GP: Women's health

Question 1

Definition of menopause, perimenopause, primary ovarian insufficiency

Answer 1

Menopause: permanent cessation of ovarian function (average at 51y age)- absence of menstruation for 12 mo
Perimenopause: beginning of cycle irregularity thorugh until menopause
POI: menopause <40

Question 2

Sx of menopause

Answer 2

‘When menopause hits, I’ll have sex not babies’

Weight
Mood changes
Hot flushes 
Insomnia
Headache
Sexual dysfunction + vaginal sx
Night sweats 
Breast tenderness + bones

Question 3

First line HRT

Answer 3

• Combined E+P patch
• E patch/gel + oral P/LNG-IUD
• Oral E + oral P/LNG-IUD
• Tibilone (synthetic steroid, can be used for sexual dysfunction particularly)
• E + SERM
• Review at 6-8wks
  SERM/Progesterone not needed if woman is post hysterectomy

Question 4

Risks of HRT

Answer 4

• Increased risk of VTE, CVD, stroke
• Gallbladder disease
• Breast cancer

Question 5

Contraindications to HRT

Answer 5

• High VTE/thrombophilia risk
• Undiagnosed genital bleeding
• Severe active liver disease
• Untreated HTN
• Oestrogen dependent cancer
• Age >60 years or 10y post menopause (not absolute contraindication)

Question 6

Non hormonal treatment of vasomotor symptoms

Answer 6

• SSRIs
• Clonidine
• Gabapentin, pregabalin
• CBT, hypnosis
• Weight loss

Question 7

Diagnosing osteoporosis

Answer 7

Minimal trauma fracture or T score

Question 8

Secondary causes of osteoporosis

Answer 8

Cushing's syndrome
Malabsorption e.g., coeliac disease
Inflammatory arthritis e.g., rheumatoid arthritis
Amenorrhoea > 6 months aged < 45 years
Eating disorders
Male hypogonadism
Chronic liver disease
Chronic renal disease
Hyperthyroidism
Primary hyperparathyroidism
Multiple myeloma
HIV
Medications:
Glucocorticoids > 5 mg prednisolone / day for > 3 months
Phenytoin
Depo-medroxyprogesterone - although associated with a reduction in bone density, this effect normally reverses a year after stopping the drug. In younger women, without other major risk factors for osteoporosis, monitoring of bone density is not recommended.
Pioglitazone, rosiglitazone
Proton pump inhibitors
Gonadotropin‑releasing hormone antagonists
Anti-coagulants
Aromatase inhibitors

Question 9

Signs of crush fracture: clinical and imaging

Answer 9

o Back pain
o ↓in height
o Dowager’s hump- kyphosis due to thoracic vertebrae crush fractures
- Wall- occiput test for thoracic fracture
o X-ray: wedge shape
- Anterior height must be 20% less than posterior height

Question 10

Non-pharmacological treatment of osteoporosis

Answer 10

• Adequate calcium and vitamin D
• Smoking and alcohol intake modification
• Combination of weight-bearing, balance and strength exercise

Question 11

Pharmacological management of osteoporosis

Answer 11

• Bisphosphonates- bind to hydroxyapatite binding sites to block osteoclasts
• Denosumab (antibody against RANKL)- inhibits osteoclast formation and differentiation
• Raloxifene: SERM (only prevents vertebral fractures)
• Teriparatide: synthetic PTH
• HRT: if significant menopausal symptoms + osteoporosis

Question 12

Bisphosphonates: risk factors and examples

Answer 12

• dental check before use- rare risk of osteonecrosis of the jaw (also seen in denosumab)
• Atypical femoral fractures
• Avoid in renal impairment

Examples: risedronate (daily tablet)
Zoledronic acid infusion (once yearly)