Menopause: Virtual Patient Case Flashcards
The cardinal sign of menopause is?
The final menstruation at a median age of 53.
For some this is the only manifestation, for others a variety of symptoms arise
Definition of Menopause
> 6-12 months of amenorrhoea, usually between 45-55
What are the 2 main subtypes of menopausal symptoms.
What else can you get
- Vasomotor symptoms
- Genitourinary symptoms
also
- Psychological symptoms: attributable to poor sleep quality
- Osteoporosis
What’s the definition of Premature menopause
Premature Menopause: Cessation of mestruation prior to age 40
What are the common vasomotor symtpoms women with menopause experiance
- 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
What is the average duration of vasomotor symptoms
7 years
10% will continue to have these for 12 years and some will always suffer.
What are the common genitourinary symptoms menopausal women experiance
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
DO we look at symptoms or a gonadotrophin/estrogen levels when deciding management
estrogen/gonadotrophin levels are seldom useful or neccessary.
Impact on QOL due to symptoms is more important.
When to prescribe HRT
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
What are the contraindications to HRT/oestrogen therapy
- Undiagnosed vaginal bleeding
- Previous breast cancer
- Previous VTW
- Previous heart attack
- Previous stroke
- High risk of CVD
What are the hormonal preperations of the HRT?
Oestrogens: oral, transdermal (bypasses first pass), impant, tablets
Progestogens: oral, IU (mirena), vaginal pessaries
When would you use oestrogen alone for HRT
- Only for women who have had hysterectomies
Who would use continuous oestrogen & sequential progestogen
used in perimenopausal women who are still menstruating or had a period in the last 12 months
How does continuous oestrogen & sequential progestogen get prescribed
Continuous oestrogen with 10-14 days of progesterone monthly
Why the need for progesterone if it’s lw oestrogen causes the symptoms
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
Who would use continous oestrogen and progesterone
women more then 1 year post menopausal
**Results in endometrial atrophy
Should you be concerned with bleeding after HRT ?
Breakthrough bleeding might occur in the intial six months but eventually amenorrhoea
How to withdraw Hormonal therapy once symptomatic control has been gained?
- 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
Strategies to decreasing your HRT
lower dose
cutting pills in half
you patches with decreasing dose
alternative clomidine alpha-blocker can relieve flushes
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
- Both combined and oestrogen only: associated with an increased risk of stroke, VTE and gallstones
- Combined: increase in breast cancer and alzheimers >65yrs
Do these risks surrounding HRT continue after stopping the medication?
No, after 2-3yrs most risks and benefits are gone except an increased risk of breast cancer in women using combined therapy
What is the risk of endometrial cancer with unopposed oestrogen therapy?
There is a 5-8 fold increase in risk.
THis is diminished by adding oral or IU progesterone
Is HRT an effective contraception?
No it does not provide adequate contraception unless the Mirena is added.
Can HRT be used as first line treatment for osteoporosis?
No the first line treatment is bisphosphanates, as the long term risks too health (as shown in WHI study) are too high.
