Menopause: presentation and management

Question 1

What is the definition of menopause?

Answer 1

Cessation of menstruation resulting from loss of follicular activity; occurs 12 months after last period
Difficulties surrounding menopause arise from falling oestrogen levels

Question 2

What is perimenopause?

Answer 2

Beginning with the first features of approaching menopause e.g. vasomotor symptoms and menstrual irregularities
Ends 12m after LMP

Question 3

What is the postmenopause?

Answer 3

Dating from final menstrual menopause (cannot be determined until 12m of amennorhoea)

Question 4

What is the average age of menopause in the UK?

Answer 4

52y

Question 5

What is premature menopause?

Answer 5

Menopause before the age of 40y (1% women)

Question 6

When might a surgical menopause occur?

Answer 6

After bilateral oophorectomy 
Also
-Infection
-Autoimmune causes
-Chemotherapy
-Ovarian dysgenesis
-Metabolic diseases

Question 7

What are the main symptoms of menopause?

Answer 7

Menstrual irregularity
Vasomotor disturbance
Atrophy of oestrogen dependent tissues (e.g. genitalia, breasts) and skin
Osteoporosis
Mastitis/breast tenderness

Question 8

What vasomotor symptoms might a woman present with in menopause?

Answer 8

Night sweats
Palpitations
Hot flushes (short, nasty, during life/sleep)

May persist into 60s and 70s

Question 9

What urogenital symptoms might a woman present with in menopause?

Answer 9

Vaginal and urinary infection
Vaginal atrophy (dyspareunia, cessation of sex, itching, burning, dryness)
UTI (frequency, urgency, nocturia, incontinence, recurrent infection)
Prolapse

Question 10

What sexual problems might a woman encounter in menopause?

Answer 10

Loss of desire
Loss of arousal
Problems with orgasm
Dyspareunia
Trauma (related to dryness)

Question 11

Why does menopause increase the risk of osteoporosis?

Answer 11

Menopause accelerates bone loss, predisposing #NOF, radius (Colles’) and vertebrae later in life

Question 12

What are the risk factors for the development of osteoporosis?

Answer 12

Genetic
-FHx fracture (esp NOF)
Constitutional
-Low BMI
-Early menopause (<45)
Environmental
-Smoking, alcohol abuse
-Low Ca intake
-Sedentary lifestyle
Drugs
-Corticosteroid use
Disease
-RA
-Chronic liver disease
-Malabsorption
-Hyperparathyroidism, hyperthyroidism, hypogonadism
-Neuromuscular disease

Question 13

How is osteoporosis defined in terms of bone mineral density (BMD)?

Answer 13

Normal - BMD +/- 1 SD from average
Osteopaenia - BMD -1 - -2.5 SD
Osteoporosis - BMD > -2.5 SD

Question 14

What Ix can be performed in suspected menopause?

Answer 14

FSH raised
Anti-Mullerian hormone reduced
Bloods
-TFT: menopausal hot flushes = thyrotoxicity
-Catecholamines: phaeochromocytoma
-LH, oestrodiol, progesterone: PCOS
DEXA scan

Question 15

How can the menopause be managed?

Answer 15

Ensure is menopause and not other pathology e.g. thyroid, phaeochromocytoma
Diet and exercise for symptomatic relief
Mirena for menorrhagia (may also perform endometrial biopsy in unexplained bleeding)
Contraception used until >1y amenorrhoeic if >50y; 2y if <50
Oestrogen creams for vaginal dryness (oestrogen cream 0.1% PV nightly 2w, then twice weekly/as required as needed/indefinitely)

Question 16

What can be given for hot flushes?

Answer 16

Progesterone (5mg OD norethisterone, 40mg OD megestrol acetate)
SSRIs (paroxetine, fluoxetine, citalopram, venlafaxine)
Gabapentin and clonidine may potentially help

Question 17

What can be used for prevention/treatment of osteoporosis?

Answer 17

Bisphosphonates (alendronate, risedronate, zoldedronic acid, ibandronate); note SE of GI irritation, contraindicated in future family planning
Raloxifene and bazedoxifene (SERMs, selective oestrogen receptor modulators) - reduction of fracture in established osteoporosis
PTH peptides (limit 2y use as link to osteosarcoma in rat studies)
Denosumab (MAb RANKL), reduce fracture risk where bisphosphonates contraindicated
Calcium and Vit D supplements (but note small increased risk of coronary disease and renal stones)

Question 18

What alternative therapies may be widely used?

Answer 18

Phyto-oestrogens
-Mimic oestrogenic effects
-e.g. isoflavones and lignans found in soya beans and chickpeas
Herbal remedies
-black cohosh, kava kava, evening primrose, dong quai, gingko, ginseng and wild yam cream (WellWoman vitamins)
Progesterone transdermal creams
-not protective of endometrium

Very little evidence of benefit

Question 19

What changes/clinical features are characteristic of oestrogen deficiency?

Answer 19

Early effects 
-Psychological symptoms
-Vasomotor symptoms
Intermediate effects
-Skin atrophy
-Genital/urinary tract atrophy
Late effects
-CVAs
-CVS disease
-Bony fractures