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Flashcards in Menopause Deck (65):
1

How is the menopause defined?

Last menstrual period. In practice, thought, difficult to know when this is. So in practice, this is defined as amenorrhoea for 1 yr with other causes excluded.

2

What is the average age of occurrence of menopause?

Average age is around 52, with a span of around 45 to 55. Menopause before the age of 40 is referred to as premature ovarian failure.

3

What are they symptoms of menopause?

Hot flushes, vaginal dryness, night sweats, palpations, insomnia. Can occur up to 5 years before final menstrual period. Very bad for some, not too bad for others.Other features include change in mood, irritability, depression,loss of concentration, and formication.

4

How long do menstrual symptoms last?

Vasomotor symptoms typically decrease 2 yrs after the final menstrual period, but psychological features may last longer.

5

What are the long term problems of menopause? And why?

Osteoporosis (lack of oestrogen).Cardiovascular risk increased.Urinary incontinence, esp. stress incontinence. Also bladder outflow obstruction leading to overactive bladder. (This is due to lack of oestrogen meaning degradation of connective tissue esp. in overweight people - pelvic floor disruption).Increased UTI (change in vaginal bacteria + atrophy).Sometimes skin dryness, thinness, and poor skin healing.Related to this dyspareunea --> loss of libido.

6

What different reasons might a woman want to check if she is menopausal?

1) Seeing if pregnancy still possible.2) Explain symptoms/just to know.

7

What is the test for "ovarian reserve" i.e., to see if someone is approaching the menopause in context of wanting to get pregnant?

FSH, taken on day 2-3 of a cycle.<15 - can still produce viable eggs.15-30 - perimenopausal.30+ usually post menopausal.However, not totally reliable. Anti-mullarian hormone can also be used, but though this is more accurate, it is generally not done in primary care.

8

What is a good first line way to check if someone is peri-menopausal?

Can try one month of HRT (assuming right age group + symptoms fit). If symptoms disappear, then this is highly suggestive of menopause, and can discount other causes.If no change in symptoms, have to start looking for other causes. E.g., routine bloods, note diabetes can mimic some symptoms.

9

How does the efficiency of contraception change as menopause is approached?

All forms become much more efficient.

10

What is contraceptive advice for women who enter menopause and whose periods stop?

FPA recommend women under 50 should continue contraception for 2 years; women over 50, for 1 year.

11

How many percentage of women in the UK use oral contraception?

Oral contraception is used by 25 - 30% of couples in the UK.

12

What are the reasons for using oral contraception?

1) Contraception!2) To manage irregular menstrual cycles.3) To ameliorate dysmenorrhoea .4) To manage endometriosis (preparations with relatively low oestrogen and high progesterone).5) sometimes to manage acne.

13

What factors should be considered when deciding which oral contraceptive to offer?

Loads! Age, smoking habits, BMI, cardiovascular risk, pre-existing acne/hirsuitism...

14

What hormones do COC and POP contain?

COC contains both an oestrogen and progesterone; POP just progesterone.

15

What is the maximum age that COC can be given to?

50If they smoke, then 35.If they have a BMI >30, risk of DVT is high and they should be counselled about an alternative.

16

What contraindicates the use of COC?

1) over 502) smoker over 353) focal migraines, severe or crescendo migraines, TIA's.4) BP >140/905) VTE in first degree relative (not absolute - thrombophilia screen should be performed first though)6) Existing pregnancy (you could get into all kinds of legal ho water here by causing an abortion!)7) multiple risk factors for arterial disease.8)Liver disease (gallstones, adenoma, porphyria, hepatitis, disorders of hepatic excretion).9) Personal Hx of VTE or thrombotic disease.10)Valvular heart disease with risk of thrombus or pulmonary hpt11) Varicose veins during sclerosing treatment.12)Undiagnosed vaginal bleeding.13) Breast or genital tract cancer14) Breast feeding15) Hydatiform mole until gonadotrophins normal16) If in a prev pregnancy had: pruritus, pemphigoid, chorea, cholestatic jaundice, osteosclerotic deterioration.

17

COC also reduces the risk of certain cancers - which ones?

Ovarian and endometrial.Also less risk of ovarian cyst.

18

Does COC use increase the risk of any cancers?

If taken for longer than 5 years, then the risk of cervical cancer is increased.Breast cancer in some sub groups of women.

19

What group of drugs make the COC less effective?

Liver enzyme inducers. (Additional barrier methods should be used until 4 weeks after the liver enzyme inducer is stopped!)

20

What is the relative risk of VTE in a "normal" woman taking the COC?

It is x5! BUT in absolute terms this is still relatively low, and less than in pregnancy.

21

What are the risks of taking COC?

1) failure 2) VTE3) ischaemic stroke4) ischamic heart disease (BUT only in unhealthy smokers!)5) unpredictable breakthrough bleeding (though this is more common with POP)

22

Do women who take COC put on weight?

No evidence for this.

23

How is the COC effective?

It inhibits ovulation via inhibiting GnRH. Also has effects on cervical mucous (less penetrable to sperm) and endometrium (making it more atrophic and less conductive to implantation), and interfering with transport of ova down fallopian tube (if ovulation does occur, that is!).

24

How effective is COC?

>99% (when used correctly)

25

When should COC be started in terms of the cycle?

Day 1 (i.e., the first day of bleeding) but can be started unto day 5 (otherwise additional contraception needed for first 7 days; and it can only be started then if there is no chance of pregnancy).

26

Can oral contraceptives be taken by breastfeeding women? If so, when?

COC - no!POP - yes!If they are not breastfeeding, COC can be started day 21 post partum.

27

How consistently does the COC need to be taken?

Within 12 hours of the same time each day (cf POP).

28

How many days in a month does a women take COC?

21 days. Then 7 days off (or placebo pills) during which a withdrawal bleed occurs.They are still contraceptively covered during those 7 days off/placebo.

29

When should women taking the COC be advised to come to the practice for a pregnancy test?

If they have missed or late pills, vomiting or diarrhoea, or use a new drug (as it might be an enzyme inducer) AND there is then either no withdrawal bleed or only a very light bleed.

30

Are women taking broad spectrum (but not enzyme inducing) abx contraceptively covered by the COC?

No! They should be advised to use additional barrier methods during the course of the abc and for 7 days afterwards!

31

Are women who are taking rifampicin covered contraceptively by the COC?

No! Not while taking it, and not for 4 weeks afterwards!

32

What are the two common progesterones used at low dose in COC?

Norethistrone and levonorgestrel.

33

Focusing more on arterial risk factors and the COC, what does the BNF say?

Use with caution if one risk factor, contraindicated if two.1) Smoking (>40/day = contraindication)2) Diabetes mellitus (if complications, then contraindicated).3) Over 35.4) BMI >30 (contraindicated if BMI >39)5) Fx of MI or CVA in 1st degree relative 30 - contraindicated

34

Is the POP or COC more effective?

COC - >99%POP is less effective, with a failure rate of 2-6 per 100 women years.

35

How does the POP work?

Does NOT inhibit ovulation*Increases viscosity of cervical mucous, "sperm cannot pass!"Changes in the endometrium inhibit implantation.Interfere with tubal transport of ova.*: cerezette does sometimes inhibit ovulation.

36

What are the advantages of POP over COC?

No increased risk of VTE.Do not inhibit lactation - so can take while breastfeeding.Suitable for diabetics.Useful when the COC is contraindicated.

37

What s/e's of POP?

Irregular low grade uterine bleeding, but this often settles into a regular cycle after 6-9/12.Skin reactions.Breast fullness.Depression.Increased risk of ectopic.Slight increase in breast Ca risk.

38

On how many days of the cycle are the POP taken?

Continuously, every day.

39

Does the POP increase risk of CVD?

Current evidence seems to suggest not, as opposed to the COC.

40

Does the POP affect BP?

Again, NICE are being cautious! It seems that it does not increase the BP of women taking POP. But NICE warn caution. In fact, newer POP's (e.g., drosperenone) have a anti-mineraliocorticoid effect, meaning they can actually lower BP very slightly!

41

When should the POP be started?

Generally on the first day of the cycle, i.e., day 1 of bleeding. If switching from COC, then take POP immediately after the last COC - i.e., no withdrawal bleed period.

42

How forgiving is the POP in terms of when it is taken?

Less than the COC! Should be taken within 3 hours of the same time each day. EXCEPT cerazette, which has a 12 hour window and often inhibits ovulation.NOTE - this does not make it a better contraceptive than other POP's.

43

Do enzyme inducers affect POP?

Yes! They continue to reduce POP efficiency for 8 weeks after discontinuation - extra protection advised!

44

Does taking abx affect the efficacy of POP?

Generally it does not! However, enzyme inducers (e.g., rifampicin) do, and women should be warned of this.

45

What morning after pills are there? Is there another option?

1) Levonorgestrel pill 1.5mg taken up to 3 days after intercourse.
2) Ulipristal (ellaOne) (SERM) may be used up to 120 hours after unprotected sex, taken as a single dose. (For these two pills, the earlier they are taken, the more likely they are to work).
3) Also copper IUD - failure rate of 0.1% (i.e., the best) and can be implanted up to 5 days after sex.In all cases, follow up is essential and should occur 3-4 weeks later.

46

Are there any contraindications to the morning after pill?

1. Hx of thrombosis2. Active acute porphyria3) Current severe liver disease4) Focal migraine at time of presentation.

47

What are the current British Menopause Society guidelines one HRT? (This comes from GP update - comes from a systematic review of available evidence and looking again at the million women study. The guidance is supported by RCOG, but not worldwide!)

1)The decision whether to use HRT should be made by each woman having been given sufficient information to make a fully informed choice.2)HRT dosage, regimen and duration should be individualised and reviewed annually.3)Arbitrary limits should not be placed on the duration of usage; if symptoms persist, the benefits of HRT usually outweigh the risks (this statement is not referenced by the BMS!).4)HRT prescribed before the age of 60y has a favourable benefit/risk profile.5) Encourage women with premature ovarian failure to use HRT at least to the average age of menopause.6) If HRT is to be used over the age of 60y, lower doses should be started preferably with transdermal route, because of its lower VTE risk.

48

What is the cause of the menopause, and what effect does it have? What, then, is given as HRT?

Caused by falling levels of oestrogen. This causes the vasomotor effects (hot flushes, dry vaginas and dyparaunea, urinary infections, etc); but unopposed oestrogen causes proliferation in an intact uterus; thus, women who have a uterus and have HRT are given progesterone, too.

49

What are the three main types of HRT?

1) Oestrogen only – for women who have had a hysterectomy.
2) Cyclical HRT (oestrogen and progesterone added sequentially to trigger a bleed) – minimises irregular bleeding in perimenopausal women.
3) Continuous combined HRT (daily dose of oestrogen and progesterone) – use only once women are a year or more from their last period otherwise spotting and erratic bleeding is likely.

50

Although there are three main types of HRT, there are other approaches - what are the three?

1) The progesterone component can be delivered as a Mirena IUS, with oral or topical oestrogen used alongside this.2) Transdermal patches of oestrogen alone and combined HRT are also available.3) In perimenopausal women who also need contraception, if there are no contraindications, the COCP will treat hot flushes.

51

What are the indications for HRT? (There are 2, but there is a third reason which is NOT an indication, for which it is often given!)

1) For control of vasomotor symptoms impacting on quality of life in perimenopausal and menopausal women.
2) HRT is recommended for women with premature (<45y) menopause until the age of 50y for symptom control and bone protection.
3) Bone protection, low libido, low mood and vaginal symptoms are not indications for oral HRT though they may be helped by taking it!

52

How effective is HRT?

It is the most effective available treatment for vasomotor symptoms:Reduces frequency of flushes by on average 18 per week!Reduces severity by 87%.There is also evidence that it reduces fracture risk, improves vaginal dryness and sexual function and may improve sleep and muscle aches and pains.

53

What are the two main risks of HRT?What other risks?

VTE and breast cancer.Slight increase in risk of cholecystitis (lower in transdermal HRT).Increase in risk of endometrial cancer IF the woman has a uterus and IF she does not take progesterone as well as oestrogen.Increased risk of stroke, especially over 60yrs.

54

What is the relationship between HRT and VTE?

-All oral forms of HRT increase the risk of DVT, PE and stroke.-This risk increases with age and is highest in the first year of use.-In prescribing HRT other risk factors such as obesity, smoking and immobility should be considered.-Previous VTE or high risk of VTE (e.g. thrombophilia) are both absolute contraindications.-Routine screening for thrombophilia is not indicated.-It is uncertain if transdermal HRT carries the same risk – it is probably lower.

55

What is the relationship between HRT and breast cancer?

-Combined HRT increases the risk of breast cancer diagnosis and breast cancer mortality.-Combined HRT increases breast density and the risk of an abnormal mammogram.-The data for oestrogen-only HRT are conflicting, however: The Women’s Health Initiative study did not show an increased risk taking oestrogen-only HRT for 7y. BUT the Million Women Study showed a small increased risk.-The starting age for HRT matters. Starting HRT before or soon after menopause (cessation of menses) was associated with a higher risk of breast cancer than starting some time later. Also, longer duration of use increases risk of breast cancer (J Natl Cancer Inst 2011;103:296).

56

Can you summarise the relative risk of breast cancer with either oestrogen-only HRT and with combined HRT for women who start 5yr after the menopause?

If started early, i.e., 5yr after the menopause, then the RR is 2.04 (1.97-2.12)If started late, i.e., >5yrs after menopause, RR of breast cancer is 1.05 (0.89-1.23) in oestrogen only HRT, or 1.53 (1.38-1.69) with combined HRT.So there is an increased risk, but it is not huge, it is higher if it is started early, and it is lower with oestrogen only HRT.

57

What about the relative risks of women who use HRT (oestrogen only Vs combined) by total duration of < or > than 5yrs (i.e., not when it is started?

If the total duration is less than 5yrs, the RR of breast Ca is 1.24 (1.14-1.35) in oestrogen only HRT and 1.62 (1.54-1.71) in combined HRT.If the total duration of HRT is > 5yrs, the RR of breast Ca is 1.44 (1.37 - 1.52) in oestrogen only HRT, and 2.19 (2.10-2.27) in combined HRT.So, again, longer use, and use of combined HRT increases the risk of breast Ca, though the RR is not huge.

58

What about HRT and stroke?

-HRT increases the risk of stroke and this becomes a greater risk with age and duration of use, particularly over age 60y.-Avoid HRT and tibolone (basically an oestrogen) in women at high risk of stroke.(This comes from Cochrane data).

59

What about HRT and cardiovascular disease?

-There are conflicting data depending on age of starting HRT and whether there is pre-existing cardiovascular disease.-HRT should generally be avoided in women over the age 60y where pre-existing cardiovascular disease is more likely.-Cochrane also concluded that we should NOT prescribe HRT for the primary or secondary PREVENTION of cardiovascular disease. (!!)

60

Does HRT protect against dementia?

No! But some people think it does, despite a complete lack of evidence. Disabuse them of their ignorance!

61

Looking at the BENEFITS of HRT - consider 100 0 women who suffer from hot flushes, vaginal atrophy, fractures, diabetes, and colorectal cancer. How many of those 1000 women would NOT suffer from these things, both with oestrogen HRT and combined HRT?

Benefit Oestrogen CombinedHot flushes 900 820Vaginal atrophy 800 870Fractures 6 5Diabetes 11 11Colo Ca 0 1

62

In summary, what are the benefits of HRT?

Used for as short a time as possible, massive symptom control when it comes to hot flushes and vaginal atrophy, but less good at preventing osteoporosis, especially when risks considered.

63

But haven't studies shown that HRY=T actually DECREASES CVD risk? This is really confusing!

A small Danish study (open label RCT BMJ 2012;345;e6409) SEEMED to show a reduced rate of death from MI over 10 years in women taking HRT - but the general feeling from the sum of existing evidence is that HRT does NOT improve CVD risk (and if anything, it makes it worse) and larger RCT's are needed.

64

What are the precautions and contraindications to the COC? (Amazingly, no absolute consensus on this 0 Red Whale suggests the following 7 points...)

1) Avoid HRT and tibolone in women with breast cancer or a history of breast cancer.
2) Seek advice before starting HRT in women with a history of endometrial or ovarian cancer.
3) Exclude or investigate breast symptoms before starting HRT.
4) Avoid HRT in a women with a personal history of VTE or arterial thrombotic disease.
5) Avoid HRT in uncontrolled hypertension.
6) Ix abnormal vaginal bleeding before starting HRT.
7) Migraines do not seem to be exacerbated by low dose HRT, but transdermal preparations may be helpful.

65

What about monitoring in HRT?

1) Women on HRT should be monitored annually - discuss symptom control, Ongoing indication, Side effects.
2) Monitor BMI and BP.
3) Do a CVD risk assessment and offer appropriate lifestyle advice.
4) Check if cervical and breast screening are up to date.
5) Ask about bleeding pattern - with combined preparations, unscheduled bleeding may occur in the first 6 months of use, but if it persists beyond 6 months of use, it should be investigated.
6) Consider whether anxiety or depression may be contributing to the somatic symptoms of menopause.