7.6 - Menopause Flashcards
(39 cards)
Define the Climacteric phase explaining its physiology.
When does this typically occur?
Explain the consequences of these changes
It is the Perimenopausal phase in the reproductive life where there is a gradual decline in ovarian function resulting in decreased sex steroid production and its sequelae
Typically occurs 3-5 years before complete loss of menses (menopause)
Due to the reduced sex steroid production, there is reduced negative feedback leading to unopposed oestrogen production leading to Anovulatory cycles.
What are the consequences of anovulatory cycles?
Infertility/sub fertility, Irregular menstrual cycle, heavy menses, and endometrial hyperplasia.
Define Menopause
Define Early menopause
Define Premature menopause
12 months of amenorrhoea at the appropriate age (50-55, median 52)
Early: <45 yo
Premature: <40 yo
What are the causes of early/premature menopause?
Radiation therapy, surgery (TAH/BSO)
Chromosomal abnormalities e.g. Turner’s
Crohn’s/celiac disease
Ovulation induction
Gnrh
What estrogen is dominant in the post-menopausal period?
Estrone (E1)
What are hot flushes?
What are the associated symptoms?
Sudden intense hot sensation over face and chest that last a few seconds to minutes with multiple episodes per day.
It is associated with palpitations, sweatingm nausea, dizziness, anxiety, headaches
A 55 year old woman presents to the OPD complaining of night sweats and disturbed sleep. She does not have any psychiatric conditions/mood disorders, and has no fever or weight loss. Why is this ocurring?
Hot flushes may occur at night causing night sweats and hence disturbed sleep, depression, fatigue.
What are the 5 main groups of complications of Menopause?
1) Vasomotor instability
2) Urogenital symptoms
3) Osteoporosis
4) Heart disease
5) Psychiatric
What are the vasomotor instability symptoms of menopause
Hot flushes (palpitations, sweating, nausea, lightheadedness, anxiety), may occur at night (fatigue, depression, lethargy)
What are the urogenital symptoms of menopause?
Vulval and vaginal dryness (estrogen in charge of secretions) => Dyspareunia and increased risk of bacterial vaginosis
Urethral + Bladder tissue atrophy => readuced elasticity => Increased frequency, dysuria (pain on urination), Nocturia = Incontinence
What is the significance of the dryness brought about by menopause?
How would you directly treat vulval/vaginal dryness?
Dyspareunia
Bacterial vaginosis (reduced sectretions include reduced glycostores of the vagina => reduced native lactobacilli => increase pH (no longer acidic) => Bacterial vaginosis
Define Osteoporosis
Why is it more common in menopause?
Low bone mass on DXA scan <2.5
mass or fragility fracture.
Reduced estrogen in menopause leads to increased osteoclast activity => net loss of bone mass => fragility fractures
What does the DEXA score represent?
It can be represented as T score for adults (and Z score for adolescents and children).
It compares the mean peak bone mass of normal adults aged 20-40 with that of the patient
What is the most common site of a fragility fracture?
T10-L2
More specifically T12-L1 (esp because of the transition between thoracic and lumbar)
Give RFs, for Osteoporosis
Menopause, reduced BMI, smoking, sedentary lifestyle, !!Corticosteroid use.
How would the physiotherapist help a patient with osteoporosis?
Weight bearing exercises
How would you manage a patient with a fragility fracture
DEXA scan
Conservative: reduce RF => Stop smoking, dietitian referral (Vit D, calcium, nutrition) physiotherapy referral (Weight bearing exercises)
Medical:
First line: Bisphosphonates (ibandronate)
2nd Line: Tamoxifen - ERM (selective estrogen receptor modulator)
!!+ Vit.D and Calcium supplementation
A 54 year old patient presents with a fragility fracture in T12 on MRI. You decide to perform a DEXA scan which reveals her score to be <2.5. You ask the patient if shes been on bisphosphonates before and she tells you her previous doctor told her she cant take it. What does the patient likely have (2)?
What drug is she likely on now?
Give 1 contraindication and 1 disease that this drug increases the risk for.
Bisphosphonates are contraindicated in oesophageal disease or CKD (renaly excreted)
She is likely on the second-like drug Tamoxifen. It is contraindicated in pregnancy and severely increases the risk of endometrial cancer
Menopause leads hypo-oestrogenism. What are the signs and symptoms associated with menopasue/hypoestrogenism?
1) Vasomotor instability: Hot flushes, (=> night sweats, palpitations, sweating, nausea)
2) Urogenital symptoms:
Vulval and vaginal dryness (estrogen in charge of secretions) => Dyspareunia and increased risk of bacterial vaginosis,
Urethral + Bladder tissue atrophy => readuced elasticity => Increased frequency, dysuria (pain on urination), Nocturia = Incontinence.
3) Osteoporosis
DXA <-2.5 or Fragility fracture
4) Heart Disease: RF for CVD
5) Psychological: Mood Lability
How long should hormonal therapy be prescribed to a women in menopause?
As long as the patient wishes but she should be counselled about the risks especially that of heart disease and VTE.
What questions should you be asking the patient when determining the ideal treatment therapy for HRT?
Does the patient have a uterus (previous hysterectomy) or not?
Is the patient pre or post-menopausal?
Is the patient’s family complete or not?
When would you give sequential HR therapy? What is it?
You would give it to pre-menopausal woman (with a uterus). It involves giving continuous oestrogen (patch/spray/gel/oral) while giving cyclical progestogen (allowing for monthly withdrawal bleed)
When would you give continuous HR therapy? What is it?
You would give it to post-menopausal women (they dont need monthly bleeds), with a uterus => Both oestrogen and progestofen are given continuously. This can be given as a combined oral/patch or Mirena + oestrogen gel/patch
Explain your management approach to a 52 patient presenting with amenorrhoea for the past 14 months.
If the patient does not wish for hormonal therapy, Natural Phytoestrogens (diet) will help.
In terms of hormonal replacement therapy, this depends on whether the patient has a uterus or not. If there is no uterus, Oestrogen-only therapy would be used.
If the patient does have a uterus then the next thing to look at is whether they are pre- or post-menopausal. If the patient is pre-menopausal, then we would have a Sequential approach whereby the patient will have continuous oestrogen + Cyclical progesterone to ensure monthly withdrawal bleed. If the patient is Post-menopausal, then a Continuous approach is used whereby both oestrogen and progesterone are continuous.
