Menopause

Question 1

Define menopause

Answer 1

The state when a woman has not menstruated for a year, without the influence of any hormonal contraception

Question 2

What is the average age of menopause in the UK?

Answer 2

51yrs

Question 3

Define premature menopause

Answer 3

Menopause before age 40yrs

Question 4

What are the potential causes of premature menopause?

Answer 4

Primary premature ovarian insufficiency
FHx
Chromosomal abnormality such as Turners syndrome
Autoimmune disease
Iatrogenic -> bilateral oophrectomy

Question 5

How does the frequency of periods change in the build up to menopause?

Answer 5

At birth women have a finite number of occytes in utero.
At menarche -> 4000 primordial follicles
Number goes down with age -> more FSH required to stimulate oocyte maturation -> results in irregular and infrequent menstrual cycle.
At menopause no more primordial follicles -> no more ovulation

Question 6

What are the two different forms of oestrogen in the body?
How are they different?

Answer 6

Oestradiol -> produced by dominant ovarian follicle during menstrual cycle, cause endometrial proliferation

Oestrone -> produced by the adipose tissue, less potent than oestradiol.

Question 7

What are the key clinical features of menopause?

Answer 7

• Vasomotor -> hot flush, dry skin, fornification, night sweats
• Genitourinary -> vaginal dryness, urinary frequency and urgency
• Effect on mood -> depression, irritability, mood swings, insomnia and fatigue
• MSK -> muscle pain, joint pain, backache, headache
• Sexual difficulties -> low libido, painful sex.

Question 8

How should menopause be diagnosed?

Answer 8

Clinical diagnosis based on symptoms and menstrual cycle
May aid by bloods: Anti-mullerian hormone (dec with age), oestradiol, follicle count + ovarian vol

Question 9

What investigations should be done for premature menopause?

Answer 9

Check FSH on two occasions 4-6w apart -> elevated indicated ovarian insufficiency
Can not be done if on hormone contraceptives/HRT

Always done in under 40yrs, considered in under 45yrs.

Question 10

What differential diagnosis should be considered for menopause?

Answer 10

HYpothyroidism
Anaemia
Depression
Fibromyalgia

Question 11

What are the different combination of treatment available for HRT?

Answer 11

1. Oestrogen only or combined (O+P)
2. Combined can be sequential (P stopped for breakthrough bleed) or continuous
3. Either can by roal or transdermal (patch, gel, spray)

Question 12

What factors play a role in deciding what HRT method is most appropriate for a woman?

Answer 12

Uterus -> needs combined (reduce endometrial cancer risk)
No uterus -> oesotrgen only (P has breast cancer risk)
Last menstrual period -> frequent may want break through bleed
Risks/contraindications
Preference

Question 13

Draw a decision guide for the different types of HRT available?

Answer 13

Question 14

What are some potential side effects of HRT?

Answer 14

Headache
Nausea
GI symptoms -> bloating
Breast tenderness
Fluid retention/weight gain
Irregular vaginal bleeding (initially)

Question 15

What health conditions does HRT increase the risk of?

Answer 15

Breast cancer -> combined, in oral + transdermal, increase with duration.
Endometrial cancer -> due to P
Ovarian cancer -> both, reduce when stop
VTE
Stroke
Coronary heart disease

Question 16

What should be considered regarding VTE risk when starting HRT?

Answer 16

Higher risk with oral preparations
Transdermal risk same as baseline population
Transdermal and review if RF e.g FHx or PH, obesity, immobility
If significant family history of VTE or thrombophilia refer to haematologist

Question 17

What are the main contraindications for HRT?

Answer 17

Active breast/endometrial cancer
Active VTE
Active cardiovascular disease
Undiagnosed vaginal bleeding
Uncontrolled HTN
Active liver disease with abnormal LFTs
Pregnancy.

Question 18

How should transdermal HRT be applied?

Answer 18

Patches -> clean, dry, non-hair bearing skin below waist
Gel -> upper, outer arm and shoulder or inner thigh
Spray -> dry skin, light mist

Question 19

What additional/alternative medication might be offered to women on HRT?

Answer 19

Contraceptives -> can get pregnant on HRT
Tibolone -> testosterone supplement to help inc libido
Lubricant for vaginal atrophy
Topical moisturisers for dry skin
Clonidine -> vasodilator -> for vasomotor symptoms -> contraindicated in severe bradyC or 2/3rd heart block

Question 20

What lifestyle changes might be recommended in menopause?

Answer 20

Healthy BMI
No smoking
Alcohol <2 units a day
Healthy diet
150 mins exercise per week
Sleep Hygiene
Adequate supplements

CBT if needed

Question 21

What is the link between HRT and osteoporosis?

Answer 21

HRT should not be given post-meno solely to treat osteoporosis
In isolation bisphosponates are more effective
Does have some benefit -> consider in premature menopause when HRT needed regardless

Question 22

What alternative medication can be used to treat osteoporosis in post-menopausal women?

Answer 22

Raloxifene -> selective oestrogen receptor modulator

Question 23

What follow up is required for a woman starting on HRT?

Answer 23

3 months appointment
Some erratic bleeding common
Max benefit reached in 3m
Check effectiveness/bleeding pattern/ SE/compliance/BP/BMI
If bleeding persists after 3m -> refer for investigation of post-meno bleeding

Question 24

What is important to consider for a woman on HRT for surgery?

Answer 24

Stop 4-6weeks prior to planned surgery to reduce VTE risk
Advise compression stokcing + proph LMWH

Question 25

What is the guidance around HRT and contraception?

Answer 25

HRT is not a form of contraception <50yrs contraception for 24months from LMP >50yrs contraception for 12months from LMP

Question 26

What is the key epidemiology of atrophic vaginitis

Answer 26

Peak 50-60yrs Less common than thrush and bacterial vaginosis

Question 27

What is the key pathology of atrophic vaginitis?

Answer 27

Reduction in oesotrogen levels -> post-menopausal women. Leads to alteration in vaginal tissues and local pH Mucus is drier, thinner, easily broken causing irritationand inflammation Glycogen falls -> decrease lactobillia -> increase pH -> infection more likely to develop

Question 28

What conditions can predispose to atrophic vaginitis?

Answer 28

Premature ovarian failure Ovarian failure following chemo/radio Menopause Anti-oestrogen medis such as tamoxifen and danazol Post-partum changes in hormones

Question 29

What are the key clinical features of atrophic vaginitis?

Answer 29

Dryness (57%) Local irritation -> pruritis, pressure or bunring Painful intercourse Vaginal bleeding -> post-coital or haematuria Urinary -> UTI, incontinence, pain with urine Discharge -> white/yellow might be malodorous

Question 30

What are the key signs of atrophic vaginitis?

Answer 30

External - reduced pubic hair, loss of labial fat pad, narrowing introitus, thinning of labia minora Internal - smooth/shiny walls with loss of folds, dryness, loss of muscle tone, erythema or bleeding

Question 31

What is the key management for atrophic vaginitis?

Answer 31

Topical oestrogens -> is absence of other post-meno sympts -> cream, ring or pessary 3 weeks to work, 3 months for maximal effect Or topical lubricants/moisturisers.