Menopause & Menstrual Issues Flashcards
The average women in the UK goes through the menopause when she is
51yrs old
The climacteric is
the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail
It is recommended to use effective contraception until the following time:
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Menopause is defined as
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.
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.
7 years
Menopause Management with lifestyle modifications
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
Menopause Management with HRT
Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
treatment with HRT brings certain risks:
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.
Menopause Management
Management with non-HRT
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Menopause Management Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Menopause Management
Urogenital symptoms
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.
Menopause - stopping treatment
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.
Menopause: symptoms
The symptoms seen in the climacteric period are caused by
reduced levels of female hormones, principally oestrogen
Menopause: Longer term complications
osteoporosis
increased risk of ischaemic heart disease
Menorrhagia was previously defined as
loss > 80 ml per menses
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.
true
Causes menorrhagia
anovulatory cycles uterine fibroids hypothyroidism intrauterine devices* pelvic inflammatory disease bleeding disorders, e.g. von Willebrand disease
dysfunctional uterine bleeding: this describes
menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
anovulatory cycles these are more common ?
these are more common at the extremes of a women’s reproductive life
Amenorrhoea may be divided into
primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer).
Causes of primary amenorrhoea
Turner’s syndrome
testicular feminisation
congenital adrenal hyperplasia
congenital malformations of the genital tract
Secondary amenorrhoea is defined as
when menstruation has previously occurred but has now stopped for at least 6 months.
Causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Amenorrhea intial investigations
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
Dysmenorrhoea is characterised by
excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.
Primary dysmenorrhoea is
In primary dysmenorrhoea there is no underlying pelvic pathology. Excessive endometrial prostaglandin production is thought to be partially responsible.
Primary dysmenorrhoea affects who
It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche.
Primary dysmenorrhoea Features
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
Primary dysmenorrhoea mx
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
Secondary dysmenorrhoea typically develops
many years after the menarche
Secondary dysmenorrhoea is the result of an underlying pathology
true
Secondary dysmenorrhoea primary dysmenorrhoea the pain usually starts
3-4 days before the onset of the period.
Secondary dysmenorrhoea causes
endometriosis adenomyosis pelvic inflammatory disease intrauterine devices*this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea fibroids
Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
true
The management of menorrhagia now depends on
management has therefore shifted towards what the woman considers to be excessive.
whether a woman needs contraception.
Heavy menstrual bleeding ix
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.
Heavy menstrual bleeding does not require contraception mx
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
Heavy menstrual bleeding does require contraception mx
intrauterine system (Mirena) should be considered first-line combined oral contraceptive pill long-acting progestogens
short-term option to rapidly stop heavy menstrual bleeding
Norethisterone 5 mg tds
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
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.
Mittelschmerz is
Usually mid cycle pain. Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours.
Mittelschmerz ix
Full blood count- usually normal
Ultrasound- may show small quantity of free fluid
Hormone replacement therapy (HRT) involves
the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
HRT side effects
nausea
breast tenderness
fluid retention and weight gain
HRT potential complications
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
HRT - increased risk of breast cancer mx
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
HRT - increased risk of endometrial cancer mx
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
HRT - increased risk of venous thromboembolism mx
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)
PMS mx mild symptoms can be managed with lifestyle advice
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
PMS mx moderate symptoms
may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
PMS mx severe symptoms
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)
