how should menopause be defined?
when are you perimenopause?
> 12 consecutive months of spontaneous amenorrhoea
time of first symptoms until 12 months after LMP
what is the mean age of menopause in UK? what causes it?
when is menopause premature?
- 51
- occurs when there is loss of ovarian follicular activity
- majority of oestrogen generated from testosterone and androstenedione (granulosa and thecae cells)
- <40 years
what do granulosa cells produce?
what happens with regards to oocytes in the menstrual cycle? and progesterone?
- oestradiol
- progesterone production decreases
- number of anovulatory menstrual cycles increases
what can be looked at to clinically clarify menopause?
what is the predominant form of oestrogen in post-menopausal women? how does it compare to oestradiol?
what happen to androgen production?
- FSH levels above 30 IU/L
- androstenedione made by adrenals, converts to oestrone by fat cells
- less potent
- stays the same
what occurs in premature ovarian failure?
- ovaries don’t produce enough oestrogen
- causes secondary amenorrhoea
what are signs and symptoms of menopause?
- vaginal bleeding: irregular periods, menopause can be recognised in retrospect after 2 months amenorrhoea
- hot flushes: (50-85%), lasts around 3 mins associated nausea and palpitations, lack of sleep
- genitourinary atrophy: genitals, urethra and bladder gradually atrophy after menopause
what can genitourinary atrophy cause?
- dyspareunia, dryness and bleeding,
- loss of vaginal glycogen causes a rise in pH, predisposing infection
- urinary symptoms: urgency, frequency, dysuria from atrophic change in trigone
What are the cardiovascular effects of menopause?
- oestrogen protect against vascular disease
- decreased oestrogen causes changes to lipid profile so atherosclerosis
- estradiol promotes vasodilation so higher BP
how does it cause osteoporosis?
what is a dowagers hump?
- trabecular bone oestrogen sensitive (vertebrae, femoral neck, distal radius)
- bone resorption accelerated by menopause
- oestrogen receptors demonstrated on bone cells, oestrogen stimulates osteoblasts directly
- compression fracture of the spine
what hormone can be used as a better marker of follicular reserve than FSH?
what is treatment of menopause? why give progesterones?
- anti-mullerian hormone
- HRT (oral tablets, transdermal, SC, IUS, vaginal rings, nasal spray)
- progesterones have a role in vasomotor symptoms prevent endometrial hyperplasia
- also prevents unopposed oestrogen therapy to avoid endometrial cancer
what are the risks/ SE of HRT?
- nausea and breast tenderness
- endometrial carcinoma (unopposed) 4 fold risk
- mirena protects endometrium in oestrogen only HRT
- breast cancer
- stroke
what are the contraindications to HRT?
- pregnancy
- thromboembolic disease
- history of recurrent thromboembolism
- liver disease
- undiagnosed vaginal bleeding
- following Breast cancer and advanced endometrial cancer
how long should HRT last?
- 2-3 years then stopped, review symptoms and weigh up risks benefit of osteoporosis
what non-hormonal treatment can be given for HRT?
- SSRIs (depression, loss of libido/ self confidence)
- B-blockers for palpitations and tachycardia
- bisphosphonates for osteoporosis
- Vit D and calcitonin
- progestogens for hot flushes)
what are the causes of primary premature ovarian failure?
- chromosome abnormalities (Turners, fragile X)
- FSH receptor gene polymorphism
- enzyme deficiencies/ autoimmune disease
secondary causes of premature ovarian failure?
- chemo/radiotherapy
- bilateral oophorectomy
- hysterectomy
- infection
what diseases is it commonly associated with?
- Addisons, DM, hypothyroid, chromosome abnormalities
What is the most common causes of PMB? (4)
- atrophic vaginitis
- endometrial/ ovarian cancer
- cervical pathology
- endometrial hyperplasia or polyps
what should endometrial thickness be in a postmenopausal woman? How is it measured?
what must you do if thicker?
what drug apart from unopposed HRT will cause thickened endometrium?
- <4mm, transvaginal ultrasound
- biopsy and hysteroscopy if >4mm
- tamoxifen, oestrogen proliferates it, therefore should be hysteroscopy and biopsy
how would you treat:
- atrophic vaginitis
- cervical polyp
- endometrial polyp
- simple/ complex hyperplasia
- atypical hyperplasia/ endometrial ca
- topical oestrogen
- removal via polyp forceps
- hysteroscopy removal
- IUD progesterone (mirena)
- TAH + BSO
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Antenatal Checks17
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Physiological changes in pregnancy6
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Normal development of pregnancies18
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Pregnancy Issues17
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Twins2
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Hypertensive disease and pre-eclampsia14
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Diabetes9
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Medical disorders affecting pregnancy9
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Abnormal labour15
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Disorders of menstrual cycle26
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PCOS11
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The menopause20
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endometriosis and pelvic pain15
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Non-STIs16
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STIs27
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STIs part 2 (HIV syphilis)36
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Molar Pregnancy11
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Infertility10
