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Questions and Answers
Bilateral salpingo-oophorectomy may be performed prophylactically for women at high risk of inherited malignancies such as breast and __________ cancer.
ovarian
Immediate effects of menopause include vasomotor symptoms such as hot flushes and __________.
night sweats
Long-term effects of menopause that may occur include osteoporosis and __________ disease.
cardiovascular
The exact aetiology of a vasomotor symptom is unknown but is thought to be loss of the modulating effect of __________ on serotinergic receptors.
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The menopause is defined as the woman's final ______ period.
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Vasomotor symptoms can occur in up to __________% of women experiences.
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The average age of menopause is between ______ and 52 years.
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Psychological symptoms during menopause may include low mood, irritability, and lack of __________.
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Primary ovarian insufficiency occurs before the age of ______ years.
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The initial irregular vaginal bleeding during menopause is due to a reduction in oestrogenic __________ stimulation.
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Women with a high body mass index (BMI) tend to get worse __________ symptoms.
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Secondary amenorrhoea may lead to a diagnosis of ______.
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GnRH agonists such as ______ can induce a temporary menopause.
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Add-back therapy is used to relieve unwanted menopausal ______.
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Iatrogenic menopause can occur due to treatments like ______ or chemotherapy.
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Women in surgical menopause aim to treat benign ______ conditions.
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Changes in serum lipid levels include increases in triglycerides and total cholesterol, along with a reduction in ______ cholesterol.
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Regular exercise, stopping smoking, and reducing alcohol consumption can help maintain a normal ______.
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Hormonal replacement therapy includes ______ and progestogen to protect the endometrium.
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In women who have not had a hysterectomy, progestogen is necessary to prevent ______ hyperplasia.
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Systemic oestrogen-only HRT is suitable for women who no longer have a ______ following a hysterectomy.
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Absolute contraindications for hormone therapy include suspected __________.
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Testosterone is traditionally given to women with disorders of sexual ______ and energy levels.
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Cyclical HRT usually includes ______ days of oestrogen alone and 10–12 days of oestrogen and progesterone combined.
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One potential side-effect associated with progestogen is __________ retention.
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Breast cancer risk may increase by an additional __________ to six cancers with combined HRT use.
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The oral route of HRT is convenient and cheap but can influence lipid metabolism and the ______ system.
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Transdermal HRT may have a lower effect on __________ incidence due to its avoidance of hepatic effects.
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One of the side-effects associated with oestrogen is __________ or swelling.
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The transdermal route delivers oestradiol directly into the __________.
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Levonorgestrel may be administered as an intrauterine releasing system called __________.
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For osteoporosis prevention, a daily intake of __________ grams of calcium is recommended.
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Vitamin D3 supplementation of __________ IU/day can help reduce osteoporosis and fractures.
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Biphosphonates, like __________, are used to treat and prevent osteoporosis.
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Hormonal treatment for osteoporosis may include __________, combined oestrogen, and tibilone.
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Key benefits of hormone replacement therapy (HRT) include alleviation of __________ symptoms.
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Cessation of smoking and reducing alcohol intake are important for preventing __________ loss.
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Study Notes
Overview
- Menopause: Final menstrual period, confirmed retrospectively after 1 year of amenorrhea.
- Cause: Cessation of regular ovarian function.
- Average age: 51-52 years old, with 95% of women experiencing menopause between 45 and 55.
Diagnosis
- Elevated FSH levels (over 30 IU) at least 6 weeks apart are needed for diagnosis.
Non Physiological Menopause
- Premature Ovarian Insufficiency (POI): Occurs before 40 years of age.
- Affects approximately 1% of women under 40 and 0.1% under 30.
- Gamete donation is the only option for conception.
- Diagnosed after primary or secondary amenorrhea.
- Can cause unpredictable bleeding and a small risk of pregnancy.
- Causes of POI:
- Primary:
- Chromosome anomalies (e.g. Turner's, Fragile X)
- Autoimmune disease (e.g. hypothyroidism, Addison's, myasthenia gravis)
- Enzyme deficiencies (e.g. galactosemia, 17a-hydroxylase deficiency)
- Secondary:
- Chemotherapy or radiotherapy
- Infections (e.g. tuberculosis, mumps, malaria, varicella)
- Primary:
Iatrogenic Menopause
- Medical treatments that induce menopause:
- GnRH agonists (e.g. buserelin, goserelin): Used for endometriosis and other gynecological problems.
- Cause temporary menopause with rapid onset.
- Managed with hormone therapies and add-back therapy.
- GnRH agonists (e.g. buserelin, goserelin): Used for endometriosis and other gynecological problems.
- Surgical Menopause:
- Performed to treat benign gynecological conditions (e.g. menstrual disorders, fibroids, endometriosis).
- Bilateral salpingo-oophorectomy (BSO) is also performed prophylactically for women at high risk of inherited malignancies (e.g. breast and ovarian cancer).
Effects of Menopause by Time of Onset
- Immediate (0-5 years):
- Vasomotor symptoms: Hot flushes, night sweats.
- Psychological symptoms: Mood swings, anxiety, tearfulness.
- Loss of concentration, poor memory.
- Joint aches and pains.
- Dry and itchy skin, hair changes.
- Decreased sexual desire.
- Intermediate (3-10 years):
- Vaginal dryness, soreness.
- Dyspareunia (painful intercourse).
- Urgency of urine.
- Recurrent urinary tract infections.
- Urogenital prolapse.
- Long term (>10 years):
- Osteoporosis.
- Cardiovascular disease.
- Dementia.
Central Nervous System and Vasomotor Symptoms
- Vasomotor symptoms:
- Colloquially known as "hot flushes." Night sweats are hot flushes that occur at night.
- Thought to be caused by the loss of oestrogen's modulating effect on serotinergic receptors in the brain.
- Result in exaggerated peripheral vasodilatory responses to minor temperature changes.
- Occur in up to 80% of women, with less than 30% seeking help.
- Night sweats can be highly distressing.
- Triggers include alcohol, caffeine, and smoking.
- Worsened by high BMI.
Psychology and Mood
- Menopause is associated with low mood, irritability, lack of energy, tiredness, and impaired quality of life.
Endometrial Effects
- Initial irregular or scanty bleeding is caused by reduced oestrogenic endometrial stimulation.
- Periods cease when the endometrium is no longer stimulated.
Lifestyle Issues
- Changes in body fat distribution: From gynecoid (breasts and hips) to android (abdominal).
- Changes in serum lipid levels: Increase in triglycerides, total cholesterol, and LDL cholesterol with a reduction in HDL cholesterol.
Management
- Diet and lifestyle:
- Regular exercise.
- Smoking cessation.
- Reduced alcohol consumption.
- Normal BMI.
- Reduced calorie intake.
- Benefits:
- Fewer, less severe vasomotor symptoms.
- Beneficial effects on bone loss.
- Reduced incidence of breast and endometrial cancer.
- Reduced risk of CVD.
- Prevention of lung cancer.
- Improved bone health.
Non-Hormonal Approaches
- Phytoestrogens: Contain isoflavones, which may reduce vasomotor symptoms, osteoporosis, cardiovascular disease, and the risk of breast and endometrial cancer.
- Biphosphonates: Pyrophosphate analogues that interfere with osteoclastic resorption (e.g., alendronate). Used to prevent and treat osteoporosis and fractures.
Hormonal Replacement Therapy (HRT)
- Types of hormones:
- Oestrogens:
- Risk of endometrial hyperplasia and cancer if given without progestogen.
- Systemic oestrogen-only HRT is suitable for women who have had a hysterectomy.
- Oestrogen with progestogen:
- Needed to protect the endometrium in women who have not had a hysterectomy.
- Given cyclically over a 28-day cycle.
- Can cause regular monthly menstruation.
- Suitable for women during the perimenopause or early postmenopausal years.
- Can be given continuously.
- Testosterone:
- Traditionally given to women with sexual desire and energy level issues.
- Oestrogens:
- Routes of HRT delivery:
- Oral: Convenient and cheap, but influences lipid metabolism and coagulation through its effects on the liver.
- Transdermal: Patches or gels applied to the skin.
- Delivers oestradiol directly into circulation, avoiding liver and coagulation effects.
- Vaginal tablets, rings, and creams:
- Useful for lower genital tract symptoms.
- Progestogen can be administered via an intrauterine releasing system (IUS, Mirena®).
- Provides contraception, controls bleeding, and offers endometrial protection for up to 5 years.
Tibilone
- Synthetic hormone preparation.
Osteoporosis Prevention and Treatment
- Non-hormonal treatments:
- Lifestyle modification:
- Supplementary calcium: 1-1.5 g/day
- Weight-bearing exercise: Walking, jogging
- Vitamin D supplementation: 1500-2000 IU/day
- Sunlight exposure: Enhances vitamin D3 synthesis.
- Smoking and alcohol cessation.
- Reduced high coffee intake.
- Reduce medications that cause bone loss (e.g. corticosteroids).
- Nutritious diet: Balanced with calcium and protein.
- Periodic bone density evaluation (hip).
- Phytoestrogens: May lower the incidence of vasomotor symptoms, osteoporosis, CVD, and the risk of breast and endometrial cancer.
- Biphosphonates: Interfere with osteoclastic resorption (e.g., alendronate).
- Lifestyle modification:
- Hormonal treatment:
- Oestradiol: 2mg or equivalent. Increases bone mass.
- Combined Oestrogen with progestogen.
- Tibilone.
Key Benefits of HRT
- Vasomotor symptoms:
- Improved hot flushes.
- Improved sleep patterns.
- Improved daytime performance.
- Prevention of osteoporosis:
- Increased bone mineral density.
- Reduced incidence of fragility fractures.
- Other benefits:
- Potential benefit on colon cancer incidence and mortality.
- Lower genital tract improvement: Dryness, soreness, dyspareunia, cystitis, and occasionally dysuria.
- CVD: Preventative effect if started early in menopause.
Contraindications and Potential Side Effects
- Absolute contraindications:
- Suspected pregnancy.
- Breast cancer.
- Endometrial cancer.
- Active liver disease.
- Uncontrolled hypertension.
- Current venous thromboembolism (VTE).
- Known thrombophilia (e.g. Factor V Leiden).
- Otosclerosis.
- Relative contraindications:
- Unexplained abnormal bleeding.
- Large uterine fibroids.
- Past history of benign breast disease.
- Unconfirmed personal or family history of VTE.
- Chronic stable liver disease.
- Migraine with aura.
- Side effects associated with oestrogens:
- Breast tenderness or swelling.
- Nausea.
- Leg cramps.
- Headaches.
- Side effects associated with progestogen:
- Fluid retention.
- Breast tenderness.
- Headaches.
- Mood swings.
- Depression.
- Acne.
Risks of HRT
- Breast cancer:
- Background risk in the 50-59 age group is 22.5 per 1,000 women.
- 7.5 years of HRT use may result in an additional 2-6 breast cancers.
- Cardiovascular disease and stroke:
- Beneficial effects when given to younger women.
- May be deleterious when given to older women.
- Stroke incidence is higher with HRT in older women (2 additional cases per 10,000 women/year).
- Venous thromboembolism (VTE):
- HRT doubles the risk of VTE in women over 50 (background incidence is 15-20 per 10,000).
- Transdermal HRT may have a lesser effect on VTE incidence.
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Description
Test your knowledge on menopause and premature ovarian insufficiency (POI) with this quiz. Explore the causes, diagnosis, and physiological impacts of menopause. Uncover key statistics and factors that influence women's reproductive health.
