Menopause

Question 1

Predominant postmenopausal oestrogen?

Answer 1

Estrone
From androgens produced by ovarian stroma which are aromatised

Question 2

Define menopause

Answer 2

Period following final menstrual period, diagnosis made retrospectively

Normal range 45 - 55; mean 51

Question 3

Define climacterium

Answer 3

Aka perimenopause.

Transitional period leading up to fmp characterised by variation in menses and fluctuating FSH

Question 4

Define premature menopause

Answer 4

Before age 40

(Average 48 - 52 years)

Question 5

Define early menopause

Answer 5

Before age 45

Question 6

Describe the reproductive stages of life according to STRAW (stages of reproductive aging workshop) (4)

Answer 6

• -5: early reproductive phase after menarche. Variable duration. Menstruation variable - regular.
• -4: peak reproductive phase. Regular menstrual cycle.
• -3: late reproductive phase.
  → - 3a: regular menstrual cycle. Low FSH, Amh (anti mullerian hormone) and central follicle count.
  → - 3b: subtle changes in flow/length. Variable FSH (blood draw on cycle days 1-5 = elevated); low AMH, inhibin ß and antral follicle count

Question 7

Describe the menopausal transition stages of life according to STRAW (stages of reproductive aging workshop) (2)

Answer 7

All considered premenopause.

• -2: early menopausal transition. Variable duration. Menstrual cycle variable length but persistent 7 or more day difference in length of consecutive cycles. Increased variability of FSH (blood draw on cycle days 1 -5 = elevated); low AMH, inhibin b, antral follicle count.
• -1: late menopausal transition. Duration 1-3 years. Menstrual cycle interval of amenorrhea 60 days or less. FSH > 25 iu/l; low AMH, inhibin b, antral follicle count. Vasomotor symptoms likely.

Question 8

Describe the postmenopause stages of life according to STRAW (stages of reproductive aging workshop) (4)

Answer 8

• +1: early postmenopause.
  → +1a: premenopausal phase without periods, 1 year. Fsh variable (blood draw cycle days 1-5 = elevated); low AMH and inhibin b, very low antral follicle count. Vasomotor symptoms most likely
  → + 1 b: 1 year.
  → + 1c: 3-6 years. Fsh stabilises; very low AMH and inhibin b, very low antral follicle count. Increasing symptoms of urogenital atrophy.
• • 2: late postmenopause. Remaining lifespan

Question 9

Name negative effects of menopause (9)

Answer 9

• 75% hot flushes and night sweats
• Insomnia → lethargy, chronic tired, irritable, OSA
• deterioration mental health, libido, sad, loss interest, poor concentration, guilt…
• cognitive changes: reduced cognitive function, slower learning, reduced verbal recall
• vaginal atrophy (from dryness)
• weight gain + redistribution body fat to abdomen → insulin resistance, CVD
• bone loss: initially only trabecular bone, later cortical. → fractures, osteoarthritis
• muscle mass deteriorate→ falls, fractures
• skin thickness, elasticity, hydration, collagen reduced → wrinkling. Hair reduced

Question 10

Management bone health menopausal women? (10)

Answer 10

Lifestyle

• Exercise 150 minutes moderate per week. Esp weight bearing
• weight loss of 10.%. Improves insulin resistance but low BMI = poor BMD (less oestrogens)
• limit alcohol to 20g per day
• reduce fall risk: good lighting, handrails, non-slip bath mats, avoid loose carpets, spectacles, less aggressive management bp.

Pharmacological

• MHT: drug of choice in women 50 - 60 with increased # risk
• tibolone: synthetic, binds to oestrogen, progesterone, androgen molecules
• calcium: only supplement if clear deficiency of <1200 mg / day - excessive intake increase risk CVD, renal calculus, constipation
• vitamin D: 800 iu daily intake
• bisphosphonates: inhibit bone resorption and effective but risk atypical femur #, osteonecrosis jaw and esophagitis. Breaks in prescription recommended
• other: SERMS, parathyroid hormone, strontium ranelate, denosumab (monoclonal antibody)

Question 11

Which hormones are used for menopausal management (3)

Answer 11

• Oestrogen only if no uterus and no breast cancer: conjugated oestrogens, estradiol
• add progestogen if uterus to protect endometrium from hyperplasia, malignancy
• tibolone: synthetic drug with oestrogenic, progestogenic, androgen action. Ideal drug

Question 12

Management hot flushes menopausal women? (6)

Answer 12

Lifestyle

• weight control, regular exercise
• slow diaphragmatic breathing
• correct clothing, cold drinks
• avoid triggers eg alcohol, spicy foods

Pharmacological

• oestrogens oral/transdermal very effective
• other: ssri, snri, gabapentin (anti-epileptic)

Question 13

Define osteoporosis

Answer 13

T score < - 2,5 standard deviations

Question 14

Management cardiovascular disease menopausal women? (4)

Answer 14

Lifestyle

• weight loss, exercise, lipid control
• smoking cessation
• bp control

Pharmacological

• Mht: most benefit to women age 50 - 60 or < 10 years since FMP, advantages diminish later due to atherosclerosis and hypercoagulability of oestrogen so actually dangerous.

Question 15

Biochemical diagnosis menopause? (4)

Answer 15

• Estradiol: low
• FSH: high
• inhibin b: low
• AMH: low (not routinely done)