Menopause

Question 1

How long before menopause does peri-menopause occur?

Answer 1

• Months to years. Quite variable

Question 2

What is the definition of menopause?

Answer 2

• Lack of menses for 1 year

Question 3

What is the average age of menopause?

Answer 3

51 years old

Question 4

Why do estrogen levels decline in women in menopause?

Answer 4

• Estrogen produced by the granulosa cells in the developing follicle. In menopause no follicle so no estrogen production

Question 5

What happens to levels of follicle stimulating hormone and luteinizing hormone during menopause and why?

Answer 5

• LH and FSH increase
• Estrogen and other ovarian hormones, like inhibin, typically have negative feedback on gonadotrophs, with decreased estrogen this does not occur

Question 6

Where does the majority of a post menopausal womans estrogen come from?

Answer 6

• Fat cells convert circulating androstenedione into a less potent form of estrogen

Question 7

Why do peri-menopausal women get irregular periods?

Answer 7

• Usually the result of anovulatory cycles as the body has difficulty stimulating follicles for ovulation

Question 8

What are the clinical features of menopause?

Answer 8

• Vasomotor (tends to improve w time)
  
  • hot flashes, night sweats, nausea, palpitations, sensation of insects crawling on them (formication)
• Urogenital atrophy
  
  • dysparunia, vaginal dryness/pruritis, urinary frequency/urgency/incontinence
• Skeletal
  
  • osteoporosis, MSK pain
• Decreased breast size, skin thinning
• Psychological
  
  • mood changes, irritable, fatigue, low libido, memory loss

Question 9

What are some long term health effects associated with menopause?

Answer 9

• Cardiovascular disease
• Cerebrovascular disease
• Osteoporosis

Question 10

How does the age of menopause relate to risk of breast cancer?

Answer 10

• More time exposed to estrogen increases risk of breast cancer
• Early menopause decreases risk and late menopause increases risk

Question 11

What effect does estrogen have on the bones?

Answer 11

• Estrogen recetors on bones, estrogen shown to increase osteoblast activity
• Bone resporption and osteoclast activity increased in menopause

Question 12

What is a dowager’s hump?

Answer 12

• Kyphosis in the thoracic spine (old lady hump)

- Can occur from wedge compression fractures due to osteoporosis

Question 13

Why do underweight women have a higher risk of fractures in menopause?

Answer 13

• Less fat and therefore less circulating estrogen produced by conversion of androstenedione to estrogen

Question 14

Testing for follicle stimulating hormone, what level are you expecting in a post-menopausal woman?

Answer 14

• Greater than 30 IU/L

Question 15

Why are progesterones added to HRT regimes if symptoms are primarily caused by estrogen deficiency?

Answer 15

• Unopposed estrogen leads to proliferation of endometrium, which can become hyperplastic and neoplastic
• Progesterone is protective by counteracting this effect

Question 16

In what case would you treat a woman with estrogen only hormone replacement therapy?

Answer 16

• If they have had a hysterectomy

Question 17

What are the risks associated with hormone replacement therapy?

Answer 17

• Endometrial Ca (if unopposed)
• Breast Ca
• Venous thromboembolism
• Stroke
• Nausea
• Breast tenderness
• Bloating
• Mood change
• Cholelithiasis

Question 18

What are the absolute contraindications to hormone replacement therapy?

Answer 18

ABCCD
A - Acute live disease
B - Bleeding (undiagnosed vaginal) 
C - Cancer (Br, uterus)
C - Cardiovascular disease
D - DVT or other thromboembolic disease

Question 19

How long is someone typically on hormone replacement therapy for?

Answer 19

• Generally 2-3 years for vasomotor symptoms.

- If symptoms return with discontinuation a discussion balancing risks and benefits of continuing should occur.