Menopause Flashcards Preview

Obstetrics and Gynaecology > Menopause > Flashcards

Flashcards in Menopause Deck (23):
1

Define normal, early

Cessation of menses for >12 months

Early is when <40 yo

2

Average age of onset

Usually 45-55, average age is 50-51

3

The four phases

1. Phase 1 Premenopausal: up to 5 years before the last menstrual period.

2. Phase 2 Perimenopausal: the presence of early menopausal symptoms with vaginal bleeding (usually irregular) 3. Phase

3 Menopausal: the last menstrual period

4. Phase 4 Postmenopausal: approximately 5 years after the menopause

4

During menopause, does the ovary produce must estrogen or androgens

1. The ovary produces little estrogen 2. Produces ++androgens

5

Symptoms overview

1. Vasomotor

2. Psychogenic

3. Urogenital

4. MSK

5. Skin and other tissue changes

6. Other

6

Vasomotor symptoms

1. Hot flushes

2. Night sweats

3. Palpitations

4. Lightheadedness

5. Migraine

7

Psychogenic symptoms

1. Depression

2. Irritability

3. Mood swings

4. Anxiety

5. Tearfullness

6. Poor concentration

7. Sleep disturbance

8. Loss of self confendence

8

Urogenital symptoms

1. Atrophic vaginitis

2. Vaginal dryness

3. Dysparaneuria

4. Decline in libido

5. Bladder dusfunction

6. Stress incontinence

9

Musckuloskeletal symptoms

1. Non-specific muscular aches

2. Non-specific joint aches and pains

10

Skin and other tissue symptoms

1. Dry skin

2. Fornicatioin

3. New facial hair

4. Breast glandular atrophy

11

Other symptoms

1. Unusual tiredness

2. Headache

12

History

1. Symptoms of estrogen deficiency

2. Gynaecological history

3. Obstetric history

4. Mental state symptoms

5. Sexual history

6. Contraception

7. Micturition

8. Social history

9. Family history of osteoporosis, cancer, cardiovascular disease

13

Examination

1. BP, height, weight, waist

2. Breast

3. Abdomen

4. Vaginal examination

5. Pap smear

14

Investigations

1. Urinalysis

2. FBC

3. Fasting lipids, glucose

4. LFTs

5. Mammography

If in doubt, or early

1. Serum FSH

2. Serum estradiol

15

Management

1. Education and lifestyle Diet Obesity Relaxation Exercise Smoking Caffeine and alcohol reduction Pelvic floor

2. Continue sexual relations->use lubricant

3. Contraception for 12 months after last period

4. OCP available until 50/51

5. Consider HRT->allow 6 months to stabilise

6. Estrogen pessary for vaginal dryness

7. Consider non-hormonal: Paroxetine or venlafaxine

8. Consider short term testosterone if loss of libido issue 9. Regular followup

16

Important aspects of the women's health initiative study

1. first prospective, randomized, controlled clinical trial of hormone replacement therapy (HRT), it aimed to recruit more than 16,000 women and do follow-up on them for 8.5 years.

2. A 37% reduction in colon cancer

3. 34% decrease in hip fractures

4. 2.11-fold increase in deep venous thromboses 

5. 26% increase in invasive breast cancer This finding was surprising, since a recent comprehensive review of previous epidemiologic studies had concluded that no convincing link between breast cancer and HRT was present.

6. The big WHI surprises were the 29% increase in heart attacks and the 41% increase in strokes that were seen.

7. A major problem is that HRT is the only potent therapy for vasomotor symptoms and genital atrophy in menopausal women

8. In addition to increased adherence to dietary/lifestyle modifications, women concerned with osteoporosis might be better served by taking SERMs (eg, raloxifene hydrochloride) or bisphosphonates (alendronate sodium, risedronate sodium); either seems to give the same approximate fracture prevention as HRT

17

Indications for HRT

1. Relieving distressing symptoms of hot flushed, urogenital symptoms, sleepiness and joint

2. Transdermal most favoured.

18

Golden rule in HRT

1. Progesterone must be give with estrogen in women who still have a uterus

19

Tibolone

1. SERM

2. Alternative to traditional HRT

3. Vasomotor, urogenital, BMD and fracture risk

4. Not for perimenopausal

5. Breakthrough bleeding and virilisation are the concerns

20

Contraindications to HRT

1. Estrogen dependent tumor

2. Recurrent VTE

3. Acute IHD

4. CAD

5. Cerebrovascular

6. Uncontrolled HTN

7. Undiagnosed vaginal bleeding

8. Acute liver disease

9. Active SLE

10. Pregnancy

11. Osteosclerosis

12. Acute intermittent porphyria

21

Complications

1. Uterine enlargment->irregular bleeding

2. Continued periods

3. Maignancy? No increase in cervical or ovarian cancer Risk of endometrial Ca->relates to unopposed estrogen and duration of use: 3-6X risk after 5 years, 10X risk after 10 years. Breast cancer

4. VTE

5. MI

6. Stroke

7. Cholecystitis and cholelithiasis

22

Side effects

1. Generally well tolerated

2. May have some breast tenderness, HA, breast fullness, often resolves after 3 months.

23

Components of WHI to explain: end point, criticisms, conclusion

1. Were older, had other risks, cannot extrapolate to younger, healthy women early in menopause wanting symptom releif

2. End point- Breast Ca

Secondary end-points +Myocardial infarction +Cerebrovascular accidents +Pulmonary thrombosis

-ve Fracture of the hip

-ve Cancer of the colon

?Endometrial carcinoma

Stopped early as incidence of breast carcinoma increased, not mortality

3. Concluded not suitable for primary prevention->relative risk of adverse effects +15% however, absolute risks not great.