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FP MFSRH Part 2 2025 > Menopause > Flashcards

Menopause Flashcards

(62 cards)

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1
Q

What % of women have POI before 40?

A

1%

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2
Q

What % of women have POI before 30?

A

0.1%

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3
Q

Etiology POI

A

Familial 10%
Chemo, radio, surgery
Genetic conditions (turners, fragile x)
Autoimmune

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4
Q

Menopause diagnosis in age >45?

A

Symptoms alone

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5
Q

Menopause diagnosis in age 40-45?

A

Early menopause
5% of women

40-45
3/23 Oligo/amenorrhoea
FSH >30 2 samples 4-6 weeks apart

(unless on CHC or high dose progestogens)

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6
Q

POI
Diagnosis menopause in <40

A

<40
3/12 Oligo/amenorrhoea
Two FSH levels 4-6 weeks apart: >30

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7
Q

When to check FSH for menopause

A
  1. Age 40 - 45 with menopause symptoms and change in menstrual cycle
  2. <40 and menopause suspected
  3. POI
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8
Q

Symptoms of menopause

A

Last around 7 years

1/3 last longer

  1. Vasomotor (hot flushes/night sweats). 70 - 80%.
  2. GU sx, dry, pain, dysuria
  3. Mood, anxiety
  4. MSK
  5. Sexual difficulties
  6. Disturbance to cycles
  7. Disturbed sleep
  8. Low energy
  9. Impaired concentration, brain fog.
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9
Q

Average age of early perimenopause

A

47
cycles 6 to 7 weeks apart
Menopause symptom may start

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10
Q

Average age of late perimenopause?

A

49
Cycles few months apart and worsening of menopause symptoms

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11
Q

Long-term health implications

A
  1. Osteoporosis
  2. Increased risk of CVD
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12
Q

Progestogen for HRT in perimenopause

A
  • sequential giving monthly bleed
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13
Q

Progestogen for HRT in postmenopause

A

Continuous, no bleeds

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14
Q

Types of progestogen for HRT

A

Micronised are plant derived, natural and bioidentical with slightly lower risk of breast cancer and no impact on VTE.

Synthetic progestogens: tablet, patch or IUS, impact VTE and higher risk of breast cancer

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15
Q

Testosterone indicated in HRT

A

Low libido and and drive
Possibly for mood and energy

Replaced at physiological level unlikely to cause adverse effects.
Consider if oestrogen alone not helpful
5 mg a day gel (unlicensed for women but used)

Check baseline level and against 3 months to ensure within female physiological range

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16
Q

HRT and breast cancer

A

Small increased risk in combined HRT only
Eastern alone Little/no risk
FHX not CI
Alcohol and obesity likely to have a greater impact than HRT.
The most women benefits outweigh risk of breast cancer
HRT use = lower mortality

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17
Q

Lifestyle measures for menopause

A
  1. Diet low salt/fat, high ca, vit D
  2. Exercise
  3. Smoking (increases risk CVD and osteoporosis).
  4. alcohol 2/3 units day and alcohol free day
  5. relaxation meditation/yoga
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18
Q

Advantages of HRT over CHC for POI?

A

Either can be used but HRT may be more beneficial for bone health, BP, lower CVD risk

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19
Q

When does HRT increase risk of endometrial cancer?

A

> 5 years use of sequential HRT

Continuous use may reduce risk

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20
Q

Dose of progesterone for continuous use

A

0.5mg/day norethisterone
2.5mg medroxyprogesterone

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21
Q

dose of progesterone for sequential HRT?

A

1mg norethisterone 10 days
200mg micronised PO progesterone 12 days
10mg medroxyprogesterone 10-14 days
10mg dydrogesterone 14 days

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22
Q

Dose of progesterone in high dose oestrogen HRT?

A

300mg micronised progesterone 12 day for sequential
200mg 10 days/month for cont use

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23
Q

Use of LNG-IUD for HRT

A

Only mirena licensed for 4 years
But evidence suggests 5 years protection
Lower dose devices need to add in further progesterone

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24
Q

HRT: Is progesterone required for subtotal hysterectomy

A

Trial three months of sequential HRT if no bleed can stop progesterone

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25
Alternatives to vaginal oestrogen?
1. Vaginal Prasterone DHEA 2. Ospemifene oral (if vaginal application difficult due to disability etc)
26
St John’s wort as non hormonal treatment option
Can be used in breast cancer but may interact with other meds
27
Which antidepressants must be avoided if on Tamoxifen?
Fluoxetine and paroxetine Should not be used for vasomotor symptoms as interact
28
Vaginal oestrogen options
Estradiol - vagifem tablets or Eststring Estriol - Ovestin/gynest cream, imvaggis peasant, blissel gel Used nightly for 2-3 weeks Then twice weekly for long term maintenance
29
Indications for transdermal oestrogen?
- Poor control with PO – poor oral absorption – Hx or FHx VTE – BMI >30 – variable BP control – migraine – hepatic enzyme inducers – gall bladder disease
30
Can systemic HRT be used with aromatase inhibitors?
No
31
Menopausal vagina symptoms with history of breast cancer
1. Vaginal moisturiser 2. Ultra low-dose topical oestrogen considered 3. Avoid topical oestrogen with aromatase inhibitor
32
Why does oral oestrogen reduce effectiveness of testosterone?
PO oestrogens go through the liver first past metabolism and stimulate production of SHBG defines the sex hormones including testosterone and oestrogen Therefore total testosterone levels may be normal but free (active) testosterone is bound and inactive,
33
Use of inverting-based therapies (GLP receptor antagonists) such as semaglutide and tirzepatide and HRT
Risk of reduced absorption of oral progesterones, therefore reduced endometrial protection Switch to non-oral route or Increased dose of progesterone for 4 weeks when starting treatment with GLP and 4 weeks after any dose change
34
What HRT regime should be used for induced menopause in endometriosis and why?
Continuous combined or tibolone to prevent reactivation of residual disease Usually in younger women so may need a higher dose of oestrogen Sudden menopause may equal more severe symptoms. HRT protective for osteoporosis, CVD Add back HRT for surgical/GnRH agonists
35
Major risk factors for endometrial cancer?
- BMI >40 - Lynch/Cowden syndrome - Unopposed estrogen >6/12 - tricycling progesterone >12 months - prolonged sHRT: >5 years when started age >45 - 12 months using NET/MPA for <10 days or micronised for <12 days
36
Minor risk factors for endometrial cancer? (7)
- BMI 30-39 - DM - PCOS - Unopposed estrogen >3 but <6 - tricycling progesterone >6 but <12 months - 6-12 months using NET/MPA for <10 days or micronised <12 days - >12 months progesterone or expired IUS
37
For women over 45, when should they switch from sequential to continuous HRT?
- after 5 years - by aged 54 Whichever first
38
When to investigate bleeding on HRT? (X4)
1. If no RF adjust dose for up to 6/12, if bleeding occurs within six months of starting HRT or three months of change in HRT. If persists: urgent US or wean off HRT (to avoid invasive Ix) If settles by 4 weeks and wish to restarts HRT, adjust dose for 6/12 and US if bleeding heavy it persists 2. Urgent US if 1st episode is after 6 months of starting/3 months of changing HRT. 3. Urgent US if prolonged/heavy bleeding or two minor RF. 4. Cancer pathway if 1 major RF or 3 minor RF (stop HRT or adjust progesterone while waiting)
39
What endometrial thickness is low risk for cancer? For ccHRT and sHRT? Next steps
ccHRT ≤ 4 mm sHRT ≤ 7 mm Adjust HRT for 6/12 and ref for urgent US if increase bleeding or persistent > 6 months
40
What endometrial thickness is high risk for cancer? For ccHRT and sHRT? Next step
ccHRT > 4 mm sHRT > 7 mm Cancer pathway : Biopsy +/- hysteroscopy If biopsy normal reassure 3/12 If biopsy + hysteroscopy normal reassure 6/12
41
Risk of endometrial cancer in ccHRT compared to non-uses?
Reduced risk
42
Micronised progesterone for ccHRT and sHRT for low-moderate and for high dose estrogen?
Low-moderate: ccHRT 100mg sHRT 200mg High: ccHRT 200mg sHRT 300mg ssHRT 12 days Utogestran, cyclogest, lutigest
43
MPA progesterone for ccHRT and sHRT for low-moderate and for high dose estrogen?
Low-moderate: ccHRT 2.5 - 5mg sHRT 10mg High: ccHRT 10mg sHRT 20mg ssHRT 10-14 days Provera
44
NET progesterone for ccHRT and sHRT for low-moderate and for high dose estrogen?
Low-moderate: ccHRT 5mg sHRT 5mg High: ccHRT 5mg sHRT 5mg ssHRT 10-14 days Norethisterone/noriday 1mg suitable for low-standard but doesn’t exist as preparation, so requires off licence use of noriday POP (x3 = 1.05mg)
45
Rate of unscheduled bleeding in first 6 months of starting any HRT?
40%
46
How to decide between sequential and continuous HRT?
Period in the last 12 months = sequential Amenorrhoea in past 12 months = continuous
47
No unscheduled bleeding on HRT with incidental endometrial thickness >10 mm
Blind biopsy or hysteroscopy Major RF —> cancer pathway Otherwise —> urgent US 6/52
48
No unscheduled bleeding with incidental ET >4 ccHRT or >7mm sHRT
Cancer pathway
49
Optimising bleeding sHRT
- time start if regime with natural cycle (time progesterone for final 14 days cycle) - can trial DSG - oral better than transcendental (but high VTE risk) - increase or change progesterone/IUS - if spotting before withdrawal bleed can consider increase estrogen dose (inhibit ovulation/folliculate activity)
50
Optimising bleeding with cHRT
- reduced HRT dose - increase/change progesterone dose - IUS - oral over transdermal - reduce estrogen dose/not hormonal alternative
51
Clonidine for hot flushes
Alpha adrenergic agonist Anti hypertensive Only non-hormonal drug license for hot flushes in UK 25 µg BD for two weeks, increased to max of 50 µg TDS
52
Recommended non-hormonal treatments following breast cancer
- Clonidine - Venlafaxine - Gabapentin (avoid St John’s wort due to serious drug interactions, isoflavones, red clover and black Cohosh)
53
Menopause sx and hx breast cancer
Low does estrogen in estrogen negative tumours or in tamoxifen and only once d/w specialty Avoid in aromotase inhibitors
54
Health outcomes with HRT all cause mortality?
Combined and oestrogen only: Unlikely to change with use
55
Health outcomes with combined HRT breast cancer?
Risk increased with HRT Rises with duration, current users persists for at least 10 years. Very small increase in risk death from breast cancer with cHRT sHRT risk lower than cHRT (but higher than no HRT) No increased risk with oestrogen only HRT
56
Health outcomes with combined HRT ovarian cancer?
Combined and oestrogen only HRT: slight increase Transdermal and oestrogen only
57
Health outcomes with combined HRT endometrial cancer?
cHRT reduced risk sHRT increased risk (NB duration, fewer days P, higher dose oestrogen) Oestrogen only HRT increases risk if person has uterus
58
Health outcomes with HRT CHD?
Combined and oestrogen only HRT: CHD risk does not increase
59
Health outcomes on combined HRT dementia?
Combined: might increase with HRT if started at 65+ Oestrogen only: unlikely to increase
60
Health outcomes on combined HRT osteoporosis?
Combined and oestrogen only HRT: reduced fragility fracture. Decreases once treatment stops
61
Health outcomes of HRT on VTE and stroke?
Unaffected with transdermal oestrogen HRT Increased with oral oestrogen (increases with duration, and older age at start of HRT)
62
Treatment options for POI?
CHC or HRT till age of natural menopause

FP MFSRH Part 2 2025 (10 decks)

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