Menopause + HRT

Question 1

What are the stages of menopause?

Answer 1

Stage 1 = pre menopause
Stage 2 = premature menopause/ primary ovary failure 
Stage 3 = perimenopause 
Stage 4 = menopause 
Stage 5 = post menopause

Question 2

What endocrine changes occur at menopause?

Answer 2

Declining oocyte numbers and follicles (causing decreased oestrogen)
Ovaries not responsive
Decreased inhibin levels cause a rise in FSH through negative feedback

Question 3

What are the key features of menopause?

Answer 3

Mean age = 51
Decline in ovarian oestrogen production
Perimenopause lasts approx. 5 years

Question 4

What is atresia?

Answer 4

Degeneration of ovarian follicles that do not ovulate during the menstrual cycle

Question 5

What risks increase in pregnancy with age?

Answer 5

Miscarriage 
Trisomy 21 (Down Syndrome)

Question 6

What are the classic symptoms of menopause?

Answer 6

Classic triad = hot flushes, sweats, vaginal dryness - affects 80% of women
+ oligomennorhoea (spaced out periods) prior to menopause

[Symptoms generally due to falling oestrogen levels rather than low levels]

Question 7

What are the non-specific symptoms of menopause?

Answer 7

Headaches, migraines, palpitations, disturbed sleep, joint/ muscle ache

Question 8

What urogenitary symptoms can be caused by menopause?

Answer 8

Vaginal dryness, cystitis, urinary frequency, urinary incontinence

Question 9

What psychological symptoms can be caused by menopause?

Answer 9

Loss of concentration, poor memory, irritability, loss of libido and panic attacks

Question 10

What symptoms can be caused by atrophy of connective tissue due to menopause?

Answer 10

Skin thinning, hair loss, brittle nails, aches/ pains, osteoporosis

Question 11

What are the possible consequences of osteoporosis?

Answer 11

Loss of bone matrix, increased risk of fractures, deformity, loss of height, economic cost

Question 12

How is menopause diagnosed?

Answer 12

Clinical picture/ history: age, symptoms, signs, absence of menses for 12 months

If under 40, FSH as marker (FSH of >30mlU/mL) - also consider premature menopause

Question 13

What are the associated risks of premature menopause (POF)?

Answer 13

Premature death, neurological disease, psychosexual function, mood disorders, osteoporosis, ischaemic heart disease, infertility

Question 14

What menstrual changes can occur with POF?

Answer 14

Oligomenorrhoea (missed periods)
Polymenorrhoea (frequent periods)
Metrorrhagia (bleeding in between periods)

Question 15

What can cause premature ovarian failure (POF)?

Answer 15

Idiopathic 
Familial 
Autoimmune 
Genetic (e.g. Fragile X, Turner's) 
Radiation/ Chemotherapy 
Infections 
Oophorectomy/ hysterectomy (surgical menopause)

Question 16

What are the benefits of HRT?

Answer 16

Improves vasomotor symptoms (e.g. hot flushes, night sweats)
Improves urogenital symptoms (e.g. vaginal atrophy, vulvovaginitis, dyspareunia)
Reduces osteoporosis/ fracture risk

Question 17

What are the adverse effects/ risks of HRT?

Answer 17

Thromboembolism/ stroke
Breakthrough bleeding/ breast tenderness
Increased risk of breast cancer
Increased risk of dementia in those over 65

Question 18

What is the primary aim of HRT?

Answer 18

Administration of oestrogen in order to relieve menopausal symptoms

[Tend to use natural oestrogen rather than synthetic and lower dose than contraceptive levels]

Question 19

What does the addition of progesterone in HRT do?

Answer 19

Avoids cystic endometrial hyperplasia

[No progesterone needed if hysterectomy]

Question 20

How is HRT administered?

Answer 20

Daily tablets (oral)
Transdermal patches (can be oestrogen or combined oestrogen and progesterone, last 2 weeks)
Subcutaneous oestrogen implants (last approx. 6 months)
Topical oestrogen creams to treat urogenital symptoms

Question 21

What alternative drugs can be used to treat menopausal symptoms (other than HRT)?

Answer 21

Raloxifene (SERM) - used to treat osteoporosis via activation of positive oestrogen-like effects via oestrogen receptor function in bone but not in breasts or uterus (thus removing increased risk of cancer associated with HRT)

OR Tamoxifen (SERM)

Tibolone - synthetic steroid possessing oestrogen- and progesterone-like qualities