PR3152 IC18 (main)

Question 1

describe the menopause progression to perimenopause

Answer 1

variable length (≥7days) difference in the menstrual cycle ==> interval of >60 days of amenorrhea AND vasomotor symptoms

FSH, AMH, inhibin start to change (FSH increase, AMH, inhibin decrease)

AMH for foliculogenesis

Question 2

what is the 4 clinical presentations of menopause

Answer 2

1. Vasomotor symptoms (VMS) eg hot flushes & night sweats
2. Genitourinary syndrome of menopause (GSM)
3. Psychological / cognitive
4. Bone fragility

Question 3

what are the vasomotor symptoms during menopause (and how it happens)

Answer 3

thermoregulatory dysfunction at the hypothalamus level due to estrogen withdrawal. symptoms include
- feeling of heat on face/flushing/reddened face
- anxiety
- sleep disturbance
- sweating/cold sweats
- irregular/increase HR

Question 3

what are the symptoms of genitourinary syndrome of menopause (GSM) (and how it happens)

Answer 3

decreased oestrogen = changes in the labia, urethra, vagina, vestibules, bladder
causing:
- decreased libido/impaired sexual function/painful intercourse/lubrication difficulty during sex
- vaginal irritation/burning/dryness
- recurrent UTI
- dysuria
- urinary urgency

Question 4

describe the mechanisms causing GSM

Answer 4

the vaginal lining becomes thin and dry
less secretions produced during sexual intercourse
vaginal elasticity decreases
the urethra shortens and narrows

Question 5

what are the psych/cognitive symptoms of menopause?
(and how it happens)

Answer 5

likely multifactorial: stress and hormonal fluctuations
- depression, anxiety, mood swings, poor concentration/memory

Question 5

what are the bone fragility problems caused by menopause

Answer 5

decreased estrogen = bone fragility = increased risk of osteoporosis, fractures, joint pain

Question 6

what are some dietary supplements for vasomotor symptoms in menopause?

Answer 6

Isoflavones
- classified as a phytoestrogen
- Food sources: Soybean products, Legumes (lentils, chick pea)

Black Cohosh
- Herb native to North America
- No significant DDI
- Possible serotonergic activity at hypothalamus

Question 6

what are some non-pharmacological methods to menopause symptom resolution? (include the indication)

Answer 6

mild vasomotor:
- layered clothing easily removable
- lower room temp
- avoid spicy food/caffaine/hot drinks
- more exercise
- consider dietary supplements

mild vulvovaginal
- nonhormonal lubricant or moisturisers

Question 6

what is the indication to oestrogen therapy in menopause?

Answer 6

MODERATE to severe symptoms or unresponsive to non-phx

Question 7

what are the types of phx therapy in MHT?

Answer 7

1) estrogen only: in the form of oral, topical, local vaginal (pessaries, etc)

2) COCs

Question 7

rationale for adding progestin to menopausal hormone therapy

Answer 7

for women with intact uterus to stabilise the endometrial lining and prevent overgrowth and reduce risk of endometrial cancer

Question 8

when can estrogen only treatment be recommended in menopausal hormone therapy?

Answer 8

1) no intact uterus
2) local vaginal estrogen only

reduce risk of endometrial cancer without progestin to stabilise the end

Question 8

what is the difference between MHT and COC in terms of formulations used and dosage?

Answer 8

Replace/supplement endogenous estrogen to alleviate symptoms and risks of lower estrogen production

10-15 mcg VS 20-50 mcg
17 beta estradiol OR Conjugated equine estrogens VS Ethinylestradiol OR estradiol

Question 9

pros and cons of systemic tablet for MHT

Answer 9

PRO
Relatively inexpensive

CON
Highest dose required –> higher risk of side effects
Potential for missed doses –> irregular bleeding

Question 10

pros and cons of local vaginal (pessary, cream) for MHT

Answer 10

PRO
Lowest estrogen dose –> no need concomitant progestin
Continuous estrogen release

CON
Inconvenient/uncomfortable
Vaginal discharge
Only for localized urogenital atrophy** (NOT FOR VASOMOTOR SYMPTOMS)**

Question 10

pros and cons of systemic topicals (patch/gel) for MHT

Answer 10

PRO
Lower systemic dose than oral
Convenient
Continuous estrogen release

CON
Expensive
Skin irritation (rotating sites helps)
Gel has more variability in absorption

Question 11

counselling for systemic patches for MHT

Answer 11

Replaced twice a week
–> lower back, abdomen, thigh or buttocks –> rotate sites

Question 12

counselling for systemic gels for MHT

Answer 12

Ruler provided to measure dose of gel –> apply over arms or thigh daily –> let gel dry –> rotate sites

Question 13

counselling for systemic tablets for MHT

Answer 13

Take same time everyday –> once finished with a pack, start a new one right away

Question 14

counselling for vaginal cream for MHT (HOW TO APPLY)

Answer 14

wash hands
squeeze cream on applicator
lie down with knees facing you
insert applicator into vagina and press plunger
if applicator reusable, wash with mild soap and warm water

Question 15

counselling for vaginal pessaries

Answer 15

Inserted twice a week –> insert tablet just before bedtime to minimize movement

Question 15

what are the risks associated with oestrogen only therapy

Answer 15

increased risk of breast cancer, VTE, endometrial cancer, CHD, stroke.

increased endometrial cancer risk can be mitigated with progestin add on.
appears to have some benefit to fracture risk

Question 16

what are the two regimens for combined MHT and compare the benefits/disadvantages

Answer 16

1) continuous cyclic
2) continuous-combined

continuous cyclic may cause some withdrawal bleeding when progestin is stopped. is useful to regulate menses

continuous combined (no withdrawal bleeding) but might cause some breakthrough bleeding at the start. eventually will cause amenorrhea

Question 17

what is the regimen for continuous cyclic MHT

Answer 17

initiated 1st or 15th day of the month, continued for 11-14 days

Question 18

what is the regimen for continuous combined MHT

Answer 18

progestin and oestrogen daily

Question 19

types of progestin available for MHT

Answer 19

Types available: Dydrogesterone, norethisterone, medroxyprogesterone, micronized progesterone, norgestrel, levonorgestrel, gestodene, desogestrel, norgestimate

Question 19

counselling for MHT

Answer 19

understand the risk vs benefits
note that will take 2-3 months for vast improvement
follow up is important
50% patients will have symptoms once stopped

Question 20

what are the follow up required for MHT

Answer 20

1) Annual mammography

2) Endometrial surveillance
- Unopposed estrogen: any vaginal bleeding
- Continuous cyclic: if bleeding occurs when progestin is still on
- Continuous combined: if bleeding is prolonged, heavier than normal, frequent, persists after >10 months after treatment started

Question 21

other pharmacological management other than MHT

what are some other available drugs for use

Answer 21

Antidepressants
- Serotonin and norepinephrine reuptake inhibitors (SNRIs) esp venlafaxine
- Selective serotonin reuptake inhibitors (SSRIs) esp paroxetine

Gabapentin
- Night sweating
- Sleep disturbances

Tibolone ($$$)
- Synthetic steroid with estrogenic, progestogenic and androgenic effects
- Improves mood, libido
- Protects against bone loss, menopause symptoms, vaginal atrophy (less than estrogen)
- Risk of stroke, breast CA recurrence, endometrial cancer
- Only indicated in postmenopausal women ≥ 12 months since last natural period