Menopause & HRT

Question 1

Definition of menopause

Answer 1

• LMP more than 12 months ago
• Average age 52 years
• Premature if <40 years

Question 2

Folliculogenesis

Answer 2

• FSH stimulated proliferation of pregranulosa cells into granulosa cells
• Theca cells arrange around the follicle
• This causes primordial follicle to become primary follicles and later antral follicles
• Eentually one follicle becomes dominant and is releases the oocyte in response to the LH surge

Question 3

Other causes of menopause

Answer 3

• Surgical removal of ovaries
• Radio/chemotherapy
• Hysterectomy with conservation of ovaries
• Smoking
• Deletions of the X chromosome - 46XO

Question 4

Diagnosis of menopause

Answer 4

• >45 years
  
  • Clinical history of symptoms (hot flushes, night sweats, vulvo-vaginal dryness, sleep disturbance, mood disturbance, sexual dysfunction)
• <45 years old
  
  • FSH
  • Consider genetic testing

Question 5

Changes in the urogenital tract

Answer 5

Question 6

Natural oestrogens native to humans

Answer 6

• 17β-Oestradiol (E2)
• Oestrone (E1)
• Oestriol (E3)
• Estetrol (E4)

Question 7

17β-Oestradiol

Answer 7

• Options
  
  • Oral
  • Transdermal patch
  • Vaginal ring
  • Pessaries
  • Gel
  • Cream
• Can be cyclical (sequential) or contunuous combined
• Improves vaginal symptoms and sexual dysfunction

Question 8

Risks of HRT

Answer 8

• Risk of VTE with oral treatment not transdermal
• Small increase in Br Ca risk with E+P

Question 9

Other factors to consider in management

Answer 9

• Osteoporosis
  
  • Patients should be assessed using FRA
  • Prevention of falls, mobility loss and nutrition problems
• CV disease
  
  • HRT reduces risk by 50% if started within 10 years of menopause

Question 10

Alternatives to HRT

Answer 10

• Gabapentin
• SSRI or SNRI
• Clonidine
• Red-clover isoglavones
• Soy isoflavones