Menopause

Question 1

What is the menopause?

Answer 1

Onset of the menopause is heralded by the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhoea

Question 2

What is the average age for the menopause?

Answer 2

51 years

Question 3

What is defined as early and premature menopause?

Answer 3

<45 years

<40 years

Question 4

What is defined as late menopause?

Answer 4

> 54 years

Question 5

What is the physiology of the menopause?

Answer 5

Reduced oestrogen due to lack of follicle production and lack of granulosa cells
Therefore FSH and LH will be raised due to a lack of negative feedback

Question 6

What are the effects of oestrogen?

Answer 6

Secondary sexual characteristics
Hair distribution, body shape and fat distribution 
Effects of collagen 
Bone growth 
Proliferates endometrium

Question 7

What are the main categories of symptoms for the menopause?

Answer 7

Vasomotor
Irregular periods
Psychological
Sexual

Question 8

Why should FSH and LH not be measured in perimenopausal woman over 45?

Answer 8

Released in a pulsatile fashion

Single raised or normal level does not confirm or rule out the menopause

Question 9

What things are known to increase FSH and LH levels?

Answer 9

Raised just prior to ovulation
Raised with stopping COC or depo provera
Raised with breastfeeding or certain medications (SSRI)

Question 10

What are the main physical symptoms of the menopause?

Answer 10

Hot flushes
Night sweats
Palpitations 
Insomnia
Joint aches
Headaches

Question 11

What percentage of woman will have hot flushes?

Answer 11

60-80%

20% have severe symptoms

Question 12

How long do hot flushes on average last?

Answer 12

Average is 2 years
10% for 15 years
Last for 3-5 mins

Question 13

What psychological symptoms are associated with the menopause?

Answer 13

Mood swings
Irritability 
Anxiety 
Difficulty concentrating
Forgetfulness

Question 14

What sexual symptoms are assoc with the menopause?

Answer 14

Vaginal dryness

Libido

Question 15

What physiological change leads to vaginal dryness seen in the menopause?

Answer 15

Lack of collagen

Question 16

What hormonal change leads to reduced libido seen in the menopause?

Answer 16

Testosterone

Question 17

What are the later symptoms of menopause?

Answer 17

Urinary frequency 
Recurrent UTIs 
Dysuria 
Incontinence 
Dry hair and skin 
Atrophy of breast and genitals

Question 18

Describe the perimenopausal dysfunctional uterine bleeding?

Answer 18

Irregular periods
Inter-menstrual bleeding
Post menopausal bleeding

Question 19

What is the concern with post menopausal bleeding?

Answer 19

Endometrial cancer

Question 20

What is the conservative management of the menopause?

Answer 20

Diet; phytoestrogens such as soy 
Wt loss
Exercise
Caffeine
CBT
Mindfulness

Question 21

What are the treatment options for menorrhagia?

Answer 21

Mefenamic acid 
Tranexamic acid 
Progesterones 
Intrauterine system 
Endometrial ablation 
Hysterectomy

Question 22

What are the mode of actions for mefenamic acid and tranexamic acid?

Answer 22

Mefenamic acid; NSAID, affects prostaglandins in uterus and decreases blood supply to womb
Tranexamic acid; anti fibrinolytic to stop body from breaking down clots

Question 23

What are the different forms of HRT?

Answer 23

Oestrogen alone
Oestrogen and progesterone combined
Topical or oral
Continuous or sequential

Question 24

When should woman with early menopause be advised to continue HRT?

Answer 24

Continue until at least the natural age of menopause (around 51)

Question 25

Should FSH be measured in woman presenting with the menopause >45?

Answer 25

No

Question 26

What is the 1st line treatment for women with vasomotor symptoms and low mood or anxiety?

Answer 26

HRT

Question 27

What can be considered to alleviate low mood or anxiety?

Answer 27

CBT

Question 28

When should transdermal instead of oral HRT be considered?

Answer 28

Increased risk of VTE BMI over 30 Breast cancer risk

Question 29

When should vaginal oestrogen be offered to post menopausal women?

Answer 29

Urogenital atrophy (including those on systemic HRT) but ONLY after examination to exclude other pathologies

Question 30

Why is mirena IUS used in menopausal symptoms?

Answer 30

Does NOT help menopausal symptoms | Can be used for endometrial protection

Question 31

Contraindications for HRT?

Answer 31

``` Breast ca Undiagnosed abnormal vaginal bleeding Endometrial cancer Pregnancy Active thromboembolism disease Recent myocardial infarction Active liver disease with abnormal LFT Porphyria cutanea tarda ```

Question 32

What are the benefits of HRT?

Answer 32

Symptom control Increased QOL Reduced osteoporotic fracture Reduced incidence of bowel cancer Protective for alzheimer's and parkinson's HRT <10 years after menopause fewer risks and less CV events

Question 33

What are the risks assoc with HRT?

Answer 33

``` VTE CVA Breast ca Gallbladder disease HRT > 20 years after menopause greater risk of harm ```

Question 34

Why can clonidine be given in menopausal women?

Answer 34

Regulates temperature at the level of the hypothalamus

Question 35

What is the mode of regelle, yes and sylk in the menopause?

Answer 35

Vaginal lubricants

Question 36

What is the referral criteria to the postmenopausal bleeding clinic?

Answer 36

Post menopausal women (>12 months after LMP) Vaginal bleeding on continuous HRT more than 6 months after start of HRT Vaginal bleeding persisting 6 weeks post stopping HRT

Question 37

What are the benefits of systemic HRT?

Answer 37

Reduction of vasomotor symptoms Improvement of low mood assoc with perimenopause Prevention and treatemnt of vulovovaginal/ urogenital atrophy Reduction of osteoporosis risk and fragility # Improvement of sexual function

Question 38

What are the recommended investigations for menopause below 40?

Answer 38

``` 2 x FSH 4 to 6 weeks apart (menopausal levels >30) Testosterone Sex hormone binding globulin Prolactin TFT Autoimmune studies ```

Question 39

Describe the HRT given to women with a hysterectomy?

Answer 39

Continuous oestrogen only HRT

Question 40

Describe the HRT given to perimenopausal women with an intact uterus?

Answer 40

Sequential combined HRT

Question 41

Describe the HRT given to postmenopausal women, aged 54 or after >4 years on sequential HRT?

Answer 41

Continuous combined HRT

Question 42

Describe the general rules around contraception in the perimenopause?

Answer 42

Perimenopausal woman can get pregnant HRT is NOT a contraceptive unless using IUS/ estradiol regimen Contraception required for 2 years post LMP if <50 or 1 year if >50

Question 43

Which contraceptive methods can be used in perimenopausal women?

Answer 43

CHC and DMPA may be stopped at 50 years but can be continued if benefits outweigh risks but NOT in conjunction with HRT 1st line CHC in women over 40 contains 30 mcg EE or less and a 2nd generation PG (LNG, NE) to lower VTE and CVD risk POP, SDI or Cu-IUD can be used in conjunction with HRT