Menopause and postreproductive health Flashcards
What is menopause?
The permanent cessation of menstruation, resulting from a loss of ovarian follicular activity. Natural menopause is recognised to have occurred after 12 consecutive months of amenorrhoea.
What is the median age of menopause?
51 years old
What is perimenopause?
Time beginning with the first features of menopause, and ends 12 months after the last menstrual period.
What is postmenopause?
Defined as dating from the last menstrual cycle (cannot be determined until 12 months after)
What is premature menopause?
When menopause occurs before the age of 40 years old.
What are the causes of post-menopausal bleeding?
Endometrial carcinoma Endometrial hyperplasia +/- atypia and polyps Cervical carcinoma Atrophic vaginitis Cervicitis Ovarian carcinoma Cervical polyps
Explain the investigations and management in post-menopausal bleeding?
- Bimanual and speculum
- Cervical smear if not had one
- Transvaginal sonography - measures endometrial thickness and can tell you if they have polyps or ovarian cysts.
What are the guidelines for endometrial thickness and number of bleeds?
If they don’t have endometrial thickening >4mm and one PMB, they do not need endometrial biopsy/hysteroscopy.
If they are found to have endometrial thickening (>4mm) or they have had multiple PMB then they have a biopsy +/- hysteroscopy.
What happens once malignancy has been excluded?
They are given topical oestrogen or oral ospemifene (selective oestrogen receptor modulator) for atrophic vaginitis.
What are the symptoms and consequences of menopause in women?
Cardiovascular disease
Vasomotor symptoms - hot flushes/night sweats (70%)
Urogenitcal problems - atrophic vaginitis can cause painful sex, stopping sex, itching, burning and dryness. Urinary symptoms include frequency, urgency, nocturia, incontinence and recurrent infection.
Osteoporosis.
What is osteoporosis?
A skeletal disorder characterised by compromised bone strength predisposing to an increased risk of fracture.
What are the most common osteoporotic fractures?
Wrist (Colles’ fracture), hip and spine.
What tool is used to calculate the 10 year probability of a fracture based on individual patient clinical factors.
FRAX
What are the risk factors for osteoporosis?
Smoking Low BMI Early menopause Alcohol abuse Low calcium intake Sedentary lifestyle Corticosteroid usage Hyperthyroidism/rheumatoid arthritis/NMD/chronic liver disease/malabsorption syndromes
What tests are used to confirm menopause?
FSH - high due to no oestrodiol/inhibin having a negative feedback on pituitary. Measured between days 2-5 to avoid the peak.
AMH - produced by small follicles and therefore would be low in menopause. Can be measured whenever.
What non-invasive method can be used to check bone density for suspected osteoporosis?
DEXA scan.
What are the different ways to administer HRT?
Pills, patches, implants, gels
What are the components of HRT?
Oestrogen and progesterone
What HRT is given to perimenopausal women?
You need to consider contraception as they are not post menopausal yet. Therefore, you need to use the intrauterine progesterone IUD with an oestrogen component or a cyclical or sequential preparation.
What HRT is given to women without a uterus?
Oestrogen only because there is no uterus to worry about it being unopposed.
What is tibolone?
Tibolone is a synthetic steroid with weak estrogenic, progestogenic, and androgenic activity, and hence is an agonist of the estrogen, progesterone, and androgen receptors.
It treats post-menopausal women who desire amenorrhoea and treats vasomotor, psychological and libido problems. It conserves bone mass.
What can be used to help libido in post-menopausal women?
Androgens (testosterone)
Why is oestrogen alone not used to prevent bone density loss in menopause?
Progesterone reduces the risk of endometrial hyperplasia and carcinoma, which occurs with unopposed oestrogen
What HRT is given to women who have a uterus?
Progesterone can be given cyclically for 10-14 days every 4 weeks, for 14 days every 3 months or continuously (monthly, 3 monthly and no bleeds respectively).
What HRT is given to women post-menopausal?
Unlike perimenopause, HRT should not be used cyclically and should be used continuously. This does not need to be a contraceptive HRT.
What are topical oestrogens used for? Do they require progesterone?
Topical oestrogens are used to treat urogenital symptoms. These low-dose preparations do not elevate systemic oestrogen levels, so there is no requirement for progesterone to protect the endometrium.
What are the types of topical oestrogens and what do women take when they cannot take thing?
Cream, pessary, ring.
They can have oral ospemifene (SERM)
What symptoms of the menopause can oestrogen help with?
Vaginal dryness/soreness/atophic vaginitis
Urinary problems
Hot flushes
Superficial dyspareunia
How is low libido treated in menopause?
Oestrogen alone might be effective enough, but usually testosterone is needed in addition.
What are the cancer increased risks of HRT?
Endometrial (unopposed oestrogen) Breast cancer (combined increases risk, not oestrogen alone)
What are the non-cancer increased risks of HRT?
Gallbladder disease
Venous thromboembolism
How long are women generally treated for HRT?
5 years and then they are taken off and reassessed.
How long are premature menopausal women advised to continue HRT for?
Until the median menopausal age.
What non-hormonal class of drug can be used in prevention and treatment of osteoporosis?
Bisphosphonates
