Menopause/HRT Flashcards
Define menopause
Menopause occurs at an average age of 51.7 years old and coincides with the disappearance of ovarian primordial follicles. This is associated with 12 months free of menstruation.
The Permezel Four: What are the 4 principal consequences of menopause? (lack of oestrogen)
- Vasomotor Symptoms
- Urogenital Atrophy
- Osteoporosis
- Adverse Lipid Profile
What vasomotor symptoms are associated with menopause?
Hot Flushes -> heat, redness and sweating in upper chest and face. These waves last 30-60 seconds and vary in frequency between once an hour or once every couple of days. This can be associated with palpations or sweating which can happen at night and be called night sweats.
Usually occurs in the years around menopause and can last 1-2 years post menopause.
What are the 5 clinical features which you have to look out for when a woman is going through menopause?
- Menstruation
- Vasomotor Symptoms
3, Urogenital Atrophy - Bone Loss
- Increase in Cardiovascular Risk
Discuss the increased cardiovascular risk associated with menopause.
There are metabolic alterations in menopause such as an adverse lipid profile (increased cholesterol) and associated with cardiovascular risk factors in older women -> there is an increased cardiovascular risk.
What are the basic principles of management when it comes to menopause?
Hx, Ex and Ix
From the Hx, it is important to get components that are for and against the beginning of therapy.
For - vasomotor, urogenital atrophy, osteoporosis (if predisposing RF exist for osteoporosis -> DEXA scan is important)
Against - breast cancer, atheroma (or CV RFs), thromboembolism
What are the 4 main benefits of HRT?
- Vasomotor Symptoms - decrease in hot flushes and night sweats which leads to increase in sleep
- Bone loss prevention - decrease in bone loss and decrease in risk of fracture
- CONTROVERSIAL Adverse Lipid Profile - The benefit of HRT only works if it starts early as the HRT is vascular protective and reduces the adverse lipid profile and therefore retards the development of further atheroma. However, if started late (>60yo) then there is an increase in atheroma in older females.
- Decrease in cancers other than breast cancer. These include colorectal and endometrial.
Discuss the bone loss associated with menopause.
There is cortical bone loss in menopause which can lead to osteoporeotic fracture of the hip or wrist, compression fracture of the vertebrae. This increases after menopause.
Discuss the following considerations when it comes to choosing HRT regimen.
- Oestrogen vs Oestrogen + Progesterone
- Oral vs Transdermal patches, gels or implants
- Cyclical vs Continuous
- If uterus still intact -> oestrogen + prog to protect from endometrial hyperplasia and cancer. IUD can be used to protect the woman from the systemic effects of progesterone as it only delivers local progesterone. If no uterus -> oestrogen only.
- oral is used initially but other methods are used because the drug does not undergoe first pass metabolism from the liver and there is decreased risk of VTE.
- Cyclical regimen is used pre-menopause and continuous is used post menopause.
What are the basic principles of management when it comes to menopause?
Hx, Ex and Ix
From the Hx, it is important to get components that are for and against the beginning of therapy.
For - vasomotor, urogenital atrophy, osteoporosis (if predisposing RF exist for osteoporosis -> DEXA scan is important)
Against - breast cancer, atheroma (or CV RFs), thromboembolism
What are the two adverse effects with HRT?
- Increased risk of VTE
2. Increased risk of breast cancer especially if there the use of progesterone and oestrogen.
Discuss the following considerations when it comes to choosing HRT regimen.
- Oestrogen vs Oestrogen + Progesterone
- Oral vs Transdermal patches, gels or implants
- Cyclical vs Continuous
- If uterus still intact -> oestrogen + prog to protect from endometrial hyperplasia and cancer. IUD can be used to protect the woman from the systemic effects of progesterone as it only delivers local progesterone. If no uterus -> oestrogen only.
- oral is used initially but other methods are used because the drug does not undergoe first pass metabolism from the liver and there is decreased risk of VTE.
- Cyclical regimen is used pre-menopause and continuous is used post menopause.
Discuss Post Menopausal Bleeding. What is it? How is it managed?
All vaginal bleeding post menopause is abnormal. Important to investigate in case of endometrial hyperplasia or cancer. Along with Hx and Ex, need to do a cervical smear, endometrial assessment using U/S or a biopsy. If this is abnormal then might need a hysterscopy and currettage.
Discuss premature menopause and the clinical features you can expect.
Ovarian failure before 40 years. Idiopathic in up to 90% of the cases. In other cases there can be a FHx and sometimes genetic conditions which predispose the individual to have premature menopause.
Clinical Feature include: amenorrhoea but infrequent preiods can delay diagnosis. Also can be hidden by the pill or IUD.
How do you manage a patient with premature ovarian failure?
- Diagnosis - important for fertility implications and hormonal millieu
- Determine aetiology
- Treatment - If high risk of osteoporosis + adverse lipid profile –> HRT till age of actual menopause. Need to discuss fertility –> prospect of spontaneous pregnancy is extremely low. Need to explain that there are no known strategies to increase pregnancy rate.
