O&G menopause

Question 1

Menopause definition

Answer 1

Permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.

Question 2

Menopausal symptoms

Answer 2

Hot flushes
Sleep disturbance
Mood
Cognitive symptoms

Menopausal symptoms are very common and affect roughly 75% of postmenopausal women. Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.

Question 3

Management of menopausal symptoms: lifestyle

Answer 3

Hot flushes
- regular exercise, weight loss and reduce stress

Sleep disturbance
- avoiding late evening exercise and maintaining good sleep hygiene

Mood
- sleep, regular exercise and relaxation

Cognitive symptoms
- regular exercise and good sleep hygiene

Question 4

Management of menopausal symptoms: HRT

Answer 4

the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Contraindications of HRT:

• Current or past breast cancer
• Any oestrogen-sensitive cancer
• Undiagnosed vaginal bleeding
• Untreated endometrial hyperplasia

Do NOT give unopposed oestrogen in people with uteruses
Mirena coil can act as progesterone part of HRT

Question 5

HRT: side effects

Answer 5

• nausea
• breast tenderness
• fluid retention and weight gain

Question 6

HRT: adverse effects

Answer 6

• Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT. Refer to haematology if at high risk of VTE before any treatment. Increased by addition of progestogen
• Stroke: slightly increased risk with oral oestrogen HRT.
• Coronary heart disease: combined HRT may be associated with a slight increase in risk.
• increased risk of ischaemic heart disease if taken more than 10 years after menopause
• Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised. Increased by addition of progestogen, increased risk with longer duration, 5 years after HRT risk is same as women without HRT
• Ovarian cancer: increased risk with all HRT.
• Increased risk of endometrial cancer: reduced by addition of progestogen, do not give oestrogen unopposed in people with wombs, additional risk limited if progestogen continuous

Question 7

Menopause management: non-HRT

Answer 7

Vasomotor symptoms:
- fluoxetine, citalopram or venlafaxine

Vaginal dryness:
- vaginal lubricant or moisturiser

Psychological symptoms:
- self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms:

• if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
• vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Question 8

Stopping HRT

Answer 8

For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term.

Gradually reducing HRT is better to reduce recurrence in the short term