Menopause, HRT and Amenorrhoea Flashcards
What is the average age of menopause onset?
51
What is perimenopause?
- Refers to the time during which your body makes the natural transition to menopause
- Occurs for approx 5 years before onset of menopause
Sometimes women can start menopause prematurely, at what age is considered ‘premature menopause’?
40 years or less (this only affects 1% of women)
What happens during menopause?
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Ovarian insufficiency
- Reduction of circulating oestrogen - Oestradiol (the strongest of the 3 naturally produced oestrogens and the main oestrogen found in women) levels fall
- Reduced sensitivity of the ovary to circulating gonadotropins (FSH and LH) as a result of a marked decrease in available binding sites due to the reduction in follicle numbers.
- The result of this reduced sensitivity is the reduction in oestrogen secretion and an increase in anovulatory cycles.
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FSH rises
- The low levels of circulating oestrogen in turn remove the -ve feedback on the hypothalamus and the pituitary gland. The decrease in developing follicles also reduces the amount of inhibin released – causing an enhanced rise of FSH.
What are the symptoms associated with menopause?
-
Vasomotor symptoms - due to the constriction or dilation of blood vessels. Affects 80% of women. Usually last 2-5 years but may be 10+ years.
- Hot flushes
- Night sweats
- Sleep disturbance as a result
- Vaginal dryness / soreness - can result in dyspareunia (pain during sex)
- Low libido
- Muscle and joint aches
- ? Mood changes / poor memory - possibly related to vasomotor symptoms affecting sleep
Menopause and Osteoporosis
- Oestrogen protects bone mass and density through reducing the activity of oesteoclasts.
- With the drop in oestrogen this balance is tipped and there is an increase in bone reabsorption.
- This results in an acceleration of age related loss of bone density and an increased frequency in fractures, especially of the wrist and hip.
Puts menopausal women at higher risk of fractured hip / vertebra
Prevention and treatment of Osteoporosis in Menopausal women
- Weight bearing exercise
- Adequate calcium & Vit D
- Bisphosphonates - 1st line - for osteoporosis class of drugs that prevent the loss of bone density
- HRT - oestrogen replacement
- Denosumab - monoclonal antibody to osteoclasts - slows down the natural rate your bones are broken down.
- Calcitonin - hormone replacement - works to reduce blood calcium by preventing osteoclast activity - opposite of PTH
What is the main treatment to relieve the symptoms of menopause?
Hormone replacement therapy (HRT)
Which hormones does HRT replace?
- Oestrogen - types used include estradiol, estrone and estriol
- Progesterone - a synthetic version of the hormone called progestogen is given - such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel
You can get oestrogen only HRT, however, this increases a woman’s risk of endometrial cancer so it is only indicated in women who have had a hysterectomy.
What routes can HRT be taken?
Local vaginal HRT
- pessary / ring / cream - oestrogen only - helps with dryness etc but not vasomotor symptoms. Can be taken without progestogen as they don’t carry the usual risks of HRT
Systemic HRT
- Oral - Both oestrogen-only (only indicated if you have a hysterectomy as oestrogen only can increase risk of endometrial cancer) and combined are available as tablets
- Transdermal (avoids first pass - less risk VTE) - Oestrogen-only and combined patches are available.
- Implant - if you still have your womb, you’ll need to take progestogen separately too.
What are the 2 HRT treatment routines? And describe them.
The 2 types of routines are cyclical (or sequential) combined HRT and continuous combined HRT.
Cyclical combined
- 14 days oestrogen and 14 days oestrogen + progestogen
- Expect a withdrawal bleed after the progestogen
- Used if there is still some ov function to avoid irregular bleeding
Continuous combined
- 28 days Oestrogen and Progestogen oral/patch
- Expect to be bleed-free (after the first 3 months)
- Use if > 1 year after menopause has started or age 54+
Then any age can use Mirena IUS and daily oestrogen
What are the contraindications to systemic HRT?
You should not take Systemic HRT if you have:
- Current hormone dependent cancer of the breast/endometrium - these cancers are dependent on hormones for growth and/or survival.
- Current active liver disease
- Uninvestigated abnormal bleeding
You should seek advice before starting HRT if you have:
- Had previous VTE, thrombophilia, FH of VTE
- Had previous breast cancer or BRCA carrier
Other than HRT, how else can menopausal symptoms be treated?
- Selective Estrogen Receptor Modulators (SERMs) - can both mimic and block oestrogen’s effects in different tissues (eg tibolone )
- Phytooestrogen herbs - plant-based compounds that mimic estrogen in the body eg red clover/soya
- Hypnotherapy / exercise / Cognitive behavioural therapy
- Non hormonal lubricants for vaginal dryness i.e Regular eg Replens TM or before sex ‘Sylk’ TM
Benefits and risks of HRT
Benefits
- Vasomotor symptom relief
- Local genital symptoms can be easily treated
- Osteoporosis prevention
Risks
- Breast cancer if combined HRT
- Ovarian cancer
- Venous thrombosis - if oral route
- CVA - Cardiovascular accident - stroke - if oral route
It shouldn’t increase CV risk if HRT is started before age of 60
What is Andropause?
The ‘male menopause’
- A condition associated with a reduction in testosterone levels - it falls by 1% a year after 30
- No sudden change unlike menopause
- Fertility remains
- May cause depression, loss of sex drive, erectile dysfunction, and other physical and emotional symptoms when they reach their late 40s to early 50s.
