Menopause & HRT

Question 1

What are the 5 stages of menopause?

Answer 1

Pre-menopause
Premature menopause = primary ovarian failure (POF)
Perimenopause
Menopause
Post-menopause

Question 2

What are the endocrine changes during the menopause?

Answer 2

Decline in oocyte numbers
Upper centres still working (hypothalamus/anterior pituitary)
But ovary cannot respond
Negative feedback loop: rise in FSH and LH due to reduction in oestrogen declining follicles

As number of follicles diminishes inhibin declines
Rise of FSH via negative feedback loop

Question 3

What are the key features of the menopause?

Answer 3

Cessation of menses
45-60 years
Mean age is 51
Decline in ovarian oestrogen production

Question 4

What’s atresia and what age does it kick in?

Answer 4

Increases from around age 35
There are 1.2 million follicles at birth and 1000 left by menopause
Follicles are mainly lost by atresia, rather than ovulation

Question 5

What age does fertility decline and what risks does it carry?

Answer 5

Age 37

Increased risk of miscarriage, meiotic non-disjunction and Down’s syndrome

Question 6

What are the symptoms of menopause due to?

Answer 6

More related to falling levels of oestrogen rather than low levels

Question 7

What’s oligomennorhea?

Answer 7

Periods space out

Question 8

What’s it called when menopause cease?

Answer 8

Menopause

Question 9

What’s the classic symptom triad of menopause?

Answer 9

Hot flushes
Sweats
Vaginal dryness

Affect 80% of women and bother 45%

Question 10

What are non-specific symptoms of menopause?

Answer 10

Headaches
Migraines
Palpitations
Disturbed sleep
Joint and muscle aches

Question 11

What are urogenital symptoms of menopause?

Answer 11

Vaginal dryness
Cystitis
Urinary frequency
Urinary incontinence

Question 12

What are psychological symptoms of menopause?

Answer 12

Loss of concentration
Poor memory
Irritability
Loss of libido
Panic attack

Question 13

What are some features of connective tissue atrophy as a result of menopause?

Answer 13

Skin thinning
Hair loss
Brittle nails
Aches and pains
Osteoporosis

Question 14

What are features of osteoporosis?

Answer 14

Loss of bone matrix
Loss of height
Deformity
Fractures
Economic cost

Question 15

How is menopause diagnosed?

Answer 15

Clinically: age, symptoms, signs

If less than 40 consider FSH marker (FSH>30)

Absence of menses or 12 months

Question 16

What defines premature menopause? What’re it’s risks?

Answer 16

Defined as premature ovarian failure before the age of 40 years

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

Question 17

What’s the difference between POF and menopause?

Answer 17

POF doesn’t necessarily mean a lack of viable follicles - that’s menopause

POF = disconnect between hormones and ovarian function or autoimmune problem

Question 18

What are causes of POF?

Answer 18

Idiopathic
Familiar tendency
Autoimmune/thyroiditis
Genetic: Fragile X, Turner’s syndrome
Radiation, chemotherapy, tamoxifen (acts as oestrogen blocker)
Viral infections
Oophrectomy and total hysterectomy which will trigger premature menopause

Question 19

What’s hormone replacement therapy?

Answer 19

Administration of oestrogen relieves menopausal symptoms
Use natural oestrogen
Sometimes combined with progestogen to avoid cystic endometrial hyperplasia

Question 20

What are the routes of administration for HRT?

Answer 20

Oral daily
Transdermal patches lasting 2 weeks
Subcutaneous implants lasting 6 months (progestogen is taking orally at specific times to avoid uterine symptoms)
Topical oestrogen creams to treat urogenital symptoms

Question 21

What are the benefits of HRT?

Answer 21

Improves vasomotor symptoms such as hot flushes and night sweats
Improves urogenital symptoms
Reduces fracture risk and osteoporosis

Question 22

What are adverse effects and risks of HRT?

Answer 22

Thromboembolism -> stroke
Breakthrough bleeding
Breast tenderness
Increased risk of breast cancer
Increased risk of dementia >65 years

Question 23

What are 2 other drugs that can be used to treat menopause symptoms?

Answer 23

Raloxifene - SERM to treat osteoporosis

Tibolone - synthetic steroid with metabolites possessing oestrogenic and progestogenic activities