IC18 Menopause

Question 1

definition

Answer 1

permanent cessation of menses, following loss of ovarian follicular activity

Question 2

natural etiology

stages & their production of hormones

Answer 2

perimenopause
Will have reduced production of progesterone & oestrogen; have suppression of FSH production (can be tested)
Difficult to predict menses

menopause, postmenopause
No longer produces progesterone & oestrogen

Question 3

clinical presentation

Answer 3

1. vasomotor symptoms
2. genitourinary syndrome
3. psychological
4. bone fragility

Question 4

clinical presentation: vasomotor symptoms

Answer 4

Hot flushes → intense feeling of heat on face + reddened face
* Possibly due to thermoregulatory dysfunction initiated at hypothalamus by oestrogen withdrawal

Perspiration → cold sweats, night sweats

Rapid/irregular HR
Sleep disturbances
Feeling of anxiety

Question 5

clinical presentation: genitourinary syndrome
changes in structures

Answer 5

Changes to labia, clitoris, vestibule, vagina, urethra & bladder
Due to decreased oestrogen

Vulva & endometrium undergo atrophy → thinner layers will be easily irritated

Question 6

clinical presentation: genitourinary syndrome
symptoms

Answer 6

• Genital dryness, burning/ irritation/ pain
• Sexual symptoms of lubrication difficulty, Impaired sexual function/ libido/ painful intercourse
• Urinary urgency, Dysuria, Recurrent UTI

Question 7

clinical presentation: psychological symptoms

Answer 7

• Multifactorial
• Depression, anxiety (may be new onset/ relapse if previously diagnosed)
• Poor concentration/ memory
• Mood swings

Question 8

clinical presentation: bone fragility

purpose of estrogen + problems in menopause

Answer 8

Oestrogen receptors present on bone → stimulates bone growth

Decreased oestrogen ⇒ no stimulation; more bone loss

Question 9

clinical presentation: bone fragility
symptoms

Answer 9

• Risks of osteoporosis & fractures (esp early onset menopause)
• Joint pain

Question 10

non-pharmacological indications

Answer 10

mild symptoms ONLY ⇒ first line before pharmacological therapy

Question 11

non-pharmacological managements

Answer 11

1. vasomotor symptoms
2. genitourinary syndrome

Question 12

non-pharmacological: vasomotor symptoms

Answer 12

• Layered clothing that can be removed/ added as necessary
• Lower room temperature
• Less spicy food/ caffeine/ hot drinks
• More exercise
• Dietary supplements
  Isoflavones: soy beans, legumes (lentils, chickpea)
  Black Cohosh: possible serotonergic activity at hypothalamus

Question 13

non-pharmacological: genitourinary syndrome

Answer 13

Non Hormonal vaginal lubricants/ moisturisers
If have issues with intercours

Question 14

pharmacological managements

Answer 14

1. menopausal hormone therapy (MHT) -> first line, gold standard
2. antidepressants
3. gabapentin
4. tibolone

Question 15

pharmacological indication

Answer 15

moderate/ severe symptoms OR insufficient response to non-pharmacological

Question 16

pharmacological: MHT types

Answer 16

1. estrogen-only
2. estrogen + progesterone

Question 17

pharmacological: MHT
oestrogen-only

indication

Answer 17

NO intact uterus OR if patient is on levonorgestrel IUD

Question 18

pharmacological: MHT
oestrogen-only

types

Answer 18

1. systemic oral contraceptives
2. systemic topical (gels & patch)
3. local vaginal (cream & pessary)

Question 19

pharmacological: MHT
oestrogen-only

administration

Answer 19

Systemic oral tablets
Take same time everyday
(once finish pack, start new one immediately)
Gel
Use the ruler provided to measure the dose.
Apply over arms/ thighs daily & let dry.
Rotate sites
Patch
Replaced twice a week on lower back, abdomen, thighs or butt → rotate sites
Cream
Squeeze cream from tube into applicator.
Lie down with knees drawn towards you.
Insert applicator into vagina & press applicator downward.
Wash the applicator with mild soap & warm water.
Pessary
Inserted 2x a week before bedtime (minimise movement)

Question 20

pharmacological: MHT
oestrogen-only

advantages

Answer 20

Systemic oral tablets
Inexpensive
systemic topical
Lower systemic dose than oral
Convenient (external application)
Continuous oestrogen release
local vaginal
Lowest oestrogen dose → no need for concomitant progestin
Continuous oestrogen release

Question 21

pharmacological: MHT
oestrogen-only

disadvantages

Answer 21

systemic oral tablets
Highest dose required → higher risks of SE
Potential for missed dose → irregular bleeding
systemic topical
Expensive
Skin irritation; Good to rotate sites
Gel → more variability in absorption
local vaginal
inconvenient/ uncomfortable
Vaginal discharge
Only for localised urogenital atrophy

Question 22

pharmacological: MHT
combined

indication

Answer 22

INTACT uterus OR if patient does not have levonorgestrel IUD

Question 23

pharmacological: MHT
combined

role of estrogen & progesterone

Answer 23

Oestrogen → causes growth in lining of endometrium

Progestin → To protect endometrium from overgrowth (increased risk of endometrial cancer associated with unopposed oestrogen
* If oestrogen not kept in check, endometrium will keep growing

Question 24

pharmacological: MHT
combined

types

Answer 24

1. combined cyclic
2. combined continuous

Question 25

pharmacological: MHT combined (cyclic)

Answer 25

* Progestin added on either 1st or 15th of month, for 10-14 days * Withdrawal bleeding when progestin stopped → menses occurs * Regulate menses → predictable bleeding

Question 26

pharmacological: MHT combined (continouous)

Answer 26

* Oestrogen & Progestin daily * No withdrawal bleeding although chance of breakthrough bleeding initially spotting might occur until body is adjusted * After several months, amenorrhea likely to occur

Question 27

pharmacological: MHT combined | when will improve, tests upon initiation, problem of discontinuation

Answer 27

* Might require 2-3 months of use before improvements of menopausal symptoms Should continue MHT if there is need **Tests Upon initiation** * Annual mammography * Endometrial surveillance ***Unopposed oestrogen***: any vaginal bleeding ***Continuous-cyclic***: if bleeding occurs when progestin is still on ***Continuous-combined***: if bleeding is prolonged, heavier than normal, frequent, persists after >10 months after treatment started **Discontinuation of treatment** ⇒ ~50% chance of symptoms returning

Question 28

pharmacological: antidepressants | drugs & importance of evaluation

Answer 28

* Serotonin & norepinephrine reuptake inhibitors (SNRIs) → venlafaxine * Selective serotonin reuptake inhibitors (SSRIs) → paroxetine * Important to evaluate & differentiate mood changes from menopause & depression

Question 29

pharmacological: gabapentin purpose

Answer 29

Night sweating, sleep disturbances

Question 30

pharmacological: tibolone | drug composition

Answer 30

Synthetic steroid with estrogenic, progestogenic & **androgenic** effects * May have hirsutism & acne

Question 31

pharmacological: tibolone | indication

Answer 31

postmenopausal women ≥ 12 months since last natural period * Cannot be <12 months → will cause bleeding

Question 32

pharmacological: tibolone | advantage

Answer 32

* Improves mood, libido, menopause symptoms, vaginal atrophy (less than oestrogen) **Affects ALL symptoms of menopause** * Protects against bone loss

Question 33

pharmacological: tibolone | disadvantage

Answer 33

Risk of stroke, breast CA recurrence, endometrial cancer * Due to estrogenic component