Menopause

Question 1

What is menopause?

Answer 1

The point in a woman’s life where menstruation stops permanently due to loss of ovarian function

Question 2

How is menopause typically diagnosed?

Answer 2

Retrospectively - 12 months of amenorrhea

Question 3

What is peri-menopause?

Answer 3

The period before the menopause characterised by irregular periods

Question 4

What is post menopausal?

Answer 4

The time after a woman has had no period for 12 months

Question 5

When is early menopause and premature?

Answer 5

40-45 years old and <40

Question 6

What hormonal changes occur during menopause?

Answer 6

1. During peri-menopause - the ovaries begin to fail and oestrogen production decreases
2. Reduced negative feedback to the pituitary
3. FSH and LH levels increase
4. FSH levels fluctuate on a daily basis during this stage
5. Falling oestrogen levels disrupt the menstrual cycle and cause typical menopausal symptoms
6. Cycles become anovulatory and follicular development stops
7. Estradiol levels become too low to stimulate the endometrium and amenorrhea occurs
8. Final result is high levels of FSH and LH and low levels of oestrogen

Question 7

What are the symptoms of menopause?

Answer 7

1. Low mood
2. Low sex drive
3. Muscle and joint pain
4. Vaginal dryness
5. Difficulty concentrating
6. Hot flushes
7. Changes to period
8. Trouble sleeping due to night flushes
9. Palpitations
10. Headaches can become worse
11. Changes in body shape and weight
12. Dry and itchy skin
13. Recurrent UTI

Question 8

How would you diagnose menopause?

Answer 8

Women over 45 - symptoms alone

Any abnormal bleeding - investigated and underlying pathology ruled out

Women less than 45 - FSH levels are checked providing they aren’t taking combined HC or HRT

Question 9

What lifestyle advice would you give for menopause?

Answer 9

1. Regular exercise
2. Maintain a healthy BMI
3. Stop smoking
4. Reduce alcohol consumption
5. Avoid triggers
6. Reduce stress
7. Sleep hygiene
8. Relaxation exercises
9. Frequent showers to cool down
10. Wear layers of clothes

Question 10

HRT has a beneficial effect on…

Answer 10

1. Sexual function
2. Urogenitak atrophy
3. Musculoskeletal symptoms
4. Bone mineral density

Used for first line treatment of vasomotor symptoms and low mood

Question 11

Why is transdermal chosen over oral HRT?

Answer 11

Used in women women with:

1. Increased risk of VTE
2. S/E’s from oral preps
3. Concomitant use of hepatic enzyme inducing drugs
4. Malabsorption condition
5. Lactose sensitivity
6. History of migraine

Question 12

What are the C/I’s for HRT?

Answer 12

1. Current, past or suspected breast cancer
2. History/active VTE
3. Oestrogen dependant cancer
4. Undiagnosed vaginal bleeding
5. Untreated endometrial hyperplasia
6. Active liver disease
7. Pregnancy
8. Thrombophillic disorder
9. Active or recent arterial thromboembolic disease

Question 13

What is unopposed HRT?

Answer 13

Oestrogen only

Question 14

What is opposed HRT?

Answer 14

Oestrogen and Progestogen

Question 15

Who would unopposed be used in?

Answer 15

Women who have had a total abdominal hysterectomy or mirena in situ

Question 16

Who would opposed HRT be used in?

Answer 16

Women with a uterus to reduce the risk of endometrial hyperplasia or endometrial cancer

Women with a history of endometriosis who have had a hysterectomy

Question 17

How does sequential HRT work?

Answer 17

Mimics menstrual cycle and causes a monthly bleed

Oestrogen taken continuously and Progestogen taken for the last 12-14 days of the 28 day cycle

Question 18

How does combined HRT work?

Answer 18

Bleed free regimen

Oestrogen and Progestogen are taken together with no break

Recommended in post-menopausal patients 1 year since last period

A lower dose of Progestogen is used

Question 19

What are the risks for HRT?

Answer 19

1. VTE
   - oral greater than transdermal
   - risk with transdermal HRT at standard doses no greater than baseline risk
2. CHD
   - baseline risk will vary from woman to woman
   - HRT with oestrogen alone no/reduced risk of CHD
   - combined little or no increase risk of CHD
3. Endometrial cancer
   - reduced by using opposed
4. Ovarian cancer
   - small increased risk with both HRT
   - risk disappears after a few years of stopping

Question 20

What are the benefits associated with HRT?

Answer 20

1. Fragility fractures
   - risk reduced taking HRT
2. Colorectal cancer
   - 5-10 years of use halves the risk

Question 21

What is tibilone?

Answer 21

Synthetic steroidal compound with oestrogenic, Progestogenic and androgenic activity licensed for the treatment of menopause in post menopausal women

Patients do have a withdrawal bleed

Question 22

What are the risks of tibilone?

Answer 22

1. Stroke
2. Endometrial cancer
3. Breast cancer

Question 23

What is the treatment for urogenital symptoms?

Answer 23

Low dose oestrogen

Blissel gel - 1 applicator contains 50 micrograms estriol
Vagifem - 10 micrograms vaginal tablets
Ovestin - 0.1% cream 1mg cream
Estring - replaced every 3 months max 2 years

Question 24

How do you treat vasomotor symptoms?

Answer 24

• fluoxetine OD
• citalopram 20mg OD
• paroxetine 10mg OD
• venlafaxine 37.5mg for one week then 75mg if tolerated
• clonidine 50 micrograms bd for two weeks then increased to 75 bd if needed
• gabapenin 300mg tds

Question 25

How do you treat urogenital symptoms?

Answer 25

- ky jelly for sec - vaginal moisturisers such as replens MB - used in conjunction with vaginal oestrogen

Question 26

What are alternative therapies to HRT for symptomatic relief?

Answer 26

Isoflavones and black cohosh may relieve vasomotor symptoms but the quality, purity, constituents and safety may be unknown and diff preps may vary

Question 27

How often should women be reviewed?

Answer 27

Every 3 months after starting/changing HRT then annually

Question 28

What should you review?

Answer 28

Efficacy and tolerability, side effects, monitor BP and weight Ensure she doesn’t need to transition from sequi to conti Enquire ab unscheduled bleeding