Menopause Flashcards
Definition
- Women have a finite number of oocytes (eggs) at birth
- These gradually decline with each menstrual cycle
- When the oocyte store is depleted, menstruation stops = MENOPAUSE
Epidemiology and riskfactors
- Early menarche
- Nulliparity or low parity
- Smoking
- Overian surgery or cancer treatment
- Loose association with maternal age of menopause
Perimenopause Pathophysiology
Menopause can cause problematic symptoms which can start before menstruation stops = perimenopause = can last several years.
Hormonal changes during perimenopause:
- Oestrogen and inhibin levels decrease + FHS, LH increased
- Estradiol levels drop with reduced ovarian activity
- Eventually, the level becomes insufficient to stimulate the endometrium, and menstruation stops
- The reduction in oestrogen = contributes to the development of vasomotor symptoms
Menopause pathophysiology
- Early menopause = between 40 to 45 years
- Premature menopause = under the age of 40. This may be secondary to surgery or chemo radiotherapy.
- Premature ovarian failure: This is a clinical syndrome defined by loss of ovarian function before the age of 40
= Unlike in premature menopause, this loss of function may be temporary and there may be a return of ovulation and menstruation.
Signs
- Reduced bone mineral density
- Vaginal atrophy
Symptoms
Vasomotor symptoms:
- hot flushes
- night sweats
Change in menstrual pattern
- during perimenopause = may become more irregular
- eventually ceases completely
Psychological symptoms
- cognitive impairment: ‘brain fog’, poor connection, poor memory
- mood disorders: anxiety, low mood, irritability
- sleep disturbances.
Genitourinary symptoms:
- Vulvovaginal dryness and discomfort
- Urinary symptoms: dysuria, frequency, urgency, recurrent UTI
Sexual dysfunction:
- Reduced libido
- Dyspareunia secondary to vaginal dryness
Genital symptoms
- Fatigue and headache
- Joint and muscle pain
Diagnosis
Clinical diagnosis
Investigations to consider:
- FSH levels: in women with suspected menopause < 45 years + atypical symptoms
= 2 FSH levels done 4-6 weeks apart
= >30 IU/L suggestive of menopause.
= FSH levels may be normal during the perimenopause due to variability in levels throughout the cycle.
Pregnancy test
Investigations to rule out other hot flushes: hyperthyroidism, phaeochromocytoma, malignancy
Investigations to rule out other causes of irregular menstrual bleeding: vaginal swabs, pelvic USS, colposcopy/hysteroscopy
Treatment (Hormonal)
FIRST LINE = HRT:
- Oestrogen therapy: for women with intact uterus, no hysterectomy
- Combined regimes: can either be continuous or sequential
= Continuous regime: offered to women who have had amenorrhoea for >12 months. Oestrogen and progesterone administered continuously throughout the month
= Sequential regime: perimenopausal women, where progesterone is added for only part of the month = causes regular monthly bleed
Forms of HRT
Tablets, patches, and gels
When is vaginal oestrogen used
If symptoms are predominantly vulvovaginal, or in combination with systemic HRT
Benefits of HRT
- Symptom control
- Improved quality of life
- Maintenance of bone mineral density and reduction in osteroporotic fractures
- Reduced risk of colorectal cancer
Risks of HRT
Endometrial cancer: if oestrogen is used alone in women with an intact uterus
DVT: greated risk in first 12 months on HRT
Breast cancer: HRT> 5 years
CVD : HRT in women +60
Non hormonal treatments
Less effective than HRT
- Vaginal moisturisers and lubricants
- For vasomotor symptoms:
= selective serotonin reuptake inhibitors (SSRIs) (e.g. fluoxetine),
= selective noradrenaline reuptake inhibitors (e.g. venlafaxine), clonidine, gabapentin,
- cognitive behaviour therapy (CBT)
Lifestyle advice
- Avoid possible triggers for hot flushes, including spicy foods, caffeine, alcohol, smoking
- Regular exercise
- Weight loss if appropriate
- Stress management
- Contraception :
= Women <50 years old: advise contraception until 2 years after the last menstrual period
= Women >50 years old: advise contraception until 1 year after the last menstrual period
Complications
Postmenopausal women are at increased risk of:
- Osteoporosis and fracture
- Cardiovascular disease and stroke
- Genitourinary syndrome of menopause: i.e. vulvovaginal and urinary symptoms causing by reducing oestrogen levels
Premature or early menopause may be associated with an increased risk of:
- Osteoporosis and fracture
- Cardiovascular disease
- Type 2 diabetes
- Depression