Menopause and post-reproductive health

Question 1

What is the definition of menopause? And early menopause?

Answer 1

Menopause = amenorrhoea for 12 consecutive months.

Early menopause = menopause before age 40.

Question 2

What are the main causes of post-menopausal bleeding?

Answer 2

Cancer: carcinoma of the endometrium / cervix / ovaries.

Premalignancy: endometrial hyperplasia and atypia,

Atrophic vaginitis.

Cervicitis, cervical polyps.

Question 3

How would you investigate post-menstrual bleeding?

Answer 3

Clinical examination.

Smear if not done by screening programme.

TVUSS: endometrial thickness and other pathology. If endometrium is <4mm and only one episode of PMB, then hysteroscopy+biopsy not required.

Endometrial biopsy +- __Hysteroscopy to exclude malignancy.

Question 4

What are the symptoms / consequences of the menopause?

Answer 4

Cardiovascular disease.

Vasomotor: hot flushes and night sweats.

Urogenital: Vaginal atrophy (dyspareunia, itching, burning), frequency, urgency, nocturia, incontinence.

Sexual: old people want less sex.

Osteoporosis.

Question 5

What score defines osteopaenia and osteoporosis?

Answer 5

T score of -1 - -2.5 = osteopaenia, >-2.5 = osteoporosis.

Question 6

Where are the most common sites for osteoporotic fractures?

Answer 6

Wrist (colles).

Hip.

Spine.

Question 7

What are the risk factors for osteoporotic fracture?

Answer 7

FH.

Early menopause.

Long term steroids.

Prolonged immobilisation.

Prior fracture.

Question 8

How would you investigate the menopause?

Answer 8

FSH levels: Increased as ovaries fail. Best taken on day 2-5.

Anti-mullerian hormone: low levels correlate with few follicles. Can be measured any day.

TFTs, Catecholamines and 5-hydroxyindolacetic acid if response to HRT inadequate.

DEXA scan for osteoporosis.

Question 9

What components make up HRT?

Answer 9

Oestrogen: for atrophic vaginitis, osteoporosis, hot flushes, loss of libido, incontinence.

Progestogen: protect the endometrium (unnecessary if hysterectomy).

Tibolone: steroid converted in vivo to have oestrogenic, progestogenic and androgenic effects. Treats vasomotor, psychological and libido problems and conserves bone mass.

Androgens: testosterone can be given to improve libido.

Question 10

What HRT regimen is suitable for a woman with/out a uterus?

Answer 10

With: Oestrogen + progestogen.

Without: Oestrogen only.

Question 11

How does HRT affect cancer risk?

Answer 11

Breast: increased in combined regime.

Endometrial: increased in oestrogeon only regime

Colon: decreased.