Postmenopausal Syndromes

Question 1

What is Menopause?

Answer 1

• Permanent cessation of menstruation. It is caused by loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when woman has not had a period for 12 months
• Symptoms typically last for 8 years but may resolve quicker or longer than this. Duration and severity also variable and may develop before or years after onset of menopause. An average woman in the UK goes through menopause at 51 years old.*

Question 2

What are hormonal changes in Menopause?

Answer 2

• Pituitary gland releases FSH and LH to stimulate the ovary but the ovaries cannot produce enough oestrogen and progesterone so there is reduced negative feedback to the hypothalamus and anterior pituitary leading to increased GnRH, FSH and LH

Question 3

What are symptoms of Menopause?

Answer 3

Change in Periods

• Change in length of menstrual cycles
• Dysfunctional uterine bleeding may occur

Vasomotor symptoms (80%) usually daily and continues for 5 years

• Hot flushes
• Night sweats

Urogenital changes (35%)

• Vaginal dryness and atrophy
• Urinary frequency

Psychological

• Anxiety and depression
• Short term memory impairment

Question 4

What is the Climacteric and Perimenopause?

Answer 4

Climacteric

• Period prior to menopause where women may experience symptoms as ovarian function begins to fail. This leads to reduced levels of female hormones primarily oestrogen

Perimenopause

• Time when women are having symptoms of menopause before their final period

Question 5

How is contraception used in Menopause?

Answer 5

Recommended to use effective contraception until:

• 12 months after last period in women >50 years
• 24 months after last period in women <50 years

Question 6

What are long-term complications of Menopause?

Answer 6

• Osteoporosis
• Increase risk of ischaemic heart disease

Question 7

How is Menopause diagnosed?

Answer 7

• No blood test needed if patient is over 45 years but symptoms only
• Blood test could be done between 40-45 years of age
• Blood test should be done if before 40 years of age

Confirmed when serum FSH level are more than 40 milli international units/ml at least twice 4-6 weeks apart

Question 8

What is the management of Menopausal Symptoms?

Answer 8

• Lifestyle management
• Hormone Replacement Therapy (HRT) management
• Non-HRT management

Question 9

What are the methods of lifestyle management in menopause?

Answer 9

• 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
• Smoking cessation, reduction in alcohol and coffee intake
• Mediterranean diet is recommended

Question 10

What are the medications for Hormone Replacement Therapy?

Answer 10

• Oral/Transdermal Combined HRT or Mirena IUS
  
  • If woman has a uterus, important to avoid unopposed oestrogens and it increase endometrial cancer risk
  • Oestrogen alone given either orally or in transdermal patch if woman does not have uterus
• Tibolone: own class of HRT
• Vaginal oestrogen: vaginal pessaries or cream to help with vaginal and urinary symptoms

Question 11

What are the practicalities of administering HRT?

Answer 11

• Sequential HRT: started within 12 months of last period to minimise risk irregular bleeding patterns
• Continuous Combined HRT: not had a period for 12 months. Women can experience irregular bleeding in first 3 months of treatment

Question 12

What are the benefits of HRT?

Answer 12

• Most effective treatment for hot flushes and low mood
• Decline in sexual function is due to lack of oestrogen and HRT which can improve sexual desire and reduce vaginal dryness and pain with sex
• Prevents osteoporosis thereby reducing risk of falls associated fractures
• HRT reduces some urinary symptoms and risk of urine infections particularly when used topical vaginal preparations

Question 13

What are contraindications for HRT treatment?

Answer 13

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

Question 14

What are risks of HRT treatment?

Answer 14

• Venous Thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
• Stroke: slightly increased risk with oral oestrogen HRT.
• Coronary Heart Disease: combined HRT may be associated with a slight increase in risk.
• Breast Cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
• Ovarian Cancer: increased risk with all HRT.

Question 15

What are non-HRT methods of management in Menopause?

Answer 15

• Vasomotor symptoms: fluoxetine, citalopram or venlafaxine
• Vaginal dryness: vaginal lubricant or moisturiser
• Psychological symptoms: self-help groups, cognitive behaviour therapy or antidepressants
• Urogenital symptoms: vaginal oestrogen if suffering from urogenital atrophy. Appropriate if taking HRT or not. Moisturises and lubricants can be offered as well for vaginal dryness
• Alternative therapy: occupressure, acupuncture, reflexology or homeopathy. Role of aromatherapy is not proven beneficial
• Androgen (testosterone) therapy: used for fall in libido or sex drive. Also used for loss of energy and concentration

Question 16

What are important details in regards to stopping treatment of Menopause?

Answer 16

• Vasomotor symptoms: 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term.
• When stopping HRT, it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.
• Referral to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Question 17

What is Post-menopausal bleeding?

Answer 17

Vaginal bleeding occurring after twelve months of amenorrhoea in women at the age where menopause can be expected.

• Can occur in younger women however who have experienced premature ovarian failure or premature menopause. Usually benign but endometrial malignancy should be ruled out

Question 18

What are causes of Post-menopausal bleeding?

Answer 18

• Vaginal atrophy: thinning, drying and inflammation of walls of the vagina due to reduction in oestrogen following menopause causing vaginal bleeding
• HRT
• Endometrial Hyperplasia
• Endometrial cancer (10% of patients with postmenopausal bleeding)
• Cervical cancer
• Ovarian cancer (especially oestrogen secreting (theca cell) tumours)
• Vaginal cancer
• Trauma
• Vulval cancer
• Bleeding disorders

Question 19

What has to be enquired about in the history of a patient with post-menopausal bleeding?

Answer 19

Thorough history necessary

• Timing, consistency and quantity of bleeding
• Gynaecological and obstetric history.
• Important to ask about risk factors for endometrial cancer
• Establish menstrual timelines from menarche to menopause.
• Full drug history including HRT use
• Red flag symptom for gynaecological cancer should be inquired about.

Question 20

What are examinations for Post-menopausal bleeding?

Answer 20

• Vaginal and full abdominal examination: looking for any masses or abnormalities within abdomen or felt from within vagina.
• Immediate test: urine dipstick for haematuria or infection, FBC for anaemia or bleeding disorder, and CA-125 levels.

Question 21

How should women suspected of endometrial cancer be investigated?

Answer 21

• In women over age of 55 with postmenopausal bleeding, transvaginal ultrasound should be done within 2 weeks for endometrial cancer
• Endometrial lining thickness is assessed. Acceptable depth is <5mm. It may miss some pathology so further testing may be required
• Imaging in secondary care could include a CT or MRI of the uterus, pelvis and abdomen

Question 22

How should post-menopausal bleeding be managed?

Answer 22

Managed according to presentation

• Vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy. HRT can also be used
• HRT dependant bleed: Different HRT preparations can be used to try to reduce this
• Endometrial hyperplasia: Usually dilatation and curettage is performed to remove the excess endometrial tissue

Question 23

What are side effects of HRT?

Answer 23

• Nausea
• Breast tenderness
• Fluid retention and weight gain

Question 24

What are potential complications of HRT?

Answer 24

• Increased risk of breast cancer (1.26 Relative Risk at 5 years)
  
  • Increase by addition of progestogen
  • Risk of breast cancer begins to decline when HRT is stopped and by 5 years reaches same level as women who have never taken HRT
• Increase risk of endometrial cancer
  
  • Reduced by addition of progestogen but not eliminated completely
• Increase risk of venous thromboembolism
  
  • Increased by addition of progestogen
  • Transdermal HRT does not appear to increase risk of VTE
  • NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment
• Increase stroke risk
• Increase risk of ischemia heart disease if taken more than 10 years after menopause

Question 25

What are clinical signs of Atrophic Vaginitis?

Answer 25

* Vaginal dryness * Dyspareunia * Vagina may appear pale * Occasional spotting

Question 26

How is Atrophic Vaginitis managed?

Answer 26

* Vaginal lubricants and moisturisers. If It doesn’t help, then topical oestrogen cream can be used

Question 27

What are the types of Urogenital Prolapse?

Answer 27

* **Cystocele, Cystourethrocele:** womans bladder bulges into her vagina * **Rectocele:** tissue between rectum and vgina (rectovaginal septum) becomes week and thin overtime resulting in prolapse the rectum into the vagina * **Uterine prolapse** * **Urethrocele** * **Enterocele:** herniation of the pouch of Douglas, including small intestine, into the vagina)

Question 28

What are the degrees of Uterine prolapse?

Answer 28

* **1^st Degree:** Cervix drops into the vagina * **2^nd degree:** Cervix drops to level just inside opening of vagina * **3^rd degree:** Cervix is outside the vagina * **4^th degree:** Entire uterus is outside the vagina. Condition is also called procidentia. Causes by weakness in all supporting muscles

Question 29

What are risk factors of Urogenital Prolapse?

Answer 29

* Increasing age * Obesity * Spina bifida * Multiparity, vaginal deliveries

Question 30

What is the presentation of Urogenital Prolapse?

Answer 30

* Sensation of pressure, heaviness, bearing down * Dragging discomfort in vagina * Urinary symptoms: frequency, incontinence, urgency * Feeling or seeing bulge or lump coming out of your vagina * Discomfort or dumbness during sex

Question 31

What is the management of Urogenital Prolapse?

Answer 31

* Asymptotic and mild prolapse then no treatment * Conservative management: weight loss, pelvic floor muscle exercises, stop smoking * Ring pessary: plastic or silicone device that fits into the vagina to support pelvic organs and hold up the uterus. * Surgery

Question 32

What are surgical options for treating Urogenital Prolapse?

Answer 32

* **Cystocele/Cystourethrocele:** anterior colporrhaphy, colsuspension * **Uterine prolapse:** hysterectomy, sacrohysteropexy * **Rectocele:** posterior colporrhaphy * **Sacrocolpopexy or Sacrospinous fixation:** Operations that aim to lift up and attach your uterus or vagina to a bone towards bottom of spine or ligament with your pelvis

Question 33

What are risk factors for Urinary Incontinence?

Answer 33

* Advancing age * Previous pregnancy and childbirth * High body mass index * Hysterectomy * Family history

Question 34

What are classifications for Urinary Incontinence?

Answer 34

* **Overactive Bladder (OAB)/Urge Incontinence:** due to detrusor overactivity * **Stress Incontinence:** leaking small amounts when coughing or laughing. Mechanism is due to incompetent urethral sphincter. There is positional displacement of bladder neck or intrinsic sphincter weakness * **Mixed Incontinence:** both urge and stress * **Overflow Incontinence:** due to bladder outlet obstruction

Question 35

When should Vesicovaginal fistulae be suspected?

Answer 35

* Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.

Question 36

What are the initial investigations for Urinary Incontinence?

Answer 36

* Bladder diaries should be completed for a minimum of 3 days * Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) * Urine dipstick and culture * Urodynamic studies * Pads testing

Question 37

What are the investigation results for Stress Incontinence?

Answer 37

**Examination** * Mobile bladder neck when patient performs valsalva * May be prolapse: cystocele, urethrocele **Cystometry** * Normal capacity bladder * Leakage in the absence of detrusor pressure rise * Provoked by cough test * Usually small to moderate loss

Question 38

What are the investigation results for Urge Incontinence?

Answer 38

**Examination** * May demonstrate leakage on coughing and signs of nervous system involvement **Cystometry** * Reduced capacity bladder * Leakage with detrusor pressure rise * Often large loss * Trigger include running water, washing hands

Question 39

What is the general management for Incontinence?

Answer 39

* Sensible fluid intake. Reduce tea, coffee and alcohol * Mobility aids or downstairs toilets. * Pads, bedpans and commodes

Question 40

How is Urge Incontinence managed?

Answer 40

* **Conservative** * **Bladder retraining** – last minimum of 6 weeks and idea is to gradually increase intervals between voiding. * **Electrical stimulation** can also be used for temporary relief * **Medical management** * Antimuscarinics are 1^st line: oxybutynin, tolterodine, tropsium or darifenacin * Immediate release oxybutynin avoided in frail older women * Mirabegron (beta-3 agonist) useful if there is a concern about anticholinergic side effects in frail elderly patients * 2^nd line treatment is Botulinum toxin

Question 41

How is Stress incontinence managed?

Answer 41

* **Pelvic Floor Muscle Training:** recommend at 8 contractions performed 3 times per day for minimum of 3 months * **Surgical procedures** (e.g. retropubic mid-urethral procedures) * Tension free vaginal tape (other tape are transobturator tapes and single incision tapes * Cx: Difficulty emptying bladder completely, and urge incontinence * Burch colsuspension * Cx: Difficulty emptying bladder completely, discomfort during sex and UTIs * Periurethral injections * **Duloxetine** offered to women if they decline surgical procedures

Question 42

What is the mechanism of action and side effects of Duloxetine?

Answer 42

Combined noradrenaline and serotonin reuptake inhibitors * **Mechanism of action:** increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve leads to increased stimulation of urethral striated muscle within the sphincter causing enhanced contraction * **Side effects:** nausea, dry mouth, extreme tiredness, and constipation

Question 43

What is Sacrocolpopexy, Anterior colporrhaphy, and Vaginoplasty?

Answer 43

* **Sacrocolpopexy:** Procedure that suspends the vaginal apex to the sacral promontory. Support is usually afforded by the uterosacral ligaments. * **Anterior colporrhaphy:** Vaginal wall repair following a cystocele. * **Vaginoplasty:** Reconstruction of the vagina for 'tightness' following childbirth