Menopause

Question 1

Question 2

What are the current recommendations for cervical screening?

Answer 2

In Australia, the Cervical Screening Test (CST) is recommended for women aged 25–74 years who have ever been sexually active. The test is performed every 5 years if results are normal. It replaces the 2-yearly Pap smear and involves testing for high-risk human papillomavirus (hrHPV). Screening starts at age 25, even if vaccinated against HPV, and ends at 74, provided there is an adequate history of negative screening results.

Question 3

Why has the recommended interval for cervical screening been extended to 5 yearly?

Answer 3

The interval was extended because the Cervical Screening Test (CST) now detects hrHPV, the virus responsible for nearly all cervical cancers, rather than just looking for abnormal cells. HPV testing is more sensitive and predictive of future risk, enabling earlier identification of women at risk before cellular changes occur. This improved accuracy makes 5-yearly screening both safe and effective, reducing unnecessary interventions while maintaining cancer prevention.

Question 4

Who is eligible for self-collected cervical screening?

Answer 4

All people eligible for cervical screening (aged 25–74 and ever sexually active) can choose self-collection. This change (from July 2022) aims to improve uptake, especially in under-screened or never-screened populations (e.g. those with trauma, cultural sensitivities, or disability).

Ineligible:
Under 25
HIstologically confirmed AIS
Symptomatic - eg. post coital bleeding
Hysterectomy - history of HSIL

Question 5

What should patients be informed about regarding follow-up of self-collected screening?

Answer 5

Patients should be told that self-collected samples are now equivalent in accuracy for detecting HPV. If HPV is not detected, routine 5-year recall applies. If HPV is detected, a clinician-collected sample is needed for reflex cytology. Instructions to patients: Use a dry flocked swab. Insert into the vagina (not cervix), rotate gently for 10–30 seconds. Do not touch the swab tip. Replace in the tube and return it as directed.

Pathology formed needs to be marked self-collected or physician collected.

2% will have 16/18 and need to go on to Colposcopy.

Question 6

What other information would you seek in the history?

Answer 6

Explore the following:
Menopausal symptoms: hot flushes, night sweats, mood, fatigue, sleep, vaginal dryness;
Cycle history: onset of menopause, irregular periods; Impact on life/work: safety concerns (operating machinery), mood, relationships;
Medical history: cardiovascular disease, osteoporosis, breast cancer, thromboembolism; Medications: HRT use, OTC supplements; Lifestyle: smoking, alcohol, BMI; Psychosocial: stressors, support systems; Preventive health: mammogram, bone density, vaccines.

Question 7

Question 8

What hormonal changes occur during the follicular phase of the menstrual cycle?

Answer 8

During the follicular phase (Days 1–14), there is an increase in FSH, leading to follicle maturation and an increase in estrogen.

Question 9

What hormonal change occurs during ovulation?

Answer 9

Around Day 14, there is an LH surge that triggers ovulation.

Question 10

What hormonal changes occur during the luteal phase of the menstrual cycle?

Answer 10

During the luteal phase (Days 14–28), there is an increase in progesterone from the corpus luteum, which stabilizes the endometrium.

Question 11

What anatomical changes occur to the uterine lining during the menstrual cycle?

Answer 11

The uterine lining undergoes a proliferative phase under estrogen, leading to endometrial thickening, followed by a secretory phase under progesterone where endometrial glands become secretory.

Question 12

What happens during menstruation?

Answer 12

Menstruation occurs due to corpus luteum regression, leading to decreased progesterone and estrogen, resulting in the shedding of the endometrium.

Question 13

What hormonal changes are expected in a woman who has ceased menstruating?

Answer 13

In menopause, there is a decrease in estrogen and inhibin B, an increase in FSH and LH due to loss of negative feedback, and a decrease in Anti-Müllerian hormone (AMH).

Question 14

What is the definition of menopause?

Answer 14

Menopause is defined as the permanent cessation of menstruation due to loss of ovarian follicular activity, diagnosed retrospectively after 12 consecutive months of amenorrhea.

Question 15

What does the term ‘perimenopause’ mean?

Answer 15

Perimenopause refers to the transition period leading up to menopause and the first year after the final menstrual period, characterized by fluctuating hormone levels and symptoms such as hot flushes.

Question 16

At what age do Australian women typically experience menopause?

Answer 16

The average age of natural menopause in Australia is approximately 51 years, with a typical range of 45–55 years.

Question 17

What might be causing Maddy’s hot flushes?

Answer 17

Maddy is likely experiencing vasomotor symptoms of perimenopause, but other differentials include thyrotoxicosis, pheochromocytoma, carcinoid syndrome, medications, infection, or anxiety.

Question 18

How common are hot flushes and what causes them?

Answer 18

Hot flushes affect 60–80% of women during perimenopause/menopause and are caused by hypothalamic thermoregulatory dysfunction due to estrogen withdrawal.

Question 19

What other physiological changes occur at menopause?

Answer 19

Physiological changes at menopause include vaginal dryness, increased risk of osteoporosis, increased cardiovascular risk, weight gain, mood swings, and dry skin.

Question 20

What concerns arise if menopause occurs at 35 years of age?

Answer 20

Menopause at 35 years is classified as premature ovarian insufficiency (POI), associated with infertility, increased risk of osteoporosis, cardiovascular risk, and psychological distress.

Question 21

Question 22

What tests should be requested for Maddy?

Answer 22

FSH, LH, and estradiol; TSH; HbA1c/lipids; Bone mineral density (DEXA); Mammogram; Consider STI screening. Mental health screening.

Chem 20 - liver enzymes, renal function - important for medication

Follow flow diagram from guidlines as to what is appropriate at what point.

Others:

Bowel screening

Question 23

What is the first-line treatment for Maddy’s vasomotor symptoms?

Answer 23

Menopausal Hormone Therapy (MHT) is the most effective treatment for hot flushes and night sweats.

Options include Estrogen + progestogen (oral or transdermal), with transdermal preferred if there is a history of migraines or VTE risk.

Question 24

What non-hormonal options are available if MHT is contraindicated or declined?

Answer 24

SSRIs/SNRIs (e.g. venlafaxine, paroxetine, escitalopram); Clonidine; Gabapentin.

Vaginal estrogen is also an option for genitourinary symptoms.

Question 25

What lifestyle advice can help Maddy?

Answer 25

Cooling techniques, layered clothing, regular exercise, stress reduction, alcohol/caffeine reduction.

Question 26

What alternative treatments have been explored for menopausal symptoms?

Answer 26

Yes – several complementary and alternative therapies have been explored for menopausal symptoms. Evidence quality varies: � Phytoestrogens (e.g. soy isoflavones, red clover) – weak estrogenic activity; evidence mixed, but some benefit reported. � Black cohosh – may help with vasomotor symptoms; modest effect and limited long-term safety data. � St John’s Wort – sometimes used for mood symptoms but has significant drug interactions (e.g. OCP, SSRIs). � Acupuncture – may offer subjective symptom relief. � Mindfulness, yoga, CBT – evidence supports benefit in sleep, mood, and symptom perception. Important to discuss safety, especially in context of breast cancer risk and potential interactions ## Footnote Evidence quality varies and safety should be discussed.

Question 27

Maddy has a friend who takes Venlafaxine, an SNRI. Is Venlafaxine a recommended option for Maddy?

Answer 27

Yes, venlafaxine is a reasonable non-hormonal option for vasomotor symptoms. ## Footnote Doses are lower than for depression/anxiety (37.5–75 mg/day) and it can reduce hot flushes by 50–60%.

Question 28

What considerations should be taken into account when using Venlafaxine?

Answer 28

Side effects include nausea, dry mouth, insomnia, increased BP. Gradual dose titration and tapering are required. ## Footnote Seriternergic syndrome In Maddy’s case (with no contraindications to MHT), MHT remains first-line, but venlafaxine is a valid alternative if she prefers a non-hormonal approach.

Question 29

Question 30

What are the risks associated with oestrogen use in postmenopausal women?

Answer 30

Oestrogen therapy carries risks, especially when combined with progestogen: Increased risk of VTE (DVT/PE), stroke risk, breast cancer, gallbladder disease, and endometrial cancer if unopposed oestrogen is used. ## Footnote Absolute risk is age- and route-dependent, and generally low in women <60 or within 10 years of menopause.

Question 31

What effect would oestrogen replacement have on the uterus, particularly the endometrium?

Answer 31

Unopposed oestrogen stimulates endometrial proliferation, increasing the risk of endometrial hyperplasia and cancer. A progestogen is added in women with an intact uterus to mitigate this risk.

Question 32

In Maddy’s case, are there any absolute or relative contraindications to its use?

Answer 32

No absolute contraindications identified in Maddy’s case. Absolute contraindications include undiagnosed vaginal bleeding, active or history of breast cancer, active VTE or history of unprovoked VTE, and liver disease. Relative factors include history of migraines and treated varicose veins. ## Footnote Overall, Maddy appears to be a suitable candidate for MHT.

Question 33

If Maddy had previously had a hysterectomy, would her treatment be different?

Answer 33

Yes, unopposed oestrogen (oestrogen-only MHT) would be used, as there’s no endometrium to protect.

Question 34

Would you recommend ‘Bio-identical’ HRT?

Answer 34

No, the term 'bio-identical' refers to compounded hormone preparations that are not TGA-approved, lack standardisation, and do not undergo rigorous safety testing. Evidence-based MHT uses regulated, body-identical hormones, which are safe and recommended by major guidelines.

Question 35

How can oestrogen be administered?

Answer 35

Oestrogen can be administered orally or transdermally as a patch. Oral oestrogen is convenient but may increase VTE risk. Transdermal oestrogen avoids first-pass metabolism, has lower VTE risk, and is preferred in women with migraines or obesity.

Question 36

What is cyclical vs continuous MHT?

Answer 36

Cyclical MHT involves daily oestrogen + progestogen for 10–14 days/month, leading to regular withdrawal bleeds, used in perimenopausal women. Continuous combined MHT involves daily oestrogen + daily progestogen with no withdrawal bleeding, recommended for postmenopausal women.

Question 37

When should Maddy cease treatment?

Answer 37

There is no strict time limit, but typically reassess every 1–2 years. Most women consider ceasing MHT after 2–5 years, based on symptom control and patient preference.

Question 38

Why might many women cease HRT of their own volition?

Answer 38

Reasons include fear of cancer, concern over long-term use, side effects, resolution of symptoms, perception of aging out of needing it, and personal preference for 'natural' options. ## Footnote Patient education and shared decision-making is key.

Question 39

Question 40

What treatment options are available for vaginal atrophy and dyspareunia?

Answer 40

Several safe and effective options are available: First-line: Non-hormonal vaginal moisturisers/lubricants (e.g. Replens, Sylk, YES) - Use 2–3x/week or during sex. If symptoms persist: Topical vaginal oestrogen therapy (e.g. oestriol cream, oestradiol pessaries, Vagifem, Ovestin). ## Footnote Maddy would likely benefit from topical vaginal oestrogen + lubricants, as she has introital tenderness, dryness, and visible atrophy.

Question 41

What are the risks associated with topical vaginal oestrogen?

Answer 41

Risks are generally very low: Minimal systemic absorption → breast cancer and VTE risk not significantly increased. Not contraindicated in most women with a history of breast cancer, but should be discussed with treating oncologist. Mild side effects: local irritation, discharge, rare bleeding. ## Footnote Overall: Benefits outweigh risks for topical treatment in symptomatic postmenopausal women like Maddy.

Question 42

What are the risks associated with lubricants and moisturisers?

Answer 42

Very safe; adverse effects are rare. Some women may react to added perfumes or preservatives (→ use natural, pH-balanced products).

Question 43

What are the risks associated with pelvic floor therapy?

Answer 43

No significant risk, but adherence may be a barrier.

Question 44

What adjunct treatments may help with vaginal atrophy?

Answer 44

Pelvic floor physiotherapy - helpful for rectocele support and introital tenderness. Vaginal dilators if significant atrophy/stenosis or pain with penetration.