Menopause Flashcards
(28 cards)
Definition of Menopause
Ovarian failure
What is the average age of menopause in the UK?
51
What age is premature menopause?
premature ovarian insufficiency aged <40
What are the causes of premature menopause
- Idiopathic most commonly, but has strong family link
- Congenital
- Surgical / radiotherapy
- Prolonged anorexia
- Smoking
In general what are the early, intermediate and late symptoms of Menopause?
Early- Vasomotor, psychological
Intermediate- Skin (loss of elasticity, collagen), GU tract
30% of a woman’s collagen disappears within a year of the menopause
Late- Osteoporosis
When can Menopause be diagnosed without lab tests?
- Perimenopause can be diagnosed clinically based on vasomotor symptoms and irregular periods
- Menopause can be diagnosed clinically in women who have not had a period for at least 12 months, and are not using hormonal contraception
- Menopause can be diagnosed clinically based on symptoms in women without a uterus
When would you consider lab tests when considering the Menopause?
If there is any diagnostic uncertainty
- Women aged 40-45 with menopausal symptoms (including change in menstrual cycle)
- Women under the age of 40 where menopause is suspected
Using FSH only
What is the first line treatment for women suffering vasomotor symptoms of the Menopause?
HRT
- Offer HRT and discuss the short term and longer term benefits and risks
- Oestrogen and progesterone to women with a uterus
- Oestrogen only in women without a uterus
- SSRI / SNRI / clonidine is not first line. Consider these if HRT contraindicated or as a second line treatment.
What’s the best management approach to low mood that arises as a result of the menopause?
- Consider HRT or CBT to alleviate low mood that arises as a result of the Menopause
- SSRI / SNRI hav eno evidence to ease low mood in menopausal women who have not been diagnosed with depression
What is the management approach to altered sexual function for menopausal women?
- Trial HRT (androgenic progesterones can be helpful)
- Consider testosterone supplementation for women with low sexual desire if HRT alone ineffective
- Consider topical vaginal oestrogen for vaginal atrophy if HRT is contraindicated
What are the main risks of HRT?
- Breast Ca (sl increased especially with progrstogen and tibolone)
- Endometrial Ca
- Ovarian Ca
(These are duration and dose dependent, and reduce after stopping) - CVD
- VTE
How is premature ovarian failure investigated / diagnosed?
- Menopausal symptoms (incl no or infrequent periods) in women <45
- High FSH on 2 blood samples 4-6 weeks apart
How is premature ovarian failure managed?
- HRT or COC
- Can be used up to the age of 51
Explain the importance of treatment. In early menopause, treating with HRT / COC does not increase the background risk of breast Ca just brings it back to where it would be if did not experience early menopause
Contraindications to HRT
Excluding contraindications
- Personal Hx Breast Ca, or any oestrogen dependent cancers
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- Previous idiopathic, or current, VTE. Unless anticoagulated
- Active or recent arterial thromboembolic disease (angina / MI)
- Active Liver disease with abnormal LFTs
- Pregnancy
- Thrombophilic disorder
When can HRT be prescribed with caution?
- Porphyria cutanea tarda
- Diabetes mellitus (Risk of heart disease)
- Predisposing factors to VTE
- History of endometrial hyperplasia
- Migraine and migraine-like headaches
- Increased risk of breast Ca (2+ first degree relatives, male breast Ca, personal Hx Ovarian Ca, Jewish ancestry, sarcoma in relative <45, glioma or childhood adrenal cortical carcinomas, multiple Ca at young age)
What should you assess in the history when considering starting HRT?
- Any contraindications
- Determine the FRAX score
- Any need for contraception
What examination / investigations should you assess when considering HRT?
- BP, urine, weight
- Smear Hx
- Mammography
hormone profile bloods / investigations not routine
How should women started on HRT be followed up?
Review 3 monthly first, then 6 - 12 monthly
- BP and weight
- Review SEs, encourage to continue / switch as required
- Routine smears and mammography
- Encourage regular breast self examination
Which are the more neutral progestogens (less androgenic)?
- Dydrogesterone
- MPA
- Drosperinone
Which are the more androgenic progestogens? (testosterone analogues)
- Northisterone
- Norgesterol
- Levonogestrel
What OTC preparations have some evidence for relieving vasomotor symptoms?
- Isoflavones- Phytoestrogens found in soya beans
- Black cohosh- Root of the plant is used, most evidence for a particular extract Remifemin
Multiple preparations available which may vary, no consistency of variations used in studies, safety unclear, interactions with other medications reported
Management approach to urogenital atrophy
- Offer vaginal oestrogen, including to women on systemic HRT
- Consider vaginal oestrogen in women where systemic HRT contraindicated after d/w specialist
- If vaginal oestrogen is ineffective, consider increasing dose after d/w specialist
- moisturisers and lubricants can be used alone or in addition to vaginal oestrogen
- No need for routine monitoring of endometrial thickness during treatment for urogenital atrophy
What are the risks of VTE with HRT?
- Risk of VTE is increased with oral VTE compared with baseline population
- No increased risk associated with transdermal VTE
- Consider transdermal HRT for women at increased risk of VTE ie. BMI>30
- Consider referring to haematologist for assessment before considering HRT in women with strong family Hx of VTE or hereditary thrombophilia
What are the risks of CVD with HRT?
- HRT does not increase risk of CVD when started under age 60
- Presence of cardiovascular risk factors not a contraindication- they must be optimally managed
- Oestrogen alone associated with no, or reduced, risk of CHD
- Oestrogen and progestogen associated with little or no increase in risk of CHD
- Oral oestrogen (not transdermal) associated with small increased risk of stroke
