Menopause

Question 1

What is menopause?

Answer 1

Last period 12 months ago

Question 2

What is the average age of menopause?

Answer 2

45-55

Question 3

How are the investigations for menopause?

Answer 3

FSH is a very unreliable marker of menopause in normal menopausal women

Question 4

What are the hormonal changes in menopause?

Answer 4

Gradual rise in FSH
Fluctuations in estrodiol and progesterone
Decreased ovarian inhibin B
Androgens stay the same
Estradiols eventually fall

Question 5

What determines the age of menopause?

Answer 5

Genetics
Smokers go through menopause 1-2years early
Hysterectomy: generally will go through earlier

Question 6

What is the concern with irregular anovulatory cycles?

Answer 6

Prolonged unopposed oestrogen > may lead to endometrial hyperplasia and cancer risk

Question 7

What are the consequences of menopause?

Answer 7

Short-term

• Vasomotor symptoms - most common
• Vaginal dryness and atrophic vaginitis
• Sleep disturbance
• Mood disturbance

Medium to long-term

• Reduced done density > osteoporosis
• Increased risk of CV disease and Alzheimer’s

Question 8

What are the vasomotor symptoms?

Answer 8

Hot flushes
Night sweats
General temperature intolerance

Question 9

How does vaginal dryness present?

Answer 9

Painful sex

Pain with wiping

Question 10

What is perimenopause? How long does it last?

Answer 10

Period of decline +/- symptoms

8-10 years

Question 11

When do you investigate ?menopause

Answer 11

Always, menopause is a diagnosis of exclusion

Question 12

How long do menopausal symptoms last?

Answer 12

40% women have symptoms up to 10 years after menopause

Question 13

When do you give progesterone in HRT?

Answer 13

Whenever the uterus is present due to risk of endometrial hyperplasia

Question 14

How does HRT effect osteoporosis?

Answer 14

It may reduce rapidity of loss

Question 15

When do you DEXA scan in menopause?

Answer 15

Those with risk factors
- Low Ca intake
- Low body weight
- Eating disorder
- Immobilisation
- Smoking
- Medical conditions (Prolonged corticosteroids therapy, Premature menopause, Malabsorption,
Chronic liver disease, Hyperparathyroidism)

Question 16

How much exercise should you do to prevent osteoporosis?

Answer 16

More than 3 hours per week of weight bearing exercise

Question 17

What is premature menopause? How do you confirm the diagnosis?

Answer 17

Amenorrhoea for greater than 4 months occurring before the age of 40
FSH more than 40IU/ml on two occasions
Exclude other causes

Question 18

What are the complications of premature menopause?

Answer 18

Menopausal symptoms
Possible increase CV risk
Increase osteoporosis risk 
Loss of fertility
Altered body image
Increased risk of depression

Question 19

What are the causes of premature menopause?

Answer 19

Iatrogenic - surgery, chemo, radio
Idiopathic
Genetic
Autoimmune
Other

Question 20

How do you Ix premature menopause?

Answer 20

FSH, E2 on at least occasions
Prolactin, TFT Pregnancy test - to exclude causes of secondary amenorrhoea
Karyotype and fragile X if POF under 40 years
Exclude out flow obstruction

Question 21

In what age groups is HRT recommended?

Answer 21

Until 51 years

Question 22

What is the best administration mode of HRT?

Answer 22

Transdermal - lowest risk of DVT

Question 23

What are the modes of administration?

Answer 23

Tablets
Patches
Gel
Intrauterine
COCP

Question 24

When is the COCP used for HRT?

Answer 24

Younger women as its higher dose

Question 25

What are alternative treatments to HRT?

Answer 25

Lifestyle modification - Clothing - Air conditioning - Smoking cessation

Question 26

What are the benefits of HRT?

Answer 26

Reduces frequency and severity vasomotor symptoms by 75-85% Improves vaginal dryness Maintains or improves bone density and reduces fracture risk May improve QOL and sleep, muscle aches and pains Reduce diabetes risk Reduced colorectal cancer risk

Question 27

What are the contraindications to HRT?

Answer 27

``` Hormone receptor positive cancer Hx DVT Smoking Uncontrolled HTN Unexplained vaginal bleeding ``` Relative - Migraines

Question 28

What are the risks of HRT - oestrogen alone?

Answer 28

Increased risk of stroke Increased risk of VTE Cholecystitis

Question 29

What are the risks of HRT - combined alone?

Answer 29

``` Increased risk of stroke Increased risk of VTE Cholecystitis Increase breast tissue Increase risk of breast cancer with more than 5 years use Unscheduled bleeding Increased incidence of stroke and CHD ```

Question 30

What is tibolone? How is it efficacious?

Answer 30

Synthetic steroid Improves vasomotor symptoms, libido, and vaginal dryness Improves BMD

Question 31

What are some non-hormonal therapies?

Answer 31

Effect vasomotor symptoms only - Gapapentin - SSRI/SNRI - Clonidine

Question 32

How long do you put someone on HRT for?

Answer 32

5 years

Question 33

In which type of patient is it useful to measure FSH? When do you measure it?

Answer 33

Young women or when the diagnosis is uncertain | Day 2-6

Question 34

How much calcium should be had to prevent osteoporosis?

Answer 34

1200mg/day

Question 35

How does caffeine affect bone health?

Answer 35

Negatively

Question 36

How does low E2 affect health health?

Answer 36

• Increase in bone remodelling - E2 suppresses bone reabsorption by suppressing osteoclast activity ie E2 deficiency directs increased bone reabsorption. • Directly impairs gut calcium absorption. • Directly increases renal calcium excretion.

Question 37

What is the relationship between HRT and CV risk?

Answer 37

Contraversal Likely neutral in younger women, may have adverse effects in older Does not prevent or treat CVD

Question 38

Do you start HRT in women with CVD?

Answer 38

Caution against it, transdermal is best if so