Menopause

Question 1

What is menopause?

Answer 1

• No menstruation for 12 consecutive months
• Between the ages of 45 and 55 years
• Perimenopause: Symptoms may start a few months to years
  before menstruation stops
• Changes in menstruation: cycle length may become
  shorter or longer, skipping months

Question 2

Early menopause

Answer 2

Before 45 years old
Causes
- Surgical removal of ovaries
- Cancer treatment: Radiotherapy, chemotherapy
- Idiopathic (Premature ovarian failure)

Question 3

Symptoms of menopause

Answer 3

Acute
- Cessation of menses
- Hot flushes, night sweats
- Mood swings, depression
- Decrease memory, difficulty concentrating
- Headaches

Medium-term (5-10 years in)
- Vaginal dryness, dyspareunia
- ↑ vaginal pH –> increased UTI
risk
- Loss of libido
- Stress and urge urinary
incontinence
- Skin thinning, brittle hair due
to loss of collagen
- Generalized aches and pains

Long-term
Cardiovascular
- Hypertension
- Ischemic heart disease, atherosclerosis
- Central abdominal fat redistribution (independent risk
factor for CVS, DM) Osteoporosis
- Fragility fractures
Psychological
- Mood issues
- Cognitive disorders: dementia

Question 4

Effect of estrogen on CVS

Answer 4

• Protects against cardiovascular disease
• Beneficial effect on cholesterol
• Reduces the risk of plaque formation in the arterial walls

Question 5

Management of menopause

Answer 5

1. Lifestyle and education
   - Keeping room temperature cool
   - Lighter clothing
   - Avoid triggers: spicy foods, caffeine, smoking, alcohol
   - Exercise
   - Cognitive behavioural therapy
   - Support – Daisy network for POI, Woman-to-woman support group
   - Pelvic floor exercises (keegel to prevent uterine prolapse)
   - Moisturizers, lubricants
2. Medical
   a. Hormonal
   b. Non-hormonal alternatives

Question 6

Medical - Hormone pharm

Answer 6

1. Hormonal replacement therapy
   - Replaces the hormone estrogen lost during the menopause
   - Aims to relieve symptoms related to estrogen deficiency – hot flushes, vaginal dryness, and osteoporosis
   - Reduces risks of osteoporosis, cardiovascular disease, stroke, dementia

Sequential combined vs continuous combined regime

Question 7

Sequential combined regime

Answer 7

E every day, P 50% of the time (trisequens)
- Bleeding generally lighter and shorter than own menses
- Recommended for peri-menopausal woman (ie. woman < 45yo who have menopausal sx)
-> helps to control and regulate their bleeds
-> helps to prevent future sx once they are post-menopausal

Prolonged use ↑ risk of endometrial cancer (30%)
- Only statistically significant after 10 years or more
- No substantial ↑ risk remains at 5 years after cessation

Question 8

Continuous combined regime

Answer 8

E+P every single day (femoston Conti)
- Bleed free
- Irregular bleeding in > 50% during 1st 3 months
- Recommended for true menopausal woman who no longer have menopause ie no bleed
-> helps to prevent unopposed oestrogen to reduce risk of endometrial cancer

Possible progestogen-associated side effects
- Dysphoria
- Perpetual sense of premenstrual tension

Question 9

Risks of HRT

Answer 9

Cardiovascular Disease
Stroke
Venous Thromboembolism
Breast Cancer

• Use the most suitable type of treatment for patient
• Use at the lowest effective dose
• Use for the shortest duration of time necessary

Question 10

When is HRT usually started?

Answer 10

Before age of 60 OR
Within 10 years of menopause

Question 11

Contraception use in menopause

Answer 11

If > 50yo, continue for 1 year post LMP
If < 50yo, continue for 2 years post LMP

Question 12

Contraindications to use of HRT

Answer 12

• Hormone-dependent malignancy (endometrial ca, past or present history
  of breast cancer)
• Thromboembolic disease
• Pregnancy
• Liver disease
• Uninvestigated abnormal per vaginal bleeding
• Acute intermittent porphyria
• SLE, cardiac disease (relative)

Question 13

Options to use for estrogen (HRT)

Answer 13

Estradiol
- Transdermal (patch, gel)
- Tablets
- Subcutaneous implants

Vaginal preparations (cream, ring, tablets)

Question 14

Options to use for progesterone (HRT)

Answer 14

Oral/transdermal
Mirena
Tibolone

Question 15

1st line route of administration for estrogen (HRT)

Answer 15

Transdermal

Question 16

Benefits of estrogen

Answer 16

• Vasomotor symptoms
• Cardiovascular benefits (reduces atherosclerosis, increases HDL, lowers LDL)
• Improves mood or sleep disturbances
• Genitourinary symptoms
• Osteoporosis
  -> HRT ↓ risks of fragility # by 30%
  -> Protection maintained for as long as treatment is continued – bone loss restarts once HRT stopped
• Neuroprotective (↓ Alzheimer’s)
• ↓ risks of colorectal cancer (by 1/3 but should not be used as a preventive strategy)

Question 17

Complementary or alternative therapy

Answer 17

• Acupuncture
• Aromatherapy
• Herbal treatment
• Homeopathy
• Hypnotherapy
• Yoga
• Reflexology
• Others: Black cohosh, pollen based, phytoestrogens

Question 18

Indications to start HRT

Answer 18

1. Severe post-menopausal symptoms
   - HRT is best management for this
2. Early menopause to prophylaxis against osteoporosis/cardiovascular disease