Women's Health

Question 1

What is menopause and what are the associated postmenopausal risks?

Answer 1

Biological, natural stage where menstruation stops due to the loss of ovarian follicular activity

Definitions:
- Menopause: 12 months without a period (12 months amenorrhoea)
- Perimenopause/Climacteric: time before menopause – irregular periods
- Postmenopause: time after ‘1-year period-free’
○ Premature menopause: menopause before 40 years old

Postmenopausal risks include: osteoporosis, CVD, stroke, bladder and vaginal atrophy

Question 2

What else can cause hot flushes:

Answer 2

• Endocrine: eg hyperthyroidism and phaeochromocytoma
• Tumours: eg lymphoma, thyroid, renal cell
• Spicy food, excess alcohol
• Anxiety
• Medications: eg opiates, SSRIs, nitrates, CCBs

Question 2

What are the symptoms of menopause?

Answer 2

Symptoms may include:
- Vasomotor: Hot flushes, palpitations, sweating, nausea
- Urogenital: Vaginal dryness, dyspareunia, LUTS, frequency
- Psychosocial: Irritability, memory loss, depression

Question 3

When should we consider using FSH testing?

Answer 3

• Over 45 with atypical symptoms
• 40-45 with menopausal symptoms/change in cycle
• Younger than 40 if premature menopause suspected

*note patient must not be on any hormonal treatment

Question 4

What lifestyles changing can help manage menopause?

Answer 4

• Regular exercise, cooler rooms, light clothes
• Avoid triggers, such as spicy food, caffeine and alcohol

Question 5

What non HRT treatment options are available?

Answer 5

• Vasomotor symptoms – consider SSRI/SNRI (off-label) eg fluoxetine, citalopram,
  venlafaxine for 2 week trial / Clonidine / Gabapentin (off-label) / CBT
• Vaginal dryness – lubricants/moisturiser eg Replens MD®
• Psychological symptoms eg mood disturbance, anxiety – self-help groups, CBT,
  antidepressants (if indicated)

Question 6

How should HRT treatment be managed?

Answer 6

• Aim for lowest possible dose, for shortest possible duration
• Review 3 months after starting, then at least annually
• Vasomotor symptoms:
  With uterus: oral/transdermal combined HRT* (oestrogen + progestogen)
  Without uterus: oral/transdermal oestrogen-only HRT
• Urogenital atrophy: Use low dose vaginal oestrogen first line

*can also help with mood

Question 7

What are the HRT contraindications and what contraceptive advice would given to a patient?

Answer 7

HRT contraindications include:
* breast/oestrogen sensitive cancer, VTE, angina, MI, undiagnosed vaginal bleeding,
* endometrial hyperplasia, pregnancy

Contraception advice:
* Woman are still fertile for 2 years after LMP if < 50 (1 year if > 50)
* In general can stop contraception age 55