Menopause

Question 1

Definition of menopause

Answer 1

The final menstrual period, can only be diagnosed after 12 consecutive months of amenorrhoea while not on any hormonal treatment

Question 2

Definition of perimenopause

Answer 2

The symptoms experienced in the years preceding menopause while ovarian activity fluctuates

Question 3

Definition of surgical menopause

Answer 3

Menopause occurring when functional ovaries are surgically removed

Question 4

Definition of premature menopause

Answer 4

Menopause occurring before the age of 45

Question 5

Average age of menopause in Western society

Answer 5

52 years (no change in last 150 years)

Question 6

Iatrogenic causes of menopause

Answer 6

Surgical removal of functioning ovaries
Radiotherapy
Chemotherapy
Temporarily during GnRH analogue treatment

Question 7

Causes of primary premature ovarian failure

Answer 7

Chromosome abnormalities (Turner's, Fragile X)
Autoimmune: hypothyroidism, Addison's, Myasthenia Gravis
Enzyme: galactosaemia, 17a-hydroxylase deficiency

Question 8

Causes of secondary premature ovarian failure

Answer 8

Surgical menopause
Chemo or radiotherapy
Infectiosn (TB, mumps, malaria, varicella)

Question 9

Endocrine changes in menopause

Answer 9

First change: fall in inhibin production (responsible for FSH production inhibition) - increased FSH

Reduces oestradiol levels- eventually insufficient to stimulate endometrial proliferation = menopause
Further decline in subsequent years - effects on all oestrogen-responsive tissues

Question 10

GU effects of menopause

Answer 10

Vaginal atrophy - trauma, dryness, spontaneous bleeding, infection
Distal urethra + trigone bladder - similar atrophy - urinary symptoms without infection
Pelvic floor dysfunction - weakening of supporting ligaments and tissues - increased prolapse and stress incontinence

Question 11

Osteoporosis mechanism in menopause

Answer 11

oestrogen = anti-resorptive agent on trabecular bone

Thus, dec. oestrogen - inc. bone resorption - dec. bone density

Question 12

Oestrogen effects on CVS

Answer 12

inc. LDL, dec. HDL
direct effect on vessel wall - vasodilation via NO
thus increased risk of CVD after menopause

Question 13

Short-term symptoms of menopause (0-5y)

Answer 13

Vasomotor: hot flushes, night sweats
Psychological: labile mood, anxiety, tearfulness
Cognitive: loss of concentration, poor memory
Joint aches and pains
Dry, itchy skin
Hair changes
Reduced libido

Question 14

Intermediate effects of menopause (3-10 years)

Answer 14

vaginal dryness, soreness
Dyspareunia
Sensory urgency
Urinary frequency
Recurrent UTIs
Urogenital prolapse

Question 15

Long term effects of menopause (over 10y)

Answer 15

Osteoporosis
Cardiovascular disease
Dementia

Question 16

Assessment of menopause:

Answer 16

frequency, severity and types of symptoms and impact on daily life
for most women, menopausal symptoms are relatively short lived and will settle within a few years
use as opportunity to raise awareness and practice preventative medicine

Question 17

lifestyle management of menopause

Answer 17

Smoking cessation
Optimise diet
Regular, low-intensity exercise
Minimise weight gain (average weight gain of 1kg/year around menopause)

Question 18

Alternative/complementary management of menopause

Answer 18

little is known about efficacy or safety:
Acupuncture, reflexology, magnetism
Herbal (black cohosh, evening primrose oil, st john’s wort, ginseng, ginko bilboa)
Bio-identical hormones (DHEA, natural progesterone gel, phytoestrogens - isoflavones, red clover)

Question 19

Non-hormonal pharmaceutical management options for menopause

Answer 19

SSRIs and gabapentin:

• reduce hot flushes in short term
• significant side effect profile

Alpha-adrenergic agnoists (Clonidine)

• reduces hot flushes
• far less effective than HRT

Question 20

Hormones to be given in HRT for menopause

Answer 20

Oestrogen - can only be given alone if no uterus is remaining (otherwise risk of endometrial cancer) + progesterone if uterus present
testosterone if surgical/chemo induced menopause

Question 21

Time frame of HRT

Answer 21

Minimal effective dose for shortest duration
Ideally should be discontinued by 5 years
average woman will need symptomatic relief for 2-3 years

Question 22

Routes of oestrogen administration

Answer 22

Oral - oestrone released into circulation, less expensive
Transdermal: avoids first-pass effect, reduced impact on haemostasis and coagulation (therefore better option in VTE/liver abnormalities)
+ more physiological (oestradiol released into circulation), logistically difficult to coadminister progesterone in unhysterectomised patients

Question 23

Side effects related to oestrogen

Answer 23

fluid retention
Nausea
Headaches
Breast enlargement
Leg cramps
Dyspepsia

Tend to settle within a few weeks

Question 24

Progesterone addition in HRT

Answer 24

added for 10 days per calendar month (mimic menstrual cycle)
Cyclical regimen for perimenopauseal women
Continuous for post-menopausal women (no bleeding)

Question 25

Side effects related to progestogens

Answer 25

``` Fluid retention Breast tenderness Headaches Acne Mood swings Depression Irritability Bloating Constipation Increased appetite ``` usually more trouble-some than oestrogen related side effects, especially in first few months Switching dose or type of progestogen or to Mirena IUD may help

Question 26

Symptoms of testosterone deficiency in a female

Answer 26

Loss of libido Decreased sexual activity Fatigue Reduced feeling of physical well-being

Question 27

Breast cancer risk with HRT

Answer 27

increases risk by 4 in 1000 (usually 15/1000) No increase in risk if used for less than 5 years more associated with progesterone than oestrogen

Question 28

Endometrial cancer risk with HRT

Answer 28

only in unopposed oestrogen if woman still has uterus | Therefore always use progesterone unless no uterus

Question 29

VTE risk with HRT

Answer 29

Increases risk 2- fold (overall impact small given that background risk is low) - significantly increased risk in smokers, obese, underlying thrombophilia or history of VTE Highest risk in first year of use

Question 30

Absolute contraindications to HRT

Answer 30

``` Suspected pregnancy Breast cancer Endometrial cancer Active liver disease Uncontrolled HTN Known VTE Known thrombophilia Otosclerosis ```

Question 31

relative contraindications to HRT

Answer 31

``` Uninvestigated abnormal bleeding Large uterine fibroids Past history of benign breast disease Unconfirmed personal history or strong family history of VTE Chronic stable liver disease Migraine with aura ```

Question 32

Benefits of HRT

Answer 32

Most effective therapy for perimenopausal symptoms (vasomotor, urogenital, sexual function) Treatment of osteoporosis Reduced risk of ?CVD, colon cancer

Question 33

Vaginal oestrogen

Answer 33

safe for those contraindicated for systemic HRT useful only for urogenital symptoms progesterone not required daily for 2 weeks, then 1-2 times weekly for 12 months

Question 34

Expected time for HRT to improve hot flush symptoms

Answer 34

4-6 weeks of treatment

Question 35

Production of testosterone in women and effect of menopause

Answer 35

50% occurs in ovaries other 50% in adrenals and adipose Production not generally affected by natural menopause, but may become deficient if chemoradiation or surgical induced menopause

Question 36

Regimens of HRT

Answer 36

Oestrogen only - post-hysterectomy Cyclical progesterone + oestrogen - perimenopausal women (still will have period) Continuous progesterone + oestrogen - postmenopausal women (will not have bleeding)