S10) Menopause

Question 1

What is menopause?

Answer 1

Menopause is the permanent cessation of menstruation (12 consecutive months), with no associated physiological causes, at the end of reproductive life due to loss of ovarian follicular activity

Question 2

What is physiological menopause?

Answer 2

Physiologic menopause is the normal decline in ovarian function due to ageing (45 - 55), resulting in infrequent ovulation, decreased menstrual function and eventually cessation of menstruation

Question 3

What is pathological menopause?

Answer 3

Pathological menopause is the gradual/abrupt cessation of menstruation < 40 years occur idiopathically (5% of women)

Question 4

What are the 4 phases of menopause?

Answer 4

• Pre-menopause
• Peri-menopausal (transition menopause)
• Menopause
• Post menopause

Question 5

Describe 4 physiological features of the pre-menopause phase (peri-menopausal)

Answer 5

• Changes in menstrual cycle (follicular phase shortens, early/absent ovulation)
• Less oestrogen secreted
• LH & FSH levels rise
• Reduced fertility

Question 6

What is observed in the perimenopause phase?

Answer 6

The perimenopausal phase is characterised by the physiological changes associated with the end of reproduction capacity and terminates with the completion of menopause

Question 7

What is the post-menopausal phase?

Answer 7

The post-menopausal phase is the time after which a women has experienced 12 consecutive months of amenorrhea without period

Question 8

In four steps, outline the concept of ‘burning out the ovaries’

Answer 8

⇒ In reproductive life, ~400 primordial follicles grow & ovulate

⇒ At ~45 years old, only a few primordial follicles remain to be stimulated by FSH & LH

⇒ Production of oestrogen by ovaries decreases gradually

⇒ Inhibition gonadotrophins (FSH, LH) decreases

Question 9

Which hormone is measured to diagnose physiological menopause?

Answer 9

FSH, not oestrogen because it arises from locations other than ovaries

Question 10

Identify 5 early consequences of oestrogen deficiency

Answer 10

• Hot flushes
• Sweating
• Insomnia
• Menstrual irregularity
• Psychological changes

Question 11

Identify 5 intermediate consequences of oestrogen deficiency

Answer 11

• Vaginal atrophy
• Dyspareunia
• Skin atrophy
• Stress urinary incontinence

Question 12

Identify 3 late consequences of oestrogen deficiency

Answer 12

• Osteoporosis
• Atherosclerosis (CVD & CHD)
• Alzheimer’s disease

Question 13

Describe the causes and treatment of hot flushes

Answer 13

• Hot flush occurs due to vascular changes and transient rises in skin temperature
• Relieved by oestrogen treatment

Question 14

Explain why dysfunctional uterine bleeding occurs in the pre/perimenopause phases

Answer 14

• Continued oestrogen thickens endometrium (hyperplasia)
• No ovulation = no progesterone = no corpus luteum

Leads to a late menstrual period followed by irregular bleeding and spotting

Question 15

How does dysfunctional uterine bleeding present?

Answer 15

• Spotting between cycles
• Extremely heavy bleeding
• Mid-cycle bleeding
• Longer, shorter / unpredictable lengths of time between periods
• Longer, shorter / unpredictable durations of periods

Question 16

Describe the manifestations of the psychological changes in menopause

Answer 16

• Frequent headache
• Irritability
• Fatigue
• Depression
• Insomnia

Question 17

Describe the general changes in appearance which accompanies menopause

Answer 17

• Skin: loses its elasticity, becomes thin and fine due to loss of elastin and & collagen
• Weight: likely increase around hips, waist & buttocks due irregular food habit (mood swing)
• Hair: becomes dry, coarse (± hair loss due to oestrogen decrease)
• Voice: becomes deeper as vocal cords thicken (oestrogen decrease)

Question 18

Why do menopausal women often present with constipation?

Answer 18

• Diminished motor activity of the entire GI tract
• Intestines tend to be sluggish

Question 19

Why do menopausal women often present with urinary incontinence and UTIs?

Answer 19

• Oestrogen decrease results in the tissue lining the urethra and bladder becoming drier, thinner and less elastic
• Changes in bladder due to loss of pelvic tone

Question 20

How do the internal genital organs change during menopause?

Answer 20

• Regression & shrinkage of endometrium
• Cervix becomes smaller & thinner and appears to flush with vagina, which loses its rugae

Question 21

How do the external genital organs change during menopause?

Answer 21

• Vulva – decrease in fat in the labia majora & mons pubis
• Breast – flat and shrivelled (thin women) or remain flabby and pendulous (heavy women)

Question 22

Why are post-menopausal women at high-risk of osteoporosis?

Answer 22

• Bone mass reduces by 2.5% per year for several years (Ca²⁺ moves out)
• Reduced oestrogen enhances osteoclast ability to absorb bone

Question 23

Why is there a gradual rise in the risk of heart disease and stroke after menopause?

Answer 23

Lack of oestrogen and progesterone:

• Increases plasma cholesterol (hyperlipidemia)
• Increases in systolic and diastolic pressure (hypertension)
• Carbohydrate tolerance decreases (diabetes)

Question 24

Outline the non-hormonal treatments of menopause

Answer 24

• Hot flushes & night sweats: dressing in light layers, avoid caffeine, alcohol and spicy foods
• Weight gain: lifestyle changes (dietary fat intake & exercise)

Question 25

HRT is indicated in menopausal women to overcome the short-term and long- term consequences of oestrogen deficiency.

How can it be administered?

Answer 25

• Orally (pill form)
• Vaginally (as a cream)
• Transdermally (in patch form)

Question 26

What are the possible disadvantages to HRT?

Answer 26

• Heart disease
• Stroke
• Mental decline
• Breast cancer
• Ovarian cancer

Question 27

Why aren’t oestrogen only preparations given to women who haven’t had a hysterectomy?

Answer 27

Oestrogen causes endometrial proliferation outside the uterus, possibly causing endometrial cancer