for dryness, and pelvic floor exercises for incontinence are recommended
What are the risks and benefits associated with HRT?
Benfits:
- Improves bone mineral density
- Improves muscle strength
- Improves symptoms of vasomotor symptoms, sleep pattern and performance during the day. Over 90% of women note a significant improvement within 6 weeks
- (Potential benefits on CVD mortality)
- Lower gential tract benefits (less dryness, dyspnareunia etc.)
Risks:
- Increases risk of breast cancer. However, this risk is small and varies with treatment duration. Also risk reduces after stopping HRT.
- In a patient discussion, you can quote that there might be an additional 6-7 cases per 1000 whilst on HRT (but goes down after stopping)
- Oral HRT, but not patch/gel (as they bypass the enterohepatic circulation) are linked to increased risk of blood clots
What are contraindications to HRT?
Absolute contraindications:
- Pregnancy
- Breast cancer
- Endometrial Cancer
- Active liver disease
- uncontrolled HTN
- VTE/thrombophilia Hx
Relative contraindications:
- AUB
- Large fibroids
- FHx of VTE
- Migraine with aura
- Controlled liver disease
What are side efects of HRT?
Oestrogenic SEs:
- Breast tenderness/swelling
- Nausea
- Leg cramps
- Headaches
Progestogenic SEs:
- Fluid retention
- Breast tenderness
- Headaches
- Mood swings
- Depression
- Acne
What is premature ovarian insufficiency?
How common is this?
POI (Aka premature ovarian failure, POF) is defined as the onset of menopause before the age of 40.
It occurs in roughly 1% of woman <40, and 0.1% in woman <30.
What are underlying causes for premature ovarian insufficiency?
In the majority of cases, no underlying cause is found (either the woman started out with fewer follicles, or becuase the follicles are dysfunctional).
Causes can be classified into primary and secondary POI:
Primary:
- Chromosomal abnormalities (Fragile X, Turner’s XO)
- Autoimmune diseases (hypothyroidism, Addison’s, myasthenia gravis are all associated with POI)
- Enzyme deficiencies (e.g. 17-alpha-hydroxylase deficiency)
Secondary:
- Chemo/Radiotherapy/Surgery
- Infection (Mumps, TB + others)
What are the symptoms of premature ovarian insufficiency?
The symptoms are those of menopause:
- Absent ovulation:
- Oligo/amenorrhoea
- Subfertility (woman might still get pregnant becuase they have intermittent ovarian function)
- Oestrogen Symptoms:
- Hot flushes/Night sweats
- Vaginal dryness
(Remember that in patients with POI the rates of cardiovascular risk and osteoporosis related to menopause are higher, as they enter menopause early)
How would you investigae a woman with suspected premature ovarian insufficiency?
Always exclude pregnancy first!
Bloods:
- Low oestrogen
- Raised LH/FSH
- TFTs and prolactin (exlucde DDx of hypo/hyperthyroidism and hyperprolactinaemia)
Karyotyping to look for chromosomal abnormalities; Genetic tests (for Fragile X is FHx)
Screen for other autoimmune diseases (there is some overlap between the steroid cells in the adrenal cortex and the ovarian cells).
Consider TVUSS (which would show ovaries with minimal follicular activity)
How would you manage a woman with premature ovarian insufficiency?
Consider referring women with POI to a specialist service that has the resources necessary to deal with all aspects of POI complications (incl. phsychologcaL).
Continous HRT (as opposed to cyclical) or the COCP should be given at least up to the age of natural menopause to protect bones and the cardiovascular system.
Consider also vaginal oestrogen creme. Some women benefit from testosterone replacement.
Advise that pregnancy only possible with a donor oocyte and IVF (embryo transfer).
