The approx 4yr menopausal transition spans what time? aka perimenopause
- from changes in menstrual pattern
- to menopause
Define menopause
- permanent cessastion of menstruation due to loss of ovarian follicular function
- retrospective diagnosis of 12months amenorrhea
What is menopause before 40yrs
Premature ovarian faliure
In the menopausal transition how does the length of menstrual cycle (MC) change ? Why?
-MC becomes shorter
-due to less inhibin B allowing elevated FSH so earlier oestrogen surge and ovulation
(reduced follicular phase)
-up to 4yrs before final menstrual period , irregular/amennhorea episodes may occur..why? Consequence?
- due to lack of CL (so no progesterone/oestrogen)
- impaired fertility
-up to 1yr before menopause hot flushes may occur, why is this? Name 3 other symptoms that arise as a result of this.
-increased sweating (reduced tolerance to range in temp)
-disturbed sleep
-vaginal dryness
as low oestrogen
Suggest why menopause happens?
- v few follicles left at this age, GC decreases
- implicates oocyte and more chromosomal abnormalities
What happens about 14yrs before menopause? Is there any ovarian environment factors that may play a role?
- the critical threshold, maybe due to DNA repair defects.
- there is an accelerated decline in number of ova
- smoking causes the transition 2yrs earlier
How does the critical threshold lead to accelerated follicular loss? By recruiting more.. 3 hormones involved…
- increased rate of recruitment (more die as only 1 chosen)
- as usually GC’s express AMH which inhibits FSH, but now AMH production decreases so more FSH recruits more
- inhibin B release from GC decreases so again more FSH
- less inhibin A as no luteal phase in the anovultory cycles so more FSH
How do changes in the FSH receptors contribute to the critical threshold?
-Less FSH receptors which have decreased selectivity so the dominant follicle may not be selected (more anovulatory cycles with no CL)
Why in the late MT may there be delayed/no ovulation?
-although E2 levels rise, they may not reach enough to induce the LH surge so ovulation isnt initiated
-what is the symptomatic result of longer oestrogen stimulation of the endometrium?
Heavier periods due to more proliferation
What hormone is disturbed by the steep decline in oestrogen levels that gives rise to the “hot flushes”?
-5HT levels are disturbed
What is the first hormone to decrease in the MT?
AMH (followed by inhibin B…oestrogen isnt until the late MT)
When should menopause be investigated clinically? How is this done?
- if under 45yrs
- 2x FSH level tests at least 4wks apart
Suggest 3 epidemiological variants in age of menopause onset factors:
-smoking, ethnicity, mother’s age of it, gynae surgery/chemo
Ovarian volume is used to estimate the number of follicles, what is used as an indicator of fertility?
-looking at antral follicle response to stimulation
What is HRT? Main use?
-oestrogen replacement
-1ry treatment for hot flushes (NB-contraindications)
(risks are v low short term, but breast cancer risk continues for 10yrs after stopping HRT)
Is HRT a suitable contraceptive?
No. Need to take contraception is less than 12months ammenorrhea.
What must a women take if she has a uterus or doesnt have a Mirena coil while taking HRT? Why?
- progesterone for 13days/month to allow shedding
- as it protects vs endometrial proliferation and cancer
Name 3 potential risks of HRT? And 1 unwanted effect?
- Risks: obesity, breast cancer, thrombosis
- Unwanted: nausea and mastalgia
Give 3 methods of administration of HRT.
-tablet, patches, sub-cut implants, gel patches (less risk of thrombosis), vaginal suppositories
What other things have HRT been used to treat? ?Name 2
- prevent CHD
- improve sex
- prevent dementing disorders
- prevent tiredness/irritability
What are 5 important things to consider in chronic management of menopause?
- Treat hot flushes
- Address Smoking
- More PA, monitor BMI and Nutrition
- CV Management
- Mammography and Cervical Cytology
