Menopause

Question 1

Define Menopause.

Answer 1

Absence of menses for >12 months (retrospective diagnosis)

• Depletion of oocytes → reduction in ovarian progesterone, oestradiol and testosterone

Question 2

What is the average age of the menopause?

Answer 2

• Average age = 50 ±2
• If <45 = consider investigating premature ovarian insufficiency
• Premature ovarian insufficiency = <40

Question 3

What are the signs and symptoms of the menopause?

Answer 3

• Approx. 75% get symptoms that last for 7 years:
  
  • Persistent amenorrhea – often initial oligomenorrhoea/irregular or shortened cycles
  • Vasomotor symptoms – hot flushes, night sweats, palpitations, headaches
  • Urogenital – vaginal dryness, dyspareunia, frequency, dysuria, recurrent UTI
  • Psychological – poor concentration, lethargy, mood disturbance, reduced libido = Present first

Question 4

What are the appropriate investigations for suspected menopause?

Answer 4

• Pregnancy test
• High FSH and LH
• Serum oestradiol
• Prolactin, TFTs, TVUSS (gynae cancer → bleeding = endometrial; no bleeding and mass = ovarian)

Question 5

What are the routes of HRT?

Answer 5

• Systemic – oral, implant
• Transdermal – hx of DVT/stroke, etc
• Topical – hx of DVT/stroke, etc
• Remember to consider if the women has a uterus or not

Question 6

What lifestyle changes can be made to help menopause symptoms?

Answer 6

• Lifestyle change – exercise, alcohol, caffeine, weight loss, stress reduction
  
  • Hot flushes = regular exercise, WL, reduce stress
  • Sleep disturbance = sleep hygiene (regular, good times), no late evening exercise
  • Mood = sleep hygiene, regular exercise, relaxation techniques
  • Cognitive symptoms = sleep hygiene, regular exercise

Question 7

What is the management of the menopause if lifestyle changes don’t help enough with symptoms?

Answer 7

Hormone Replacement Therapy (HRT)

• Oestrogens Alone – only in women who have had a hysterectomy
  
  • Oral oestrogen (standard therapy)
  • Transdermal oestrogen patch (BMI >30; due to lower VTE risk)
• Oestrogen with Progestogen – progesterone protects endometrium
  
  • Oral
  • Transdermal (less clot risk)
  • Vaginal creams/gel (less clot risk)
  • Implant
• Cyclical/Sequential pattern/SCT (peri-menopausal)
  
  • Monthly = oestrogen every day of month + progesterone for the last 14 days
    
    • Indication = regular periods and menopause symptoms
  • 3-monthly = oestrogen every day for 3 months + progesterone for last 14 days
    
    • Indication = irregular periods and menopause symptoms
• Continuous pattern/CCT – post-menopausal
  
  • Oestrogen and progesterone every day

Question 8

What are the benefits of HRT?

Answer 8

• Improved menopause symptoms
  
  • Vasomotor, sleep, and genital tract symptoms (dryness, dyspareunia)
• Prevention of osteoporosis

Question 9

What are the risks of HRT?

Answer 9

• Cancer
  
  • Oestrogen-only = breast cancer, endometrial cancer
  • Combined = breast cancer
• VTE
  
  • 2-4x higher
  • 2 per 1,000 taking HRT over 7.5 years

Question 10

What are the side effects of HRT?

Answer 10

• Oestrogenic = breast tenderness, nausea, headaches
• Progestogenic = fluid retention, mood swings, depression
• Unscheduled vaginal bleeding (common in first 3 months of HRT)
  
  • Sequential > continuous HRT
  • Investigate if it continues past 6 months (or after a spell of amenorrhoea)

Question 11

What are the absolute contraindications for HRT?

Answer 11

• Undiagnosed vaginal bleeding
• Pregnancy
• Breast cancer
• Severe liver disease
• History of VTE
• Current thrombophilia (AT-III, FV Leiden)

Question 12

What are the non-hormonal therapy options for the menopause?

Answer 12

• Vasomotor symptoms
  
  • 1st line = SSRIs - fluoxetine
  • 2nd line = citalopram, venlafaxine
  • 3rd line (in research) = gabapentin
  • Alpha agonists are licenced but there are lots of anti-ACh side effects
• Vaginal dryness = Lubricants
• Osteoporosis treatments (e.g. bisphosphonates)

Question 13

What are the contraceptive requirements in the menopause?

Answer 13

• Until >1-year amenorrhoeic if >50yo
• Until >2-years amenorrhoeic if <50yo