Menopause: Virtual Patient Case

Question 1

The cardinal sign of menopause is?

Answer 1

The final menstruation at a median age of 53.

For some this is the only manifestation, for others a variety of symptoms arise

Question 2

Definition of Menopause

Answer 2

> 6-12 months of amenorrhoea, usually between 45-55

Question 3

What are the 2 main subtypes of menopausal symptoms.

What else can you get

Answer 3

1. Vasomotor symptoms
2. Genitourinary symptoms

also

• Psychological symptoms: attributable to poor sleep quality
• Osteoporosis

Question 4

What’s the definition of Premature menopause

Answer 4

Premature Menopause: Cessation of mestruation prior to age 40

Question 5

What are the common vasomotor symtpoms women with menopause experiance

Answer 5

• Hot Flushes : last 30sec-5mins, every 1-2hrs up to weeks
• Night sweats which → poor sleep pattern → mood change

​80% of women experiance these symptoms

Question 6

What is the average duration of vasomotor symptoms

Answer 6

7 years

10% will continue to have these for 12 years and some will always suffer.

Question 7

What are the common genitourinary symptoms menopausal women experiance

Answer 7

These occur in 50% of women.

• As a result of the vaginal epithelium thinning:
  
  • Dyspareunia, bleeding, itching, discomfort
  • Atrophic vaginitis
  • Recurrent UTI
  • non-Infective urgency
• Low oestrogen also causes
  
  • Thin skin
  • sparse hairs
  • Loss of breast volume

Question 8

DO we look at symptoms or a gonadotrophin/estrogen levels when deciding management

Answer 8

estrogen/gonadotrophin levels are seldom useful or neccessary.

Impact on QOL due to symptoms is more important.

Question 9

When to prescribe HRT

Answer 9

Prescribe HRT short term for severe vasomotor symptoms

• Screen first
• 6monthly review
• After 1-2 years try to wean patients off HRT
• Premature menopause: HRT should be used unless contraindicated
  
  • HRT decreases osteoporosis risk

Question 10

What are the contraindications to HRT/oestrogen therapy

Answer 10

• Undiagnosed vaginal bleeding
• Previous breast cancer
• Previous VTW
• Previous heart attack
• Previous stroke
• High risk of CVD

Question 11

What are the hormonal preperations of the HRT?

Answer 11

Oestrogens: oral, transdermal (bypasses first pass), impant, tablets

Progestogens: oral, IU (mirena), vaginal pessaries

Question 12

When would you use oestrogen alone for HRT

Answer 12

• Only for women who have had hysterectomies

Question 13

Who would use continuous oestrogen & sequential progestogen

Answer 13

used in perimenopausal women who are still menstruating or had a period in the last 12 months

Question 14

How does continuous oestrogen & sequential progestogen get prescribed

Answer 14

Continuous oestrogen with 10-14 days of progesterone monthly

Question 15

Why the need for progesterone if it’s lw oestrogen causes the symptoms

Answer 15

Theres a 5-fold increase in incidence of endometrial cancer with unopposed oestrogen therapy.

The addition of progesterone removes this risk, and all women with a uterus require this

Question 16

Who would use continous oestrogen and progesterone

Answer 16

women more then 1 year post menopausal

**Results in endometrial atrophy

Question 17

Should you be concerned with bleeding after HRT ?

Answer 17

Breakthrough bleeding might occur in the intial six months but eventually amenorrhoea

Question 18

How to withdraw Hormonal therapy once symptomatic control has been gained?

Answer 18

• Gradual decrease over 6-12 weeks or longer
  
  • otherise rebound flushes are likely
• Gradually decrease Oestrogen but continue progesterone until oestrogen is stopped
• May still experiance flushes, but not as intense and for not as long

Question 19

Strategies to decreasing your HRT

Answer 19

lower dose

cutting pills in half

you patches with decreasing dose

alternative clomidine alpha-blocker can relieve flushes

Question 20

What does the WHI study show to be the adverse effects of hormone therapy

(study in which women aged 50-79)where randomised to combined (oestrogen only if hystectomy) vs placebo, and followed for 5-7 years

Answer 20

• Both combined and oestrogen only: associated with an increased risk of stroke, VTE and gallstones
• Combined: increase in breast cancer and alzheimers >65yrs

Question 21

Do these risks surrounding HRT continue after stopping the medication?

Answer 21

No, after 2-3yrs most risks and benefits are gone except an increased risk of breast cancer in women using combined therapy

Question 22

What is the risk of endometrial cancer with unopposed oestrogen therapy?

Answer 22

There is a 5-8 fold increase in risk.

THis is diminished by adding oral or IU progesterone

Question 23

Is HRT an effective contraception?

Answer 23

No it does not provide adequate contraception unless the Mirena is added.

Question 24

Can HRT be used as first line treatment for osteoporosis?

Answer 24

No the first line treatment is bisphosphanates, as the long term risks too health (as shown in WHI study) are too high.