menopause

Question 1

First of all define Menorrhagia, Dysmenorrhoea, oligomenorrhoea, IMB and PCB?

Answer 1

Menorrhagia = Heavy periods, technically >80ml but its subjective

Dysmenorrhoea = painful periods

Oligomenorrhoea = Irregular periods

IMB = Intermenstrual bleeding

PCB = Post-coital bleeding

Question 2

What questions might you ask when a patient complains of heavy or painful periods?

Answer 2

Are they clots &how large?
Do you use tampons or pads or both?
What type do you use and how often do you change them?
Do you ever flood (aka bleed through clothes)?
QOL questions like does it affect your work, hobbies or ability to go out in public?

Question 3

Age is a good way of narrowing down the likely cause of abnormal bleeding, What problems might you expect in an early teenager?

Answer 3

Probably anovulatory cycles, which is quite normal as they go through puberty
Or a coagulation disorder (unlikely to develop later)

Question 4

What problems might you expect in someone from puberty up to their 40s? (fertile age)

Answer 4

Chlamydia
Contraception issues
Endometriosis or adenomyosis
Fibroids
Endometrial or cervical polyps
Dysfunctional Bleeding

Question 5

mechanism of menopause

Answer 5

Ovarian insufficiency:
• oestradiol falls
• FSH rises
• still some oestriol from peripheral conversion of adrenal androgens in fat

Question 6

At what average age do women go through menopause?

Answer 6

51

still have 1/3rd of life after menopause

Question 7

How can menopause present?

Answer 7

• Naturally

- After radiotherapy/chemotherapy/oophorectomy

Question 8

Symptoms of menopause?

Answer 8

•	Vasomotor symptoms  ‘hot flushes’
o	80% women - 45% find them a problem
o	usually last 2-5 yrs- may be 10 years+
•	Vaginal dryness / dyspareunia
•	Low libido
•	Muscle and joint aches
•	Mood changes / poor memory
•	Itchy 
•	Sweaty 
•	Sleepy 
•	Bloated

Question 9

what are the silent changes which present during menopause?

Answer 9

OSTEOPOROSIS

Question 10

Prevention and treatment?

Answer 10

• HRT
• Bisphosphonates
• adequate calcium and vitamin D
• denosumab -monoclonal antibody to osteoclasts
• teriparatide

Question 11

Types of HRT

Answer 11

SYSTEMIC ORAL/TRANSDERMAL

• oestrogen only - no uterus
• combined - oestrogen and progesterone- has uterus

LOCAL VAGINAL

• Oestrogen only
• Pessary/ring/cream

Question 12

Why do you use progesterone?

Answer 12

To protect endometrium against endometrial hyperplasia

Question 13

Contraindications for systemic HRT?

Answer 13

• Current Hormone dependent cancer breast/endometrium
• Current active liver disease
• Un-investigated abnormal bleeding
• Seek advice if previous VTE / Thrombophilia/ FH VTE
• Seek advice if previous breast cancer of BRCA carrier

Question 14

Benefits of HRT?

Answer 14

• Vasomotor- helps control hot flushes
• Effect on local genital symptoms e.g. vaginal dryness
• Effect on osteoporosis: Reduce fractured femur
• Reduced colon cancer

Question 15

Risks of HRT?

Answer 15

• Risk of breast cancer with combined HRT
• Ovarian cancer
• Venous thrombosis if oral route
• CVA If oral route

Question 16

NICE guidelines for HRT?

Answer 16

• For severe vasomotor symptoms
• For women with premature ovarian insufficiency
• Not as first line for osteoporosis prevention- BISPHOSPHONATES
• Vaginal oestrogen if they only have vaginal symptoms