Menopause and post-reproductive health

Question 1

1st

Answer 1

1st

Question 2

What is the median age for the menopause?

Answer 2

51 years

Question 3

When has menopause occurred?

Answer 3

After 12 consecutive months of amenorrhoea

Question 4

What is the perimenopause?

Answer 4

Time beginning with the first features of approaching menopause eg. vasomotor symptoms and menstrual irregularity and ending with 12months after amenorrhoea

Question 5

When is post-menopause

Answer 5

From last menstrual period but cannot be defined until 12months later

Question 6

When is premature menopause

Answer 6

Menopause before age of 40

Question 7

What % of women have premature menopause

Answer 7

1%

Question 8

What is definition of post-menopausal bleeding?

Answer 8

Bleeding occurring at least 12 months after last menstrual period

Question 9

What is key to exclude with post-menopausal bleeding? x4

Answer 9

Endometrial or cervical cancer - or premalignant endometrial hyperplasia
Ovarian carcinoma

Question 10

Other non-malignant causes of post menopausal bleeding?

Answer 10

Atrophic vaginitis
Cervicitis
Cervical polyps

Question 11

Investigation of post menopausal bleeding?

Answer 11

Bimanual and speculum examination
Cervical smear if out of date
TV sonography - measure endometrial thickness and looks for fibroids or ovarian cysts

Question 12

Management if endometrial thickness 4mm or less + single episode of PMB

Answer 12

Endometrial biopsy and hysteroscopy not required

Question 13

Management if endometrium thicker than 4mm or multiple bleeds

Answer 13

Endometrial biopsy +/- hysteroscopy

Outpatient procedure

Question 14

Treatment of atrophic vaginitis

Answer 14

Topical oestrogens

Question 15

What are the most common symptoms of the menopause?

Answer 15

Hot flushes and night sweats - some can continue to have these into their 60s and 70s

Question 16

Urogenital problems of the menopause

Answer 16

Oestrogen deficiency can cause vaginal atrophy (dyspareunia, itching, burning and dryness) and urinary symptoms (frequency, urgency, nocturia, incontinence and recurrent infection)

Question 17

Incidence of osteoporotic fractures in women >50 years

Answer 17

1 in 3 women over 50 have one or more osteoporotic fracture

Question 18

Normal bone mineral density T score

Answer 18

Between -1 and +1 SD of young adult mean

Question 19

Osteopenia bone mineral density T score

Answer 19

Between -1 and -2.5 SD of young adult mean

Question 20

Osteoporosis bone mineral density T score

Answer 20

> -2.5 SD from young adult mean

Question 21

Most common sites for osteoporotic fractures

Answer 21

Wrist or Colle’s fracture, hip and spine

Question 22

What test gives estimate of the degree of ovarian reserve remaining

Answer 22

FSH - increased levels suggest fewer oocytes remaining in the ovaries

Question 23

When should FSH levels be tested

Answer 23

Between day 2-5 of the cycle to avoid pre-ovulatory increase and luteal phase suppression

Question 24

What test gives a direct measure of the ovarian reserve remaining

Answer 24

AMH - produced by small ovarian follicles - stable throughout the menstrual cycle so can be measured on any day

Question 25

What does a low progesterone level indicate?

Answer 25

Anovulation - secondary to other causes eg. PCOS

Question 26

What is in HRT for women who have had a hysterectomy

Answer 26

Oestrogen

Question 27

What is in HRT for women who have not had hysterectomy

Answer 27

Oestrogen and progestogen

Question 28

How can HRT be given?

Answer 28

Oestrogen - orally, transdermally (patch), SC (implant) | Progestogens - orally, transdermally or directly into uterus (IUS)

Question 29

What oestrogen is used in HRT?

Answer 29

Natural eg. oestradiol, oestrone and oestriol | Not ethinyloestradiol because greater metabolic impact

Question 30

Progestogen used in HRT and its role?

Answer 30

Levonorgestrel or norethisterone - it causes no bleed HRT regimen

Question 31

What is Tibolone?

Answer 31

Synthetic steroid compound - converted in vivo to metabolites with oestrogenic, progestogenic and androgenic actions Used in post-menopausal women who desire amenorrhoea and treats vasomotor, psychological and libido problems - conserves bone mass

Question 32

What sort of HRT regimen is good for women experiencing bleeding or are within 12months of last menstrual period

Answer 32

Sequential or cyclic therapy | Or intrauterine levonorgestrel with oral oestrogen

Question 33

What is the benefit of continuous regimens over sequential regimens of HRT?

Answer 33

Lack of induced bleeding and reduced risk of endometrial cancer

Question 34

How quickly does HRT relieve vasomotor menopausal symptoms?

Answer 34

Within 4 weeks

Question 35

What cancer does HRT reduce the risk of whilst taking it?

Answer 35

Colorectal cancer reduced by about 1/3

Question 36

What cancer risks are increased with oestrogen only HRT?

Answer 36

Endometrial cancer - hence why non-hysterectomised women have progesterone added

Question 37

What cancer risks are increased with combined HRT

Answer 37

Breast cancer - slightly increases the risk - risk falls after stopping HRT

Question 38

What vascular disease is increased risk with HRT?

Answer 38

Venous thromboembolism (VTE) - transdermal patches and gel HRT may decrease this risk

Question 39

What abdominal problem increases with HRT?

Answer 39

Gallbladder disease

Question 40

HRT and ovarian cancer?

Answer 40

Conflicting evidence, some say increase risk and some say none, if there is an increased risk it is small and only after 10 years of HRT

Question 41

Duration of average HRT treatment - if to treat menopausal symptoms

Answer 41

5 years

Question 42

Premature menopause - duration of HRT?

Answer 42

Until median age of menopause - 51 years

Question 43

What non-oestrogen therapy can help vasomotor symptoms x3

Answer 43

Progestogens can be effective SSRIs and SNRIs - effective at treating hot flushes in short term studies Gabapentin - limited evidence that it is effective

Question 44

What non-oestrogen therapy can help vaginal atrophy

Answer 44

Lubricants and moisturisers are available but less effective than oestrogen