O&G

Question 1

Indications for Vaginal Oestrogen in HRT

Answer 1

• When vaginal and/or bladder symptoms of urogenital
  atrophy predominate, vaginal oestrogen alone can be used.
• Vaginal oestrogen may also be required in addition for some women taking systemic HRT.

Question 2

Indications for Systemic HRT

Answer 2

Symptpom control
Tx of Preamture Ovarian Insufficiency
Prevention/Tx of Osteoporoisis

Question 3

Proven Benefits of HRT

Answer 3

Control of menopausal symptoms.
* Maintenance of BMD (bone mineral density)
and reduced risk osteoporotic fractures.

Additional Potential Benefits:
* Reduced risk coronary heart disease and reduced risk
Alzheimers disease when estrogen started early.
* Reduced risk colorectal cancer.
* Reduced risk Type 2 DM (diabetes mellitus)

Question 4

Risks of HRT

Answer 4

• Endometrial cancer (if oestrogen only given when
  uterus present). Reduced by addition of progestogen.
  Continuous progestogen provides better long-term protection
  than cyclical.
• DVT/PE: Background risk is 1.7 per 1,000 women aged over 50.
  Greatest risk in 1st 12 months. No increase in risk of VTE with
  transdermal.
• CHD: Possible increase when combined HRT started in older
  women(>60), or with pre-existing CHD. 1st 10 years after
  menopause = Cardiovascular ‘window of opportunity’.
• Stroke: Increased when oral HRT started in older women
  (> 60 years).
• Breast cancer: Probably increased slightly after a minimum
  of 5 years’ use of combined HRT, over the age of 50—
  additional 3-4 cases per 1,000 women. Risk associated with
  Oestrogen alone is very much less. Mortality is not increased

Question 5

Indications for Transdermal HRT

Answer 5

Individual preference
Poor symptom control with oral
GI disorder affecting oral absorption
Previous or family history of VTE
BMI >30
Variable blood pressure control
Migraine
Current use of hepatic inducing enzymes medication
Gall bladder disease

Question 6

HRT Review Timings

Answer 6

• Commenced on HRT or HRT changed —
  three months
• Established on HRT — at least annually
• Each review should assess effectiveness and
  side effects of therapy; discuss any bleeding
  pattern; review type and dose, help assess
  ongoing risk/benefit balance

Question 7

Indications for HRT Referral to Secondary Care

Answer 7

• Persistent side effects
• Poor symptom control
• Complex medical history
• Past history hormone dependent cancer
• Bleeding problems —
• Sequential HRT — if increase in heaviness or
  duration of bleeding, or if bleeding irregular
• Continuous combined — if bleeding
  beyond six months of therapy, or if occurs after
  spell of amenorrhoea.

Question 8

Common Side Effects of HRT Oestrogen

Answer 8

• Fluid retention
• Breast tenderness
• Bloating
• Nausea / Dyspepsia
• Headaches

Question 9

Common Side Effects of HRT Progestogens

Answer 9

• Fluid retention
• Breast tenderness
• Headaches
• Mood swings
• PMT-like symptoms

Question 10

Who should be offered testosterone in Menopause

Answer 10

Testosterone supplementation should only be considered in women who complain of low sexual desire after a biopsychosocial approach has excluded other causes such as relationship, psychological
and medication related HSDD e.g. SSRIs/SNRIs. However, combined hormonal and psychosexual
approaches may be beneficial in cases with mixed aetiologies.
a trial of conventional HRT is
given before testosterone supplementation is considered

Question 11

Define Menopause vs Perimenopause

Answer 11

Menopause is when menstruation stops permanently due to the loss of ovarian follicular activity. It occurs with the final menstrual period and is usually diagnosed clinically after 12 months of amenorrhoea.
In the UK, the mean age of natural menopause is 51 years.

Perimenopause is the period before the menopause characterized by irregular cycles of ovulation and menstruation and ends 12 months after the last menstrual period.

Question 12

Define Early Menopause

Answer 12

cessation of ovarian function between 40 and 45 years, in the absence of other causes of secondary amenorrhoea.

Question 13

When to measure FSH i Menopause

Answer 13

Measurement of serum FSH may be considered in women aged over 45 years with atypical symptoms; aged between 40–45 years with symptoms; and younger than 40 years with suspected POI.
Over 50 years of age using progestogen-only contraception, including depot medroxyprogesterone acetate (DMPA).

Question 14

Symptoms Associated with the Menopause

Answer 14

Hot flushes/night sweats (vasomotor symptoms)
Cognitive impairment and mood disorders
Urogenital symptoms (genitourinary syndrome of menopause): These may include vulvovaginal irritation, discomfort, burning, itching, and/or dryness; dyspareunia; reduced libido; dysuria, urinary frequency and urgency, and recurrent lower urinary tract infections. Symptoms of urogenital atrophy may appear for the first time more than 10 years after the last menstrual period.
Altered sexual function
Sleep Disturbance
Joint and muscle pains, headaches, and fatiguew