Menopause & HRT Flashcards
What is menopause?
A retrospective diagnosis after a woman hasn’t had a period for 12 months. A permanent end to menstruation.
How long after a woman’s final period is a diagnosis of menopause made?
12 months
Average age of menopause?
51
Define postmenopause
The period from 12 months after the final menstrual period onwards.
Define perimenopause
The time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Include the time leading up to the last period, and the 12 months after.
Define premature menopause
Menopause before 40 years old. Result of premature ovarian insufficiency.
What is the cause of menopause?
A lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:
- Oestrogen and progesterone are low
- LH and FSH are high, in response to an absence of a negative feedback from oestrogen
Describe the levels of oestrogen and progesterone in menopause
Low
Describe the levels of LH and FSH in menopause
High due to an absence of a negative feedback from oestrogen
Describe how a decline in development of ovarian follicles leads to menopause
1) Begins with decline in development of ovarian follicles
2) Without growth of follicles, there is a reduced production of oestrogen (usually produced by granulosa cells that surround follicles)
3) As oestrogen falls in perimenopausal period, there is an absence of a negative feedback on the pituitary gland, and increasing levels of FSH and LH (oestrogen has a negative feedback effect on pituitary gland, suppressing LH and FSH)
4) Falling follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles
5) Without oestrogen, endometrium doesn’t develop, leading to a lack of menstruation (amenorrhoea)
6) Lower oestrogen also causes perimenopausal symptoms
Describe the feedback of oestrogen on the pituitary
Negative feedback - reduces levels of LH and FSH
Where is oestrogen produced?
Granulosa cells that surround follicles
What causes perimenopausal symptoms
Lack of oestrogen
What are some perimenopausal symptoms?
- Hot flushes
- Emotional lability or low mood
- Premenstrual syndrome
- Irregular periods
- Joint pains
- Heavier or lighter periods
- Vaginal dryness and atrophy
- Reduced libido
What conditions can a lack of oestrogen increase the risk of?
- CVS disease and stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
When can a diagnosis of menopause be made without performing any investigations?
Can be made in women over 45 years old with typical symptoms
When does NICE recommend considering an FSH test for menopause?
a) Women <40 with suspected premature menopause
b) Women aged 40-45 with menopausal symptoms or change in menstrual cycle
How long should women under 50 use contraception for after the last menstrual period?
two years
How long should women over 50 use contraception for after the last menstrual period?
1 year
Does hormonal contraception affect menopause?
No - but can mask and suppress symptoms
What contraceptive options are UKMEC 1 for women approaching menopause (i.e. good options)?
- Barrier methods
- Mirena or copper coil
- Progesterone only pill
- Progesterone implant
- Progesterone depot injection (<45 y/o)
- Sterilisation
Side effects of progesterone depot injection?
- Weight gain
- Reduced bone mineral density (osteoporosis) – makes it unsuitable for women >45
At what age does the progesterone depot injection become unsuitable?
> 45 y/o
Management of menopause?
- No treatment
- HRT
- Tibolone – a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
- Clonidine – acts as agonists of alpha-adrenergic and imidazoline receptors
- Cognitive behavioural therapy (CBT)
- SSRI antidepressants e.g. fluoxetine, citalopram
- Testosterone – can be used to treat reduced libido (gel/cream)
- Vaginal oestrogen cream or tablets – can help with vaginal dryness and atrophy (can be used alongside systemic HRT)
- Vaginal moisturisers e.g. Sylk, Replens, and YES
What is tibolone?
A synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
What hormones are given in HRT
- Oestrogen to alleviate symptoms
- Progesterone (in women who have a uterus)
Why must progesterone be given alongside oestrogen in HRT in women who have a uterus?
To prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
I.e. endometrial protection
What HRT regime should women that still have periods go on?
Cyclical HRT, with cyclical progesterone and regular breakthrough bleeds
What HRT regime should postmenopausal women with a uterus and more than 12 months without periods go on?
Continuous combined HRT
What HRT regime can women without a uterus go on?
Oestrogen only HRT
Non-hormonal treatments for menopausal symptoms?
- Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
- Cognitive behavioural therapy (CBT)
- Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors
- SSRI antidepressants (e.g. fluoxetine)
- Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI)
- Gabapentin
What class of drug is clonidine?
Agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain
How is clonidine effective in menopausal symptoms?
It can be helpful for vasomotor symptoms and hot flushes:
- Lowers BP
- Reduces HR
When would clonidine be used in HRT?
Particularly where there are contraindications to using HRT.
Side effects of clonidine?
- Dry mouth
- Dizzines
- Fatigue
- Headaches
What can a sudden withdrawal from clonidine result in?
Rapid increases in blood pressure and agitation.
Patients may try alternative remedies for menopausal symptoms BUT these can have significant side effects and interact with other medications.
Ensure to ask about them in patient history.
Give some examples of alternative remedies
- Black cohosh
- Dong quai
- Red clover
- Evening primrose oil
- Ginseng may be used for mood and sleep benefits
Potential side effects of black cohosh?
may be a cause of liver damage
Potential side effects of dong quai?
may cause bleeding disorders
Potential side effects of red clover?
may have oestrogenic effects that would be concerning with oestrogen sensitive cancers
Potential side effects of evening primrose oil?
has significant drug interactions and is linked with clotting disorders and seizures
What are the 4 main indications for HRT?
1) Replacing hormones in premature ovarian insufficiency, even without symptoms
2) Reducing vasomotor symptoms such as hot flushes and night sweats
3) Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
4) Reducing risk of osteoporosis in women under 60 years