Menopause

Question 1

What is menopause

Answer 1

Permanent cessation of menses following the loss of ovarian follicular activity (no more menses for 12 months)

Question 2

Etiology of menoapuse

Answer 2

1. Natural: Perimenopause –> menopause –> postmenopause
2. Induced: Menopause experienced before natural menopause with removal of both ovaries or iatrogenic ablation of ovarian function

Question 3

How is the final menstrual period be determined?

Answer 3

Retrospectively (12 months later)

Question 4

Signs of menopause transition

Answer 4

1. Menstrual cycle starts getting longer and more infrequent (ovaries produce less and uneven hormones)
2. Vasomotor symptoms experienced early
3. Urogenital symptoms tend to occur later

Question 5

What are some vasomotor symptoms (VMS)

Answer 5

Initiated due to estrogen withdrawal
1. Hot flushes
2. Night sweats
3. Intense feeling of heat on face
4. Rapid/ irregular HR
5. Flushing/ reddened face
6. Persipiration
7. Cold sweats
8. Sleep disturbances
9. Feeling of anxiety

Question 6

What are the symptoms of genitourinary symptoms (GSM)?

Answer 6

Due to decreased estrogen
1. Genital dryness
2. Burning/ irritation/ pain
3. Sexual symptoms of lubrication difficulty
4. Impaired sexual function/ libido/ painful intercourse
5. Urinary urgency
6. Dysuria
7. Recurrent UTI

Question 7

Psychological/ cognitive symptoms

Answer 7

Due to stress/ hormone fluctuations
1. Depression/ anxiety
2. Poor concentration/ memory
3. Mood swings

Question 8

What are the clinical presentations/ symptoms associated with menopause? (4)

Answer 8

1. Vasomotor symptoms (aka hot flushes/ night sweats)
2. Genitourinary syndrome (GSM)
3. Psychological symptoms
4. Bone fragility

Question 9

Non-pharmacological therapy for mild vasomotor symptoms

Answer 9

1. Layered clothing
2. Lower room temperature
3. Less spicy food/ caffeine/ hot drinks
4. More exercise
5. Dietary supplements (isoflavones and Black Cohosh)

Question 10

Non-pharmacological therapy for mild vulvovaginal symptoms

Answer 10

1. Non-hormonal vaginal lubricants/ moisturizers

Question 11

When is Hormone Replacement Therapy (HRT) considered

Answer 11

1. Reserved for moderate/ severe symptoms
2. Insufficient response to non-pharmacological
3. Should not be used solely for the treatment of low libido/ CVD prevention/ psychiatric issues/ itchy skin and hair loss/ treatment of osteoporosis

Question 12

When is progestin + estrogen hormone replacement therapy used?

Answer 12

1. When patients have intact uterus (progestin used to protect the endometrium from overgrowth)

Question 13

What are the dosage forms of estrogen available?

Answer 13

1. Systemic oral tablets
2. Systemic topicals (Patches or Gels)
3. Local vaginal (pessary and creams)

Question 14

What are the pros and cons of systemic oral

Answer 14

Pros
1: Inexpensive

Cons
1. Highest dose of estrogen required –> higher risk for side effects
2. Potential missed doses –> irregular bleeding

Question 15

What are the pros and cons of systemic topicals?

Answer 15

Pros:
1. Convenient
2. Lower systemic dose of estrogen vs oral
3. Continuous estrogen release

Cons:
1. Expensive
2. Skin irritation
3. Gel has more variability in absorption

Question 16

What are the pros and cons of local vaginal dosage forms?

Answer 16

Pros:
1. Lowest estrogen dose
2. Continuous estrogen release

Cons:
1. Inconvenient/ uncomfortable (with pessary)
2. Vaginal discharge
3. Only for localized urogenital atrophy

Question 17

Is there a pill-free interval for estrogen-only HRT?

Answer 17

No. Since the patient does not have an intact uterus anymore

Question 18

What are the two ways of administering estrogen + progestin Hormone Replacement Therapy?

Answer 18

1. Continuous cyclic:
   Progestin is added on either the 1st or 15th of the month for 10-14 days while estrogen is continuous –> regulate menses in patients with intact uterus (withdrawal bleeding when progestin is stopped after 10-14 days)
2. Continuous-combined:
   Estrogen and progestin given daily –> no withdrawal bleeding although high risk for breakthrough bleeding initially; amenorrhea may occur after several months

Question 19

Counseling points for patients on HRT

Answer 19

It may take up to 2-3 months of use before seeing a vast improvement of menopausal symptoms –> persevere and continue taking HRT

Question 20

What to monitor when initiated on HRT?

Answer 20

1. Annual mammography –> for breast cancer development
2. Endometrial surveillance (ie. any vaginal bleeding while on estrogen-only HRT, if bleeding occurs when progestins is on)

Question 21

What is the gold standard for treatment of vasomotor symptoms?

Answer 21

Hormone replacement therapy

Question 22

What other alternative treatments are there for treatment of VMS?

Answer 22

1. Antidepressants (SNRI – venlafaxine, SSRI – paroxetine)
2. Gabapentin (for night sweating and sleep disturbances)
3. Tibolone (synthetic steroid with estrogenic, progestogenic and androgenic effects)