Menopause: presentation and management Flashcards
Green
What is the definition of menopause?
Cessation of menstruation resulting from loss of follicular activity; occurs 12 months after last period
Difficulties surrounding menopause arise from falling oestrogen levels
What is perimenopause?
Beginning with the first features of approaching menopause e.g. vasomotor symptoms and menstrual irregularities
Ends 12m after LMP
What is the postmenopause?
Dating from final menstrual menopause (cannot be determined until 12m of amennorhoea)
What is the average age of menopause in the UK?
52y
What is premature menopause?
Menopause before the age of 40y (1% women)
When might a surgical menopause occur?
After bilateral oophorectomy Also -Infection -Autoimmune causes -Chemotherapy -Ovarian dysgenesis -Metabolic diseases
What are the main symptoms of menopause?
Menstrual irregularity Vasomotor disturbance Atrophy of oestrogen dependent tissues (e.g. genitalia, breasts) and skin Osteoporosis Mastitis/breast tenderness
What vasomotor symptoms might a woman present with in menopause?
Night sweats
Palpitations
Hot flushes (short, nasty, during life/sleep)
May persist into 60s and 70s
What urogenital symptoms might a woman present with in menopause?
Vaginal and urinary infection
Vaginal atrophy (dyspareunia, cessation of sex, itching, burning, dryness)
UTI (frequency, urgency, nocturia, incontinence, recurrent infection)
Prolapse
What sexual problems might a woman encounter in menopause?
Loss of desire Loss of arousal Problems with orgasm Dyspareunia Trauma (related to dryness)
Why does menopause increase the risk of osteoporosis?
Menopause accelerates bone loss, predisposing #NOF, radius (Colles’) and vertebrae later in life
What are the risk factors for the development of osteoporosis?
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
How is osteoporosis defined in terms of bone mineral density (BMD)?
Normal - BMD +/- 1 SD from average
Osteopaenia - BMD -1 - -2.5 SD
Osteoporosis - BMD > -2.5 SD
What Ix can be performed in suspected menopause?
FSH raised Anti-Mullerian hormone reduced Bloods -TFT: menopausal hot flushes = thyrotoxicity -Catecholamines: phaeochromocytoma -LH, oestrodiol, progesterone: PCOS DEXA scan
How can the menopause be managed?
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)
What can be given for hot flushes?
Progesterone (5mg OD norethisterone, 40mg OD megestrol acetate)
SSRIs (paroxetine, fluoxetine, citalopram, venlafaxine)
Gabapentin and clonidine may potentially help
What can be used for prevention/treatment of osteoporosis?
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)
What alternative therapies may be widely used?
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
What changes/clinical features are characteristic of oestrogen deficiency?
Early effects -Psychological symptoms -Vasomotor symptoms Intermediate effects -Skin atrophy -Genital/urinary tract atrophy Late effects -CVAs -CVS disease -Bony fractures
