Menopause

Question 1

Symptoms of menopause

Answer 1

Early
• Vasomotor, period change, insomnia, mood change, cognitive function, loss of collagen, fat redistribution, hair loss

Medium
• Vagina: dryness, soreness, dyspareunia
• Bladder: Frequency, urgency, dysuria, UTIs

Late
• Bone deficiency, 1/3 after 20 years (loss of oestrogen causes calcium loss) causing osteoporosis
• Increased risk of cardiovascular disease and stroke after menopause

Question 2

Examination findings in menopause?

Answer 2

Amenorrhoea universal, hot flushes, fatigue, insomnia, poor concentration, vaginal dryness and atrophy, urinary problems, sexual dysfunction

Question 3

Risk factors and management of premature ovarian failure?

Answer 3

Risk Factors
• Bilateral salpingoopherectomy (BSO), mumps, pelvic TB, automimmune disorders, chemotherapy, ovarian degenesis, myotonic dystrophy

Management
• Give HRT until the age of 51 (average age of menopause)

Question 4

Risk factors for osteoporosis?

Answer 4

• Fam hx
• Steroid usage
• Low BMI
• Early BMI
• Increased age
• Smoking
• Alcohol
• Low calcium intake
• Sedentary lifestyle
• Chronic disease

Question 5

Investigations in menopause?

Answer 5

• LH and FSH only useful if diagnosis in doubt as they fluctuate daily in the climetaric (pre-menstrual period)
• Post menopause FSH <30
• Mammography advised every 3 years following menopause
• Endometrial biopsy for PMB
• Bone density assessment for women at increased risk of osteoporosis

Question 6

What is HRT?

Answer 6

• Oestrogen + progesterone (if not had hysterectomy) – only oestrogen if they have (progestogen reduces risk of endometrial hyperplasia  cancer)
• Oral, patch, gel, implant, spray or vaginal ring
• Up to 5 years for menopausal symptoms, can be lifelong for osteoporosis. With premature, should take up to median age of natural menopause (52).

Question 7

Contraindications to HRT?

Answer 7

• Absolute: current breast or endometrial cancer, undiagnosed vaginal bleeding, thrombosis, breast mass, active liver disease
• Relative: endometriosis, fibroids, fam or past hx of breast cancer or thrombotic disease, liver disease

Question 8

Advantages of HRT?

Answer 8

• Short term relief from symptoms
• May regulate irregular bleeding
• Protective against osteoporosis
• Reduces sensory urgency
• Improved hair and skin appearance
• Protective against Alzheimer’s, tooth loss and bowel cancer

Question 9

Disadvantages of HRT?

Answer 9

• Menstruation unless period free preparation
• Oestrogenic and progestogenic side effects
• Increased risk of breast Ca
• VTE and possible CVD
• Risk of endometrial Ca

Question 10

Causes of PMB?

Answer 10

Atrophic vaginitis (most)
Endometrial ca and hyperplasia (20%)
Cervical ca, cervicitis, ovarian ca, cervical polyps

Question 11

Risk factors for endometrial cancer?

Answer 11

• Early menarche, late menopause (prolonged oestrogen exposure results in greater proliferation of endometrium – more likely to become Ca)
• HRT (unopposed oestrogen)
• Polycystic ovaries – each cyst in an ovary is a follicle, stimulated but not released. Never get corpus luteum or release of progesterone – reduced ovulation and repeated oestrogen

Question 12

History and examination in PMB?

Answer 12

History - Menopause diagnosed by 12 months of no bleeding – bleeding after 12-month gap considered PMB.

Exam - Bimanual examination of pelvis
Speculum and cervical smear

Question 13

Investigations in PMB?

Answer 13

FAST TRACK, 10% of women with PMB have endometrial cancer
• Urgent USS
o 5mm thickness or above
o Urgent hysteroscopy and biopsy.

Question 14

Management of endometrial hyperplasia?

Answer 14

• With atypical cells seen – immediate hysterectomy
• No atypical cells seen – high dose progestogens
  o Oral or Oral and Mirena coil

Question 15

Management of endometrial cancer?

Answer 15

Refer to gynae oncology

Question 16

Management of vaginal atrophy?

Answer 16

• Reassure
• Lubricants
• Oestrodial creams (local oestrogen replacement)
  o Even if ER+ve breast cancer can use cream locally