Define menopause
Permanent cessation of menses following loss of ovarian follicular activity
Describe the etiology of menopause
Natural: Occurs in stages where FSH levels are variable and intervals of amenorrhea occur before it stabilizes during postmenopause
Induced: Happens due to removal of ovaries or iatrogenic ablation of ovarian function
What are the 4 broad categories of clinical presentations in those with menopause?
Vasomotor
Genitourinary
Psychological
Bone fragility
What are the vasomotor clinical presentations? Why do they happen?
Intense feeling of heat on face
Rapid/ irregular HR
Flushing
Perspiration
Cold sweat
Sleep disturbances
Feeling of anxiety
Happens due to estrogen withdrawal
Describe the genitourinary symptoms of menopause. Why does it happen?
Genital dryness
Burning/ Irritation/ Pain
Sexual symptoms of lubrication difficulty
Impaired sexual function
Urinary urgency
Dysuria
Recurrent UTI
Happens due to low estrogen
Describe the psychological symptoms of menopause. Why does it happen?
Depression
Anxiety
Poor concentration
Poor memory
Mood swings
Happens due to stress and hormone fluctuations
Describe the bone fragility symptoms of menopause. Why does it happen?
Increased osteoporosis and fractures
Increase joint pain
Happens due to low estrogen
What are some non pharmacological advice to give patients with mild vasomotor symptoms?
Removed layered clothes
Lower room temperature
Eat less spicy food, caffeine and hot drinks
Exercise
Consider dietary supplements such as isoflavones and black cohosh
How does dietary supplements such as isoflavones and black cohosh help with mild menopause symptoms?
Isoflavones: Natural source of phytoestrogen
Black cohosh: serotonergic activity at the hypothalamus
What are some nonpharmacological advice to give patients with mild vulvovaginal symptoms?
Non hormonal vaginal lubricants / moisturizers
When should hormone replacement therapy be considered?
Those with moderate or severe symptoms
Those with insufficient response to non pharmacologicals
When should HRT be avoided?
Treatment for low libido
CVD prevention
Depression / Anxiety / Cognitive / Memory impairment
Itchy skin
Hair loss
Treatment of osteoporosis
What are the types of HRT?
Estrogen only
Estrogen and progestin
What are the indications to using estrogen only HRT?
Women with no more uterus; can be seen by extended periods of no menses
Local vaginal use
Why do we not give women who are still premenopausal estrogen only pills?
Risk of cancer as estrogen can increase endometrial size
What are the indications of estrogen and progestin HRT?
Patients with an intact uterus
What are the types of estrogen HRT?
Oral tablet
Dermal patch
Pessary
Gel
Creams
List the advantage and disadvantages of using systemic oral estrogen tablets.
Advantage: Inexpensive
Disadvantage: High dose lead to risk of endometrial cancer, potential missed doses can cause breakthrough bleeding
List the advantage and disadvantages of systemic topical estrogen HRT.
Advantage: Lower systemic dose; Convenient; Provides continuous estrogen release
Disadvantage: Expensive, can cause skin irritation, gel can have variable absorption
List the advantage and disadvantages of local vaginal HRT such as pessary and creams.
Advantage: Lower estrogen dose (lesser ADR), continuous estrogen release
Disadvantage: Inconvenient and uncomfortable, vagina discharge can occur and is only recommended for those with localized urogenital atrophy
What are the two types of estrogen + progestin HRT?
Continuous cyclic and continuous combined
What is the difference between continuous cycle and continuous combined?
Continuous cyclic:
- Progestin added only on 1st or 15th of each month for 10-14 days
- Can cause withdrawal bleeding when stopped
- Regulates menses and allow predictable bleeding
Continuous combined:
- Progestin with estrogen
- No withdrawal bleeding but has chance of breakthrough bleeding
- Can cause amenorrhea
What is the ideal duration to see improvement of menopause symptoms?
2-3 months
What are the monitoring parameters of HRT?
Annual mammography
Endometrial surveillance to check with patients if:
- On estrogen only: check for vaginal bleeding
- On continuous cycle: Check for bleeding when progestin added
- Continuous combined: Check for frequent bleeding, bleeding prolonged, bleeding heavier than normal, symptoms persisting after > 10 months of treatment
