Menopause Flashcards
(89 cards)
1
Q
What is the menopause?
A
Permanent cessation of menstruation due to loss of ovarian follicular activity
2
Q
When is a woman said to be in menopause?
A
12 months after FMP
3
Q
What is the median age of menopause?
A
51
4
Q
What is perimenopause?
A
From beginning of menopausal symptoms to 12 months after the final menstrual period
5
Q
What is post-menopause?
A
From FMP (cannot be determined for 12 months)
6
Q
What are the 3 types of unnatural menopause?
A
- premature menopause (1%)
- post oophrectomy
- post chemo or radio-therapy
7
Q
What is premature menopause?
A
Menopause before 40yrs
8
Q
What causes premature menopause?
A
Often no cause for premautre ovarian failure
9
Q
What are some other causes of un-natural menopause? (4)
A
Infections
Autoimmune disorders
- schmidt’s – addison’s, hashimotos, hypoparathyroidism, gonadal failure
Ovarian dysgenesis
Resistant ovary syndrome
10
Q
How is premature ovarian insufficiency managed?
A
HRT or COCP until the age of the natural menopause
HRT may have beneficial effect on BP compared with COCP
11
Q
What is the physiology of natural perimenopasue?
A
Perimenopause: irregular menses (unpredictable ovarian function means that cycles can vary in length and be heavy)
12
Q
What is the physiology of natural post menopause?
A
Post menopause: oestrogen falls as granulosa cells no longer produce oestradiol
-> loss of negative feedback -> raised FSH and LH
13
Q
What is the physiology of natural menopause?
A
Supply of responsive oocytes is exhausted
(born with millions – about 400 ovulations
20-30 primordial follicles/cycle ? Add up)
Therefore more lost through aging than through ovulations. That is why menopause is not necessarily related to parity of age of menarche.
14
Q
How common are menopausal symptoms/effects?
A
- affect 2/3 women
- 10-20% describe them as distressing
15
Q
What are the short term symptoms/effects of menopause? (3)
A
- irregular or absent menstruation
- vasomotor
- psychological
16
Q
What are the medium term symptoms/effects of menopause?
A
- urogenital disease
17
Q
What are the long term symptoms/effects of menopause? (2)
A
- cardiovascular
- osteoporosis
18
Q
What is menopause a protective factor for?
A
Breast disease
19
Q
What are the short term vasomotor effects of menopause?
A
Hot flush: subjective uncomfortable feeling of
warmth in the upper part of the body
night sweats
? Hypothalamic in origin
(also musculoskeletal – joint and muscle pain)
20
Q
How common are the short term vasomotor hot flushes of menopause?
A
75% experience (25% severe)
21
Q
What is the average duration of the vasomotor hot flushes of menopause?
A
average duration 4-7 yrs, but up to
12 years in 10%.
22
Q
What are the short term psychological effects of menopause?
A
irritability, low mood, confusion, lethargy
insomnia, memory loss, loss of libido
? Due to oestrogen deficiency ? Other processes
23
Q
What are the urogenital medium term effects of menopause?
A
Vagina, urethra and trigone are affected by lack of oestrogen and atrophy
24
Q
How long do the urogenital effects of menopause last?
A
Symptoms years after menopause. Do not diminish with time
25
What are some of the symptoms of the urogenital effects of menopause?
* Superficial dyspareunia
* itching
* burning
* dryness
* FUNI
* recurrent infections
26
What does the risk of osteoporosis as a long term effect of menopause depend on?
Risk depends on peak bone mass and rate of loss
27
How does menopause increase the risk of osteoporosis?
Increase rate of loss after menopause due to decreased osteoblastic activity
28
How common is osteoporosis after menopause?
1 in 3 women over 50 will have an osteoporotic fracture
29
What is osteoporosis?
Bone strength: BMD + bone quality (architecture, turn over, damage accumulation). Osteoporosis is a problem with bone strength that leads to increase risk of fractures
30
What scan can be done to diagnose osteoporosis?
DEXA scan
31
What score from the DEXA scan means it is osteopenia?
T-score = -1 to -2.5
32
What score from the DEXA scan means it is osteoporosis?
T-score = >/= -2.5
33
How does menopause change the longterm cardiovascular risk?
-CVD unusual in women before menopause, but gap closes between men and women by age 60
-? Menopause removes the protective influence of oestrogen (not universally accepted)
-Clustering of obesity, hypertension and dyslipidaemia
34
How does menopause change the long term effect of breast cancer?
-the risk of breast ca increases with age but the rate of increase slows after menopause
-a women who has menopause in her late 50s has x2 the risk of breast ca as one who has menopause in her early 40s.
35
How does a woman discover if she is menopausal?
* primarily clincial diagnosis
* biochemical tests
36
What do the NICE guidelines 2015 say is needed for a clinical diagnosis of menopause?
a) ‘Women who have not had a period for at least 12 months and are not on hormonal contraception’
b) Based on symptoms in women without a uterus
37
What biochemical test can be done to aid the diagnosis of menopause?
FSH >30 mIU/ml X 2 (weeks apart), are most likely post-menopausal
38
Who is FSH testing not recommended in?
Women >45 yrs
39
How does menopause cause high FSH/LH?
Unresponsive ovaries produce no oestrogen therefore lack of feedback on hypothalamus-pituitary axis causes high FSH/LH
PICTURE
40
What are other useful bloods for the diagnosis of menopause?
* Anti-mullerian hormone
To out-rule other possible causes of sx and give info on current general health esp if considering starting HRT:
* FBC, TFTs (if not responding to HRT or symptoms), Glucose, Lipids
* Consider Urinary catecholamines and 5HIA
(if not responding to HRT)
* Consider LH, oestradiol, progesterone
41
What is AMH?
Produced by ovarian follicles and gives a direct measure of ovarian response
AMH is produced by the granulosa cells and inhibit the recruitment of follicles and decrease responsiveness to FSH.
42
What do low levels of AMH mean?
Ovarian failure
43
How do levels of AMH change throughout a cycle?
Levels stable throughout cycle
44
When are these blood tests to help diagnose menopause not recommended?
NICE not recommended in women >45 yrs
45
What are the DDx for the vasomotor symptoms fo menopause?
Pregnancy
Hyperthyroidism
Alcohol
Narcotic withdrawal
Phaeochromocytoma
Carcinoid
Other malignancy
Meds
46
What are the DDx for the abnormal bleeding in menopause?
Malignancy
Fibroids
MUST be investigated
47
What are the 2 options for treatment of menopause?
* non HRT
* HRT
48
What did the women’s health initiative find with regard to HRT?
Studied 16,608 women in 40 US centres
Aged 50-67, taking 0.625mg conjugated oestrogen + 2.5mg medroxyprogesterone
Trial stopped after 5.6 years (July 2002)
Findings: increased risk of breast cancer, CHD, CVA and PE
49
What did the WHI - 2017 follow up find?
Use of HRT v placebo in postmenopausal women for 5-7 years was not associated with risk of all-cause, cardiovascular or cancer mortality during 18 years of follow-up.
50
What did the million women study find about HRT?
Started in UK in 1997
Women aged 50-64
Findings:
2x increased risk of breast cancer with oest/prog
1.3x increased risk of breast cancer with oest
Risk of fracture decreased by 40%
Slight inc risk of ovarian cancer
51
What are general non HRT options to manage menopause?
avoid caffeine, alcohol
Increase aerobic exercise
52
What are non HRT options to manage the vasomotor symptoms of menopause? (4)
-Progestogens
-Clonidine (limited)
-SSRIs or SNRIs
-Gabapentin
53
What are the non HRT options to manage the urogenital symptoms of menopause?
lubricants and moisturisers for vaginal atrophy
54
What are the non HRT options to manage osteoporosis in menopause?
-mainly inhibiting bone resorption (except strontium/PTH)
-bisphosphonates, strontium, raloxifene (serm), PTH, Denosumab monoclonal ab – 6/12 injection
-calcium and Vit D3 -? Dangers
55
What are the issues with alternative treatments for menopause?
Widely used
Little evidence that they reduce symptoms
Can be concerns regarding production, drug interactions, and oestrogenic side effects
56
What are some of the alternative treatments used for menopause?
Phyoestrogens: plant substances similar to oestrogen
isoflavones: soya beans, chickpeas
lignans: oilseeds
Herbal remedies: black cohosh, evening primrose oil, gingko, ginseng, st johns wort
Progesterone transdermal creams
57
What are the NICE guidelines on non HRT vasomotor treatments for menopause?
Looked at 32 trials on vasomotor symptoms and performed a meta-analysis
-SSRIs/SNRIs not effective and high discontinuation rates (though have been shown to be effective in other trials)
-Clonidine not commented on as studies reported different outcomes
-Alternatives: St. johns’ wort, isoflavones, black cohosh more effective than placebo but some safety concerns.
58
What do the NICE guidelines suggest about psychological treatments for menopause?
Consider CBT to improve mood/anxiety symptoms arising out of menopause
No clear evidence for use of SSRIs or SNRIs in those with menopause associated mood problems, not diagnosed with depression.
59
What are the two hormones involved in HRT regimens?
Oestrogen:
-> this is what treats the symptoms/effects
(taken from plants or the urine of
pregnant horses)
Progestogens:
-> if uterus: avoid endometrial hyperplasia
or endometrial ca.
60
What are the two options for administration of progesterone as part of HRT?
* cyclical
* continuous
61
What are the options of admin of cyclical progesterone as part of HRT?
->10-14 days every month (second half of pack) – monthly bleed (if you are having regular periods)
-> 14 days every 13 weeks – 3 monthly bleed
(if you are having irregular periods)
62
Why is continuous admin of progesterone as part of HRT preferred?
No bleed. Preferred post-menopausally
(may reduce endometrial ca –v-sequential tx)
63
What needs to be done with regard to hysterectomy and progesterone admin?
Must be given post TCRE or TCRA
Post subtotal hysterectomy maybe left with some endometrium in cervical stump - caution
64
What hormones need to be given when as part of HRT for menopause?
PICTURE of table
65
What does NICE suggest is the most effective form of HRT for vasomotor symptoms?
combined HRT patches
66
What are the options for HRT admin of oestrogen?
Oral
Transdermal Patch
Transdermal Gel
Intra-vaginal Gel
Intra-vaginal Pessary
Intra-vaginal Ring
Intra-nasal Spray
Intra-abdominal implant
67
What are the options for HRT admin of progesterone?
Oral
Transdermal Patch
Mirena
68
How long should HRT be continued for to treat menopause symptoms?
Up to 5 yrs
can experience temporary recurrence of symptoms (3-6 months) so gradual withdrawal may be appropriate
69
How long should HRT be continued for osteoporosis?
lifelong – may need to change to other treatment
70
How long should HRT be continued for for premature menopause?
Up to age of expected menopause - 51
71
What are the benefits of HRT?
Improvement in vasomotor, musculoskeletal, low mood, sexual symptoms and urogenital atrophy
Osteoporosis: reduced risk of #s
Colorectal Ca: decreased by 1/3
(? When come off does risk stay low)
72
How long does it take for HRT to improve vasomotor symptoms of HRT?
4 weeks
73
What are the risks of HRT?
Breast Ca: Increased risk of breast cancer especially with combined preparations. Risk decreases on stopping therapy ( new lancet study 2019 –some increased risk can persist beyond 10 years)
VTE: increased risk of VTE (oral x two fold): highest in first year of use: Patches and gel may reduce this risk (consider transdermal rather than oral in women with increased risk of VTE e.g. BMI> 30)
Stroke (higher with oral)
Cholecystitis/Cholelithiasis/Cholecystectomy: increased with oral
Endometrial Ca: with unopposed oestrogens
74
What is the reason for the higher risk with oral HRT?
Higher steroid bolus in the liver with metabolic effects including on lipids and glucose tolerance
75
What are some of the doubts surrounding HRT use?
Cardiovascular disease
HRT does not increase the risk of cardiovascular
disease in women <60 years
Risk of coronary artery disease:
-Oestrogen alone: no increased or decreased risk
-Oes+Progest: little or no increased risk
Dementia and cognition
Unknown if HRT alters risk
Ovarian Ca
- small Increased risk: Lancet found increased risk of
1: 1000 in women using HRT > 5yrs.
76
What are the CI to HRT use?
1. Active VTE or past hx of hormone-related VTE
2. Active or past hx breast cancer
3. Pre-existing CVD
4. Unexplained vaginal bleeding
5. Endometrial cancer
6. Active liver disease
77
What is the indication of HRT?
Indication: perimenopausal and early post menopausal women with menopausal symptoms
(especially vasomotor)
78
What is the type of HRT used to manage vaginal symptoms only?
Topical oestrogen
79
What are the risks/benefits of HRT?
< 50, 50-60: benefits outweigh risks
60-70: benefits equal risks
>70: risks outweigh benefits
80
What is post menopausal bleeding (PMB)?
Vaginal bleeding 12 months after last menstrual period
81
What is PMB a 🚩 for?
Endometrial Cancer present in 10% of women with PMB.
82
What are the endometrial etiologies of PMB? (4)
-> carcinoma
-> hyperplasia (+/- atypia)
-> polyps
-> endometritis
83
What are the cervical etiologies of PMB? (3)
-> carcinoma
-> polyps
-> cervicitis
84
What is the ovarian etiology of PMB?
Carcinoma
85
what are the other etiologies of PMB? (2)
Atrophic vaginitis (exclusion only)
Withdrawal bleed from sequential HRT (or in the initial 6 months of use of rTibolone or continuous HRT)
86
What examinations and investigations would you do if there was a history of PMB?
Bimanual, speculum.
TVUS: E. thickness, fluid in endometrial cavity, other pelvic pathology
Smear test
87
What is suggested about investigations for PMB?
If 1 bleed and E. thickness < 4mm no biopsy
RCPI guidelines suggest hysteroscopy endometrial sampling in women with thickened endometrium on ultrasound or if recurrent bleed as above
Irish guidelines suggest ET < 3mm in women not on HRT or on continuous HRT: < 5mm on sequential HRT
88
Which one of the following is correct in relation to premature ovarian failure?
Affects 1 in 1000 women
Fertility has been restored in some women with the diagnosis
Ovarian function is necessary for implantation, development of the pregnancy and live birth
It is not a concern following childhood chemotherapy
Hormonally P.O.F. is defined by abnormally low levels of oestrogen and FSH
Fertility has been restored in some women with the diagnosis
89
Which one of the following conditions does HRT reduce the risk of developing
Breast cancer
Ovarian cancer
Colon cancer
VTE
Stroke
