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GYNAECOLOGY > MENOPAUSE > Flashcards

MENOPAUSE Flashcards

1
Q

Why is menopause important?

A

More than 1/3rd of life is spent in post-menopause
We have an ageing population
Symptoms are experienced by about 75% of people and are problematic for 25%
Average duration of symptoms is 5-7 years
At least 1 million women in the UK are on treatment

It’s associated with osteoporosis, CVD, strokes, urogenital atrophy and urinary incontinence

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2
Q

What is peri-menopause?
Average age?

A

The transition period. From the onset of symptoms until 1 year after the menopause. It can last several years
Average age 45-55

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3
Q

What is “menopause”?

A

A retrospective diagnosis of a single point in time where the final menstrual period ended.

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4
Q

Average age of menopause?

A

51
80% by 54

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5
Q

What is premature menopause?

A

When the final menstrual period is before the age of 40

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6
Q

What is early menopause?

A

When final menstrual period is between 40-45

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7
Q

What factors increase the risk of premature or early menopause?

A

Early menarche
Nulliparity or low parity
Smoking
Being underweight

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8
Q

what causes the symptoms in menopause?

A

The fluctuations in hormones in the perimenopausal stage and then the sudden drop in hormones, particuarly oestrogen, at menopause

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9
Q

Why is there low oestrogen at menopause?

A

Exhaustion of the follicles in the ovaries means less and less oestrogen is being produced which means more FSH is released as there is no negative feedback. Follicles become desensitised to the FSH and no ovulation occurs = menopause

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10
Q

Advice about how long to continue contraception once reaching menopause?

A

If <50 then 2 years after LMP
If >50 then 1 year after LMP

All women can stop at age 55

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11
Q

Which contraception should menopausal women use?

A

Progestogen-only methods
Combined hormonal contraception can be used in women under 50 as an alternative to HRT for relief of menopausal symptoms and prevention of loss of bone mineral density. They should be advised to switch to a progestogen-only method at age 50 though

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12
Q

What test can be used to diagnose menopause?

A

Testing FSH levels - will be raised
Need 2 blood samples to show this and they must be taken 4-6 weeks apart

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13
Q

In which women should you test FSH levels for menopause?

A

Women <40 with suspected premature ovarian insufficiency
Women 40-45 with menopausal symptoms and a menstrual cycle change
Women >45 with atypical symptoms
Women >50 using progestogen-only contraception

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14
Q

Lifestyle advice for menopause?

A

Lose weight
Impvode diet
Stop smoking
Stop alcohol
Reduce coffee
Reduce stress

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15
Q

Link between smoking and menopause?

A

Smokers undergo menopause 2 years earlier than non-smokers
It increases menopausal symptoms
Increases CVD risk
Increases osteoporosis risk

It’s toxic to the ovarian follicles

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16
Q

Link between caffeine and menopause?

A

Caffeine exacerbates vasomotor symptoms

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17
Q

Impact of obesity on menopause?

A

Increases vasomotor and menopausal symptoms
Increases the risk of CVD
Increases the risk of VTE
Increases the risk of cancer

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18
Q

How long do symptoms of menopause typically last?

A

Average 5-7 years
Some 10-15!

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19
Q

Symptoms of menopause?

A

Menstrual cycle changes e.g. change in length
Vasomotor - hot flushes and night sweats
MSK - joint pains and muscle pains
Moods - low mood, anxiety, memory loss, poor sleep
Urogenital - vaginal dryness, discomfort, itching, dyspareunia, vaginal atrophy
Low sexual desire
Other: headaches, weight gain

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20
Q

What % of those going through menopause do vasomotor symptoms affect?

A

80%

21
Q

treatment of vasomotor symptoms of menopause?

A

Regular exercise, weight loss, reduced stress, reduce caffeine
Oral or transdermal HRT - combined unless no uterus then oestrogen only as dont require endometrial protection
If they dont want HRT - SSRIs and SNRIs can be used or clonidine or gabapentin off license

22
Q

What do many women buy OTC to help with vasomotor symptoms?

A

Isoflavines and black cohosh

23
Q

What is the physiological mechanism behind hot flushes in menopause?

A

They are triggered by small elevations in core body temperature acting within a greatly reduced thermoneutral zone
Due in part to the lower oestrogen

24
Q

How do we manage psycholgoical symptoms of menopause?

A

Sleep, regular exercise, relaxation
Oral or transdermal HRT
CBT

Only SSRIs and SNRIs if underlying anxiety or depression diagnosis

For sleep - avoid late night exercise and good sleep hygiene

25
Q

Management of altered sexual function in menopause?

A

Seek specialist advice on the appropriateness or testosterone supplementation

You can give HRT + testosterone replacement e.g. testogel
Tibolone is another option (contains oestrogen, progesterone and testosterone)

26
Q

Management of urogenital atrophy in menopause?

A

Low dose vaginal oestrogen
Vaginal moisturisers and lubricants can be offered alongside

27
Q

What % of women with menopausal symptoms have some form of HRT? What does NICE want to do about this?

A

Only 10%
NICE realised that women weren’t taking it due to the fear of breast and ovarian cancer. They want to try to change this and increase the %

28
Q

Risks of HRT?

A

VTE
CVD
Stroke
Breast cancer
Ovarian cancer
Endometrial cancer if oestrogen-only

29
Q

Risk of breast cancer when taking HRT?

A

All types of systemic HRT increase the risk 1 year after use
Risk is higher for combined HRT
Long duration of HRT further increases the risk
Excess risk persists for >10 years after stopping HRT

30
Q

Risk of endometrial cancer when taking HRT?

A

Only oestrogen-only HRT. In women with a uterus, the addition of progestogen reduces the risk - but weigh this up against risk of breast cancer!

31
Q

Risk of ovarian cancer on HRT

A

Long-term use of combined HRT or oestrogen-only HRT is associated with a small increased risk of ovarian cancer; this excess risk disappears within a few years of stopping

32
Q

Risk of VTE on HRT

A

Combined or oestrogen-only HRT both increase the risk especially in the first year of use
Women at risk should have a risk assessment and may be more suitable to give transdermal HRT which has no higher risk than baseline

33
Q

Risk of stroke on HRT?

A

Combined HRT and oestrogen-only both slightly increase the risk but note risk of stroke increases with age too

34
Q

Risk of coronary heart disease on HRT

A

Increased risk in women who start combined HRT more than 10 years after menopause

35
Q

Benefits of HRT

A

Reduced menopausal symptoms
Osteoporosis
May maintain some muscle strength

36
Q

Contraindications of HRT?

A

Current, past or suspected breast cancer
Known or suspected oestrogen-dependant cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Previous idiopathic or current VTE - unless already on anticoag treatment
Active or recent arterial thromboembolic disease
Acute liver disease with abnormal LFTs
Pregnancy
Thrombophilic disorders

37
Q

Side effects of HRT?

A

Oestrogen - fluid retention, bloating, breast tenderness/enlargement, nausea, headaches, leg cramps, dyspepsia
Progesterone - fluid retention, breast tenderness, headaches, mood swings, premenstrual syndrome symptoms, depression, acne vulgaris, lower abdominal pain and back pain
Unscheduled vaginal bleeding for the first 3 months
GI symptoms

38
Q

What is sequential HRT?

A

When oestrogen is taken every day and progestogen is taken for half the month to ensure a monthly bleed

39
Q

When is sequential HRT used over continuous combined HRT?

A

If less than 6-12 months since the LMP
Important as if you start continous combined HRT too early in the menopause transition it may cause irregular frequent bleeding

40
Q

What can you do for a woman who needs sequential HRT but does not want a withdrawal bleed?

A

You can have the mirena IUS fitted alongside oestrogen only HRT

41
Q

When is continous combined HRT best?

A

If its after 12 months since the LMP
Note: this does not cause a withdrawal bleed

42
Q

Combined HRT can cause irregular bleeding. When should this stop by and when should you start investigating?

A

Should stop after 4-6 months
Investigate if it lasts >6 months

43
Q

When should you review women on HRT?

A

After 3 months of starting/changing dose
And then annually

44
Q

How long should you encourage women to persist with HRT for?

A

At least 3 months - any SE that will settle down will have done so by this point

45
Q

When should you refer menopausal women to secondary care?

A

If HRT is not successful
If there are ongoing side effects
If there is unexplained bleeding

46
Q

How should you stop HRT?

A

It can be done gradually over 3-6 months or it can be immediately stopped
In some cases gradually reducing it may limit recurrence of symptoms in the short term, but in the long-term this has no beneficial effcts

47
Q

Advantages and disadvantages of oral HRT

A

Advantages: cheap and effective
Disadvantages: first pass metabolism, variable plasma levels and higher doses required

48
Q

Advantages and disadvantages of transdermal HRT

A

Advantages: avoids first pass metabolism, reduces VTE risk, continous administration
Disadvantages: cost and skin reactions

49
Q

Advantages and disadvantages of vaginal HRT

A

Adv: good for urogenital Sx, minimal systemic absorption, licensed for 3 months use without progesterone opposition
Dis: unlikely to treat other Sx

GYNAECOLOGY (9 decks)

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