Menopause

Question 1

How is menopause defined?

Answer 1

Absence of menses for >12 months (retrospective Dx)

Question 2

Give 4 signs/ symptoms of menopause

Answer 2

Amenorrhoea

Vasomotor (hot flushes, night sweats, palpitations)

Urogenital (vaginal dryness, dyspareunia, recurrent UTI)

Psychological (poor concentration, lethargy, anxiety, depression, short term memory impairment)

Question 3

What should the FSH/LH/ serum oestradiol be in menopause?

Answer 3

FSH/LH: High (as unopposed)
Oestradiol: Low

Question 4

How should menopause be managed?

Answer 4

If have uterus: systemic oestrogen combined with progesterone to protect against endometrial carcinoma

If don’t have uterus: systemic oestrogen (note CI eg DVT)

Question 5

How can HRT be given if there is a history of DVT/ stroke?

Answer 5

Topically/ Transdermally

Question 6

When should HRT be offered in menopause?

Answer 6

When lifestyle adaptations (eg exercise + alcohol reduction) have been insufficient

Question 7

When is cyclical/ sequential HRT indicated?

Answer 7

In perimenopausal women

Question 8

How should cyclical/ sequential HRT be administered?

Answer 8

If regular periods: monthly- oesterogen every day + progesterone for last 14 days
If irregular periods: oestrogen every day for 3 months + progesterone for last 14 days
Withdrawal bleed occurs when on progesterone

Question 9

To who should continuous HRT be administered? How?

Answer 9

Post menopausal women
Oestrogen + progesterone every day

Question 10

List 7 absolute CI to HRT

Answer 10

Breast cancer (current + past)
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Hx of VTE
Pregnancy
Severe liver disease
Current thrombophilia (eg FV Leiden)

Question 11

What are alternatives to HRT for vasomotor symptoms of menopause?

Answer 11

1st line = SSRIs (eg fluoxetine)
2nd line = citalopram/ venlaxafine

Question 12

What are alternatives to HRT for vaginal dryness in menopause?

Answer 12

Lubricants

Question 13

What are alternatives to HRT for bone health can be used in menopause?

Answer 13

Osteoporosis Tx eg bisphosphonates

Question 14

For how long should effective contraception be used for in menopause?

Answer 14

12 months after the last period in >50y
24 months after the last period in <50y

Question 15

What conservative measures can be used in menopause?

Answer 15

Hot flushes
regular exercise, weight loss + reduce stress

Sleep disturbance
avoiding late evening exercise + maintaining good sleep hygiene

Mood
sleep, regular exercise + relaxation

Cognitive Sx
regular exercise + good sleep hygiene

Question 16

Why must unopposed oestrogen be avoided in women with a womb?

Answer 16

Risk of endometrial cancer

Question 17

For how long do symptoms of the menopause last on average?

Answer 17

2-5y

Question 18

What are the risks of HRT treatment?

Answer 18

VTE: slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.

Stroke: slightly increased risk with oral oestrogen HRT.

Coronary heart disease: combined HRT may be a/w a slight increase in risk.

Breast cancer: increased risk with all combined HRT although the risk of dying from breast cancer is not raised.

Ovarian cancer: increased risk with all HRT.

Question 19

What are the longer term complications of the menopause?

Answer 19

osteoporosis
increased risk of ischaemic heart disease

Question 20

What is the main cause of symptoms in the menopause?

Answer 20

Reduced levels of oestrogen

Question 21

In women with BMI >30 and a hysterectomy, what HRT should be given?

Answer 21

Transdermal patch oestrogen only

Question 22

In which 7 patient groups is transdermal HRT indicated?

Answer 22

GI disorder affecting oral absorption
Previous or FH of VTE
BMI >30
Variable BP control
Migraine
Current use of hepatic inducing enzymes medication
Gall bladder disease