Menopause & Menstrual Issues

Question 1

The average women in the UK goes through the menopause when she is

Answer 1

51yrs old

Question 2

The climacteric is

Answer 2

the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail

Question 3

It is recommended to use effective contraception until the following time:

Answer 3

12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

Question 4

Menopause is defined as

Answer 4

the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.

Question 5

Menopausal symptoms are very common and affect roughly 75% of postmenopausal women. Symptoms typically last for ? but may resolve quicker and in some cases take much longer.

Answer 5

7 years

Question 6

Menopause Management with lifestyle modifications

Answer 6

Hot flushes
regular exercise, weight loss and reduce stress

Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene

Mood
sleep, regular exercise and relaxation

Cognitive symptoms
regular exercise and good sleep hygiene

Question 7

Menopause Management with HRT

Contraindications:

Answer 7

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

Question 8

treatment with HRT brings certain risks:

Answer 8

Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.

Question 9

Menopause Management

Management with non-HRT

Answer 9

Vaginal dryness
vaginal lubricant or moisturiser

Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants

Question 10

Menopause Management Vasomotor symptoms

Answer 10

fluoxetine, citalopram or venlafaxine

Question 11

Menopause Management

Urogenital symptoms

Answer 11

if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Question 12

Menopause - stopping treatment

Answer 12

For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment.
When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.

Vaginal oestrogen may be required long term.

Although menopausal symptoms can be managed mainly in primary care, there are some instances when a woman should be referred to secondary care. She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Question 13

Menopause: symptoms

The symptoms seen in the climacteric period are caused by

Answer 13

reduced levels of female hormones, principally oestrogen

Question 14

Menopause: Longer term complications

Answer 14

osteoporosis

increased risk of ischaemic heart disease

Question 15

Menorrhagia was previously defined as

Answer 15

loss > 80 ml per menses

Question 16

The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures.

Answer 16

true

Question 17

Causes menorrhagia

Answer 17

anovulatory cycles
uterine fibroids
hypothyroidism
intrauterine devices*
pelvic inflammatory disease
bleeding disorders, e.g. von Willebrand disease

Question 18

dysfunctional uterine bleeding: this describes

Answer 18

menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients

Question 19

anovulatory cycles these are more common ?

Answer 19

these are more common at the extremes of a women’s reproductive life

Question 20

Amenorrhoea may be divided into

Answer 20

primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer).

Question 21

Causes of primary amenorrhoea

Answer 21

Turner’s syndrome
testicular feminisation
congenital adrenal hyperplasia
congenital malformations of the genital tract

Question 22

Secondary amenorrhoea is defined as

Answer 22

when menstruation has previously occurred but has now stopped for at least 6 months.

Question 23

Causes of secondary amenorrhoea (after excluding pregnancy)

Answer 23

hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)

Question 24

Amenorrhea intial investigations

Answer 24

exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests

Question 25

Dysmenorrhoea is characterised by

Answer 25

excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.

Question 26

Primary dysmenorrhoea is

Answer 26

In primary dysmenorrhoea there is no underlying pelvic pathology. Excessive endometrial prostaglandin production is thought to be partially responsible.

Question 27

Primary dysmenorrhoea affects who

Answer 27

It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche.

Question 28

Primary dysmenorrhoea Features

Answer 28

pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh

Question 29

Primary dysmenorrhoea mx

Answer 29

NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line

Question 30

Secondary dysmenorrhoea typically develops

Answer 30

many years after the menarche

Question 31

Secondary dysmenorrhoea is the result of an underlying pathology

Answer 31

true

Question 32

Secondary dysmenorrhoea primary dysmenorrhoea the pain usually starts

Answer 32

3-4 days before the onset of the period.

Question 33

Secondary dysmenorrhoea causes

Answer 33

endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea
fibroids

Question 34

Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.

Answer 34

true

Question 35

The management of menorrhagia now depends on

Answer 35

management has therefore shifted towards what the woman considers to be excessive.
whether a woman needs contraception.

Question 36

Heavy menstrual bleeding ix

Answer 36

a full blood count should be performed in all women
NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.

Question 37

Heavy menstrual bleeding does not require contraception mx

Answer 37

either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral

Question 38

Heavy menstrual bleeding does require contraception mx

Answer 38

intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens

Question 39

short-term option to rapidly stop heavy menstrual bleeding

Answer 39

Norethisterone 5 mg tds

Question 40

A number of women will present with abdominal pain and subsequently be diagnosed with a gynaecological disorder. In addition to routine diagnostic work up of abdominal pain, all female patients should also

Answer 40

undergo a bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning.

When diagnostic doubt persists a laparoscopy provides a reliable method of assessing suspected tubulo-ovarian pathology.

Question 41

Mittelschmerz is

Answer 41

Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.

Question 42

Mittelschmerz ix

Answer 42

Full blood count- usually normal

Ultrasound- may show small quantity of free fluid

Question 43

Hormone replacement therapy (HRT) involves

Answer 43

the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Question 44

HRT side effects

Answer 44

nausea
breast tenderness
fluid retention and weight gain

Question 45

HRT potential complications

Answer 45

increased risk of breast cancer
increased risk of endometrial cancer
increased risk of venous thromboembolism
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause

Question 46

HRT - increased risk of breast cancer mx

Answer 46

increased by the addition of a progestogen
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to the duration of use
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT

Question 47

HRT - increased risk of endometrial cancer mx

Answer 47

oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously

Question 48

HRT - increased risk of venous thromboembolism mx

Answer 48

increased by the addition of a progestogen
transdermal HRT does not appear to increase the risk of VTE
NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)

Question 49

PMS mx mild symptoms can be managed with lifestyle advice

Answer 49

apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates

Question 50

PMS mx moderate symptoms

Answer 50

may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)

Question 51

PMS mx severe symptoms

Answer 51

severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)