Menopause

Question 1

Define normal, early

Answer 1

Cessation of menses for >12 months

Early is when <40 yo

Question 2

Average age of onset

Answer 2

Usually 45-55, average age is 50-51

Question 3

The four phases

Answer 3

1. Phase 1 Premenopausal: up to 5 years before the last menstrual period.
2. Phase 2 Perimenopausal: the presence of early menopausal symptoms with vaginal bleeding (usually irregular) 3. Phase

3 Menopausal: the last menstrual period

4. Phase 4 Postmenopausal: approximately 5 years after the menopause

Question 4

During menopause, does the ovary produce must estrogen or androgens

Answer 4

1. The ovary produces little estrogen 2. Produces ++androgens

Question 5

Symptoms overview

Answer 5

1. Vasomotor
2. Psychogenic
3. Urogenital
4. MSK
5. Skin and other tissue changes
6. Other

Question 6

Vasomotor symptoms

Answer 6

1. Hot flushes
2. Night sweats
3. Palpitations
4. Lightheadedness
5. Migraine

Question 7

Psychogenic symptoms

Answer 7

1. Depression
2. Irritability
3. Mood swings
4. Anxiety
5. Tearfullness
6. Poor concentration
7. Sleep disturbance
8. Loss of self confendence

Question 8

Urogenital symptoms

Answer 8

1. Atrophic vaginitis
2. Vaginal dryness
3. Dysparaneuria
4. Decline in libido
5. Bladder dusfunction
6. Stress incontinence

Question 9

Musckuloskeletal symptoms

Answer 9

1. Non-specific muscular aches
2. Non-specific joint aches and pains

Question 10

Skin and other tissue symptoms

Answer 10

1. Dry skin
2. Fornicatioin
3. New facial hair
4. Breast glandular atrophy

Question 11

Other symptoms

Answer 11

1. Unusual tiredness
2. Headache

Question 12

History

Answer 12

1. Symptoms of estrogen deficiency
2. Gynaecological history
3. Obstetric history
4. Mental state symptoms
5. Sexual history
6. Contraception
7. Micturition
8. Social history
9. Family history of osteoporosis, cancer, cardiovascular disease

Question 13

Examination

Answer 13

1. BP, height, weight, waist
2. Breast
3. Abdomen
4. Vaginal examination
5. Pap smear

Question 14

Investigations

Answer 14

1. Urinalysis
2. FBC
3. Fasting lipids, glucose
4. LFTs
5. Mammography

If in doubt, or early

1. Serum FSH
2. Serum estradiol

Question 15

Management

Answer 15

1. Education and lifestyle Diet Obesity Relaxation Exercise Smoking Caffeine and alcohol reduction Pelvic floor
2. Continue sexual relations->use lubricant
3. Contraception for 12 months after last period
4. OCP available until 50/51
5. Consider HRT->allow 6 months to stabilise
6. Estrogen pessary for vaginal dryness
7. Consider non-hormonal: Paroxetine or venlafaxine
8. Consider short term testosterone if loss of libido issue 9. Regular followup

Question 16

Important aspects of the women’s health initiative study

Answer 16

1. first prospective, randomized, controlled clinical trial of hormone replacement therapy (HRT), it aimed to recruit more than 16,000 women and do follow-up on them for 8.5 years.
2. A 37% reduction in colon cancer
3. 34% decrease in hip fractures
4. 2.11-fold increase in deep venous thromboses
5. 26% increase in invasive breast cancer This finding was surprising, since a recent comprehensive review of previous epidemiologic studies had concluded that no convincing link between breast cancer and HRT was present.
6. The big WHI surprises were the 29% increase in heart attacks and the 41% increase in strokes that were seen.
7. A major problem is that HRT is the only potent therapy for vasomotor symptoms and genital atrophy in menopausal women
8. In addition to increased adherence to dietary/lifestyle modifications, women concerned with osteoporosis might be better served by taking SERMs (eg, raloxifene hydrochloride) or bisphosphonates (alendronate sodium, risedronate sodium); either seems to give the same approximate fracture prevention as HRT

Question 17

Indications for HRT

Answer 17

1. Relieving distressing symptoms of hot flushed, urogenital symptoms, sleepiness and joint
2. Transdermal most favoured.

Question 18

Golden rule in HRT

Answer 18

1. Progesterone must be give with estrogen in women who still have a uterus

Question 19

Tibolone

Answer 19

1. SERM
2. Alternative to traditional HRT
3. Vasomotor, urogenital, BMD and fracture risk
4. Not for perimenopausal
5. Breakthrough bleeding and virilisation are the concerns

Question 20

Contraindications to HRT

Answer 20

1. Estrogen dependent tumor
2. Recurrent VTE
3. Acute IHD
4. CAD
5. Cerebrovascular
6. Uncontrolled HTN
7. Undiagnosed vaginal bleeding
8. Acute liver disease
9. Active SLE
10. Pregnancy
11. Osteosclerosis
12. Acute intermittent porphyria

Question 21

Complications

Answer 21

1. Uterine enlargment->irregular bleeding
2. Continued periods
3. Maignancy? No increase in cervical or ovarian cancer Risk of endometrial Ca->relates to unopposed estrogen and duration of use: 3-6X risk after 5 years, 10X risk after 10 years. Breast cancer
4. VTE
5. MI
6. Stroke
7. Cholecystitis and cholelithiasis

Question 22

Side effects

Answer 22

1. Generally well tolerated
2. May have some breast tenderness, HA, breast fullness, often resolves after 3 months.

Question 23

Components of WHI to explain: end point, criticisms, conclusion

Answer 23

1. Were older, had other risks, cannot extrapolate to younger, healthy women early in menopause wanting symptom releif
2. End point- Breast Ca

Secondary end-points +Myocardial infarction +Cerebrovascular accidents +Pulmonary thrombosis

• ve Fracture of the hip
• ve Cancer of the colon

?Endometrial carcinoma

Stopped early as incidence of breast carcinoma increased, not mortality

3. Concluded not suitable for primary prevention->relative risk of adverse effects +15% however, absolute risks not great.