Obs and gynae Flashcards
What is menopause and what is average age?
the permeant cessation of the menstruation due to the loss of ovarian follicular function (amenorrhea for 12 months except when on pill or pathological) this is when there is no obvious pathological or physiological cause present
Average age in the UK is 51
What is perimenopause?
no consistent definition, a period of changing ovarian function which precedes menopause by 2-8 years. Includes the period beginning with the first clinical, biological, and endocrinological features of the approaching menopause, such as vasomotor symptoms and menstrual irregularity, and ends 12mths after the last menstrual period.
What is premature ovarian failure? What are the causes, and features?
Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
Unlike the menopause, premature ovarian insufficiency can be areversiblecondition so is not termed an early menopause.
It occurs in around 1 in 100 women.
Causes Primary: • Chromosomal abnormalities • FSH receptor gene polymorphisms and inhibin B mutation • Enzyme deficiency • Autoimmune disease Secondary • Chemotherapy and radiation • Bilateral oophorectomy or surgical menopause • Hysterectomy without oophorectomy • Infection
Clinical presentation • Secondary amenorrhoea or oligomenorrhoea (which may not be necessarily accompanied by hot flushes- infertility • Co existing disease may be detected particularly ○ Hypothyroidism ○ Addisons's ○ DM ○ Any chromosomal abnormalities Investigations raised FSH, LH levels If diagnosis in doubt consider anti MH
What is pre-menopause?
a term often used to refer either to the 1–2yrs immediately before the menopause or to the whole of the reproductive period before the menopause. Currently, this term is recommended to be used in the latter sense.
What is post menopause?
should be defined from the final menstrual period regardless of whether the menopause was induced or spontaneous.
What is menopausal transition?
is the period of time before the final menstrual period, when variability in the menstrual cycle usually is increased.
What is climacteric?
is the phase encompassing the transition from the reproductive state to the non-reproductive state. The menopause itself thus is a specific event that occurs during the climacteric, just as the menarche is a specific event that occurs during puberty.
What are the vasomotor symptoms of menopause?
• Hot flushes
• Night sweats
• HIGHEST AFTER THE FMP
• <5 years often but some continue to 70s
• A sudden feeling of heat in the upper body (face, neck, and chest) which spreads upwards and downwards.
• In some cases, this will become generalized, lasting for several minutes, and can be associated with excessive sweating, palpitations, or anxiety.
This can be very distressing for the woman, especially when it happens repeatedly during the day and at night.
What are the changes in sexual behaviour/activity in menopause?
Loss of sexual desire
• Loss of sexual arousal
• Problems with orgasm
• Sexual pain such as painful sex or dyspareunia
• % rises from 42-88% in early-> late menopause
• Vaginal dryness- reduced oestrogen-> dyspareunia
• Less sexual desire-> low androgen?
• Non hormonal factors: conflict between partners, life stress, depression
Male sexual problems should not be overlooked
What are the psychological problems in menopause?
• Depressed mood • Anxiety • Irritability and mood swing s • Lethargy and lack of energy Likely due to past problems or current life stresse
What are the LT consequence of osteoporosis?
• Shift to bone reabsorption
• Osteoporosis is a significant RF for fracture- fractures are a clinical consequence of osteoporosis
• Lower end of the radius (wrist or colle’s fracture)
• Proximal femur (hip)
Vertebrae
What are the LT consequences of cardiovascular disease?
• MI and stroke are the primary clinical endpoints
• CVD is the most common cause of death in women >60
• Oophorectomized women are 2-3 fold higher risk of CHD than age matched pre menopausal women
Increase LDL reduced HDL without oestrogren
What are the LT urogenital atrophy?
lower Urinary + genital tracts have a common embryological origin
• Oestrogen receptors and progesterone receptors are on vagina, urethra, bladder and pelvic floor muscles
• Oestrogen deficiency after menopause causes atrophic changes within the urogenital tract-> urinary symptoms: frequency, urgency, nocturia, incontinence and recurrent infection
May also co-exist with those of vaginal atrophy, including dyspareunia, itching, burning and dryness
What is the prognosis for premature menopause women?
• Women with untreated premature menopause (no oestrogen replacement) are at increased risk of osteoporosis and cardiovascular disease, but at lower risk of breast malignancy.
• Premature menopause can lead to reduced peak bone mass (if <25yrs old) or early bone loss thereafter.
Mean life expectancy in women with menopause before the age of 40yrs is 2.0yrs shorter than that in women with menopause after the age of 55yrs.
What is the treatment of premature ovarian failure?
Multidisciplinary team to manage both the psychological impact of the condition alongside the physical symptoms.HRTis the main treatment, alongside monitoring for cardiovascular disease and osteoporosis.
There are a few management issues:
• Fertility and contraception:
○ Reduced fertility
○ May require assisted conception
○ Need for contraception if no fertility goals
• Women need oestrogen replacement until average of natural menopause- 51
○ HRT
COCP without gaps
What are some DDx of menopause including hot flushes, irregular bleeding (perimenopause, and after menopause), vaginal atrophy, incontinence, mood changes, cognitive disturbances, libido, muscle and joint pains, skin changes, weight gain?
• Causes of amenorrhoea
• Irregular bleeding:
• During the perimenopause, possible causes include endometrial polyps; uterine fibroids; adenomyosis; endometrial hyperplasia or cancer; and vulval, vaginal, or cervical lesions.
• After menopause, possible causes include endometrial atrophy; vaginal atrophy; endometrial polyps; endometrial hyperplasia or cancer; and vulval, vaginal, or cervical lesions.
• Hot flushes:
If ovarian failure is uncertain, exclude other causes such as:
• Endocrine causes, for example, hyperthyroidism and phaeochromocytoma.
• Tumours, for example, carcinoid tumour, pancreatic tumour, mastocytoma, and paraneoplastic syndrome.
• Excess alcohol consumption.
• Dumping syndrome.
• Panic disorders.
• Tuberculosis.
• Drugs, for example, nitrates, selective serotonin reuptake inhibitors (SSRIs), diltiazem, levodopa, gonadotrophin-releasing hormone agonists, and anti-oestrogens
• Vaginal atrophy: trauma or infection
Symptoms that are associated with the menopause but are often due to other causes include:
• Urinary incontinence—this is more likely to be due to mechanical factors, such as obesity, gynaecological surgery, or multiparity, than the menopause.
• Mood changes(including anxiety, irritability, and depression)—these symptoms may not be due to the menopause alone. General population studies suggest that most women do not experience major changes in mood during the menopause transition; however, anxiety and depression should be excluded
• Cognitive disturbances(such as forgetfulness or difficulty concentrating)—cross-sectional studies suggest that these symptoms are unlikely to be related to the menopause.
• Loss of libido—this symptom can be attributed to androgen deficiency; however, non-hormonal factors, such as insomnia, inadequate sexual stimulation, life stresses, and depression, are also important possible contributors.
• Muscle and joint pains—pain and swelling resulting in restriction of mobility most often affects the small joints of the hands and feet as well as the knees, elbows, and the cervical spine. These symptoms have been linked to a decrease in oestrogen levels, but musculoskeletal causes (such as osteoarthritis and rheumatoid arthritis) are possible.
• Skin changes—it is difficult to separate skin changes due to ageing, smoking, and sun exposure, from skin changes due to declining hormonal secretion and menopause. Soon after the menopause, skin collagen content and skin thickness decrease, resulting in decreased skin elasticity.
•Weight gain—this is unlikely to be solely due to the perimenopause or the menopause. Body weight in women tends to increase with age, especially beginning at or near the menopause (the average weight gain ranges from 2.25–4.19 kg). Body fat redistribution to the abdomen also occurs with age (independently of weight gain).
What is the epidemiology of menopause, how long do symptoms last, and what is duration and severity?
• Menopausal symptoms are very common and affect roughly 75% of postmenopausal women
Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.
