The menopause

Question 1

Approximately how many menstrual cycles does a woman have in a lifetime?

Answer 1

400

In each cycle 20-30 primordial follicles begin to mature

Question 2

Perimenopause

Answer 2

Ovaries become less sensitive to FSH –> increased levels of FSH to compensate –> increase in number of anovulatory cycles and decreased levels of oestrodiol and progesterone

Question 3

Premature menopause

Answer 3

Before the age of 45 (1% of women have menopause before 40)

Question 4

Primary causes of premature menopause?

Answer 4

Chromosomal: tuner’s, fragile X
Autoimmune: Hypothyroid, Addison’s, myasthenia gravis
Enzyme def - galactosaemia

Question 5

Secondary causes of premature menopause

Answer 5

Surgical - oophorectomy
Chemo/radiotherapy
Infections - TB, mumps, malaria, varicella

Question 6

Vasomotor effects of menopause

Answer 6

Usually last <5 years:
Hot flushes, night sweats (affect 70%)
Sleep disturbance - tired, irritable, poor concentration
Reduced cognitive function
Mood changes

Question 7

Urogenital effects of menopause

Answer 7

Decreased oestrogen –> vaginal atrophy and urinary problems

Bladder: frequency, urgency, dysuria, UTI
Vagina: dryness, soreness, dyspanuria

Question 8

Cardiovascular effects of menopause

Answer 8

Risk of CHD and stroke increased (3x risk in early menopause)
Accounts for 1/3 of deaths in women

Question 9

Osteoporosis in menopause

Answer 9

Decreased oestrogen –> increased bone resorption –> decreased bone strength –> fractures (collet, hip and spine)

Affects 1/3 women >50yrs (1/12 men)

Question 10

When can solely oestrogen be given as HRT

Answer 10

When the woman has had a hysterectomy (no need for progesterone as there is no lining of the uterus)
Don’t use when uterus is present because there is an increased risk of endometrial cancer with unopposed oestrogen

Given orally, transdermal or S/C

Question 11

First line treatment for vaginal atrophy?

Answer 11

Topical oestrogen

Question 12

Preferred route for HRT?

Answer 12

Transdermal - has fewer risks than oral HRT

Question 13

If still bleeding, what is the recommended regimen for HRT?

Answer 13

Cyclical combined HRT:
Oestrogen for 28 days
Progesterone for 14 days - causes regular bleed (like a light period with no ovulation)

Question 14

If still bleeding, when can they switch to continuous combined HRT?

Answer 14

When they have been taking cyclical combined HRT for 1 year

or if their LMP was >1 year ago

Question 15

Continuous combined HRT

Answer 15

Progesterone + oestrogen
Used in ‘true’ menopause (LMP > 1 year ago)
May cause irregular bleeding for 3-6months (investigate after 6 months)

Question 16

Benefits of HRT?

Answer 16

Vasomotor: reduces hot flushes and night sweats
Urogenital: symptoms respond well to treatment but may take a few months to kick in
Osteoporosis: reduces risk of osteoporotic fractures
Colorectal Ca - risk reduced by 1/3

Question 17

Risks of HRT

Answer 17

Increased risk of breast cancer (higher risk in combined HRT) - effect is not sustained (5 years after discontinuation there is same risk as women who have not had HRT)

Increased risk of endometrial cancer

VTE risk:
x4 in first 6 months
x3 in second 6 months
normal after 12 months

Question 18

Alternatives to HRT

Answer 18

Lifestyle: diet, exercise
Reduce caffeine, alcohol, spicy food and stop smoking

Antidepressants - can help with hot flushes and night sweats

Clonidine - reduces hot flushes and night sweats (but not v. effective)

Question 19

Tibolone

Answer 19

Synthetic steroid (with weak oestrogen, progestogen and andronergic effects)
Treats vasomotor, psychological and libido symptoms
Conserves bone mass and reduces risk of fracture

Question 20

PMB

Answer 20

Atrophic vagintis
Endometrial polyps or hyperplasia
Endometrial carcinoma
Cervical carcinoma

Question 21

What does PCB indicate with PMB?

Answer 21

Cervical polyp or carcinoma

Question 22

TV USS for PMB

Answer 22

Endometrial thickness should be <3mm (<5mm if on HRT)

If thickness is >5mm then biopsy is required

Nb. unless on tamoxifen (thickens endometrium) - do hysteroscopy