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Women's Health > Menopause > Flashcards

Menopause Flashcards

1
Q

what is menopause?

A

Cessation of menses for >12/12

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2
Q

Age of menopause?

A

Western women between 45-55 with average of 50-51y

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3
Q

What is early menopause?

A

Menopause before 45y

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4
Q

What is surgical menopause?

A

Bilateral oophorectomy

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5
Q

What are the phases of menopause?

A
    1. Premenopausal: 5y before LMP
    1. Perimenopausal: presence of early menopausal symptoms with vaginal bleeding (usu irregular)
    1. Menopausal: LMP
    1. Postmenopausal: ~5y after the menopause
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6
Q

Outline physiological changes of menopause

A
  • Ovarian follicles decline rapidly
  • FSH and LH increase (15x; 3x) that of the follicular phase ==> ovary doesn’t secrete oestrogen but continues to secrete androgens
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7
Q

Urogenital aspects of oestrogen withdrawal?

A
  • Epithelium of vagina, vulva, urethra and base of bladder becomes thin and dry
  • can lead to dysuria, frequency, itching, dyspareunia and atrophic bleeding
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8
Q

How can the urogenital aspects of menopause be managed?

A

HRT can ameliorate urogenital dysfunction of menopause

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9
Q

What are the vasomotor symptoms of menopause?

A
  • Hot flushes
  • Night sweats
  • Palpitations
  • Lightheadedness / dizziness
  • Migraine
  • Formication (ants crawling under skin)
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10
Q

What are the psychogenic aspects of menopause?

A
  • Irritability
  • Depression / anxiety
  • Tearfulness
  • Loss of concentration
  • Unloved feelings
  • Sleep disturbance
  • Mood changes
  • Decreased self confidence
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11
Q

What are the urogenital symptoms of menopause?

A
  • Atrophic vaginitis
  • Vaginal dryness
  • Dyspareunia
  • Decline in libido
  • Bladder dysfunction (e.g. dysuria)
  • Stress incontinence / prolapse
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12
Q

Skin/tissue changes of menopause?

A
  • Dryness
  • Formication
  • New facial hair
  • Breast gland atrophy
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13
Q

Hx to elicit in menopause evaluation?

A
  • Menstrual Hx
  • Other Sx related to oestrogen deficiency (esp hot flushes, mental state)
  • Sexual Hx (contraception, microturition, relationships)
  • FHx: osteoporosis, CVD, Ca
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14
Q

PEx in menopause evaluation?

A
  • BP, height and weight
  • Breast exam
  • Abdo exam
  • Vaginal exam
  • Pap smear
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15
Q

Ix to consider in menopause work up?

A
  • Urinalysis
  • FBE
  • Lipids
  • LFTs
  • Mammography (better 3/12 pre or post HRT)
  • Diagnostic hysteroscopy and endometrial Bx IF undiagnosed vaginal bleeding
  • Bone density (if RFx)
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16
Q

What is the role of hormone Ix? What are they?

A

If diagnosis is in doubt (e.g.

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17
Q

Ddx of menopausal Sx?

A
  • depression
  • anaemia
  • thyroid dysfunction
  • Hyperparathyroidism
  • Gynae d/o (e.g. dysfunctional bleeding)
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18
Q

Mx of menopause?

A 
-Importance healthy lifestyle
>diet, exercise
>smoking, caffeine
>pelvic floor exercise
-Sexual activity + lubricant
-Discuss HRT
-Osteoporosis screen, Vit C and D
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19
Q

Points to emphasise when discussing HRT?

A
  • HRT pros: decreases symptoms, enhances QoL, reduces risk of bowel Ca, osteoporosis and fractures
  • HRT negs: increased risk of endometrial hyperplasia, breast Ca and VTE

-no firm evidence of increased risk of breast Ca

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20
Q

What are the hormones for consideration in HRT?

A
  • Oestrogen
  • Progesterone
  • Testosterone
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21
Q

Methods of oestrogen delivery?

A

-Oral
-Patches (most used worldwide)
-Implants
-Topical
(also injectable but rarely used)

22
Q

What is the role of topical oestrogen?

A

Usually restricted to women with mild symptoms seeking management of urogenital aspects who cannot tolerate oral

23
Q

What are the oral oestrogens in common use?

A
  • Premarin
  • Ogen
  • Progynova
24
Q

What is the role of progesterone in HRT?

A

Given to women with a uterus; prevents hyperplasia of uterus 2” unopposed oestrogen therapy (increases risk of Ca)

25
Q

Progesterone cyclical or continuous?

A

If cyclical, D1-12 of calendar month but gives withdrawal bleed so many prefer continuous.

26
Q

What is the golden rule of HRT?

A

Progestogens must be given with oestrogen in a woman with a uterus

27
Q

Testosterone in HRT?

A

For women whose libido does not improve with HRT: use cautiously, little data re AEx

  • always give with oestrogen
  • given as implant
28
Q

What is tibolone?

A

Selective tissue oestrogen activity regulator (combined oest, prog and androgen properties): alternative to conventional HRT.
Adverse effects of breakthrough bleeding and virilisation are concnerning

29
Q

Contraindications to HRT?

A
  • Oestrogen dependent tumour
  • Recurrent VTE
  • IHD acutely (absolute)
  • Hx of CAD (relative)
  • Stroke
  • Uncontrolled HTN
  • Undiagnosed vaginal bleeding
  • Active liver disease
  • Active SLE
  • Pregnancy
  • Otosclerosis
  • Acute intermittent porphyria
30
Q

AEx HRT?

A
  • PMS: decrease dose progestogen or change
  • Nausea/breast d/os: initial sensitivity to oestrogen. Reduce to starting dose or change to intravaginally
  • Bleeding problems: heavy (dec oestrogen) / breakthrough (increase progestogen) / irregular (Ix and endometrial sampling) / intolerance (continuous regime of progestogen)
31
Q

Duration of treatment?

A

Variable.

Useful rule: aim for Rx max 2y, r/v and plan for up to 5y use.

32
Q

What is THE menopause?

A

the final menstrual period

33
Q

What is the average age of menopause?

A

51 years

34
Q

What are the perimenpausal hormonal changes?

A
  • Gradual rise in FSH
  • Fluctuations in oestradiol and progesterone
  • Dec ovarian inhibin B from ovarian granulosa cells
  • androgen mostly unchanged
35
Q

Which days is it occasionally useful to measure hormonal levels? When?

A

D2-6 in younger women or when diagnosis uncertain

36
Q

Normal FSH in normal cycling women D2-6?

A
37
Q

How does smoking affect age of menopause?

A

Menopause 1-2y earlier in smokers cf non smokers

38
Q

What is the aetiology of menopause?

A
  • ovarian primordial follicle stores are exhausted by atresia and ovulation
  • follicles progressively more resistant to gonadotrophins; Graafian follicles that do develop may not secrete enough estradiol and progesterone to produce menstruation
39
Q

Why does endometrial hyperplasia and cancer risk increase around the menopuase?

A

Irregular anovulatory cycles lead to prolonged unnopposed E2 (estradiol)

40
Q

Percentage women experiencing hot flushes?

A

Up to 80%

41
Q

How does E2 (estradiol) deficiency affect bone?

A
  • E2 suppresses bone resoprtion by suppressing osteoclast activity (i.e. deficiency increases resorption)
  • Directly impairs gut calcium absorption
  • Directly increases renal calcium excretion
42
Q

What is premature menopause?

A

Menopause occurring before 40y of age

43
Q

What is the aetiology of premature menopause?

A
  • Idiopathic (karyotypically normal, spontaneous POF)
  • Iatrogenic (surg, chemo, RT)
  • Rare (galactosemia)
  • Genetic (Turner’s syndrome, Fragile X syndrome)
  • Auto immune
44
Q

How is premature menopause diagnosed?

A
  • > 4 months amenorrhoea before 40y
  • FSH >40IU/mL on 2 occasions at least one month apart; E2
  • Karytoype and Fragile X if POF under 40y
  • Exclude out flow obstruction
  • Exclusion of all secondary causes of amenorrhoea
45
Q

Investigations following diagnosis of premature menopause?

A
  • Thyroid and adrenal auto antibodies
  • Fasting glucose
  • Bone density 2yrly
  • Serum B12, gastric parietal cell antibodies
46
Q

What are the implications of premature menopause?

A
  • Menopausal symptoms
  • Increased risk CVD
  • Increased risk osteoporosis
  • Loss of fertility
  • Altered body image
  • Increased depression
47
Q

Risk of HRT oestrogen alone?

A
  • Increased risk stroke, VTE, PE

- Cholecystitis

48
Q

Risks of HRT combined oestrogen and progesterone?

A
  • Inc risk stroke, VTE, PE
  • Increased breast density and abnormal MMG
  • Increased risk breast Ca with >5y use
  • Increased incidence stroke and CAD
  • Unscheduled bleeding
  • Cholecystitis
49
Q

Method of delivery if CVD risk in woman having HRT?

A

Transdermal therapy may be preferable:

  • no effect on renin substrates
  • no effect on antithrombin III
  • no effect / reduction in TG
50
Q

When does HRT reduce fracture risk?

A

If started

51
Q

Non hormonal therapies for menopause?

A
  • Gabapentin
  • SSRI/SNRI
  • Clonidine

Women's Health (39 decks)

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