Menopause (Seminar Notes)

Menopause & HRT Perimenopause (clmacteric) may begin months or years before LMP & continue for years after Average age = 50yrs Occurs when oocytes become exhausted Physiology As number of available oocytes and therefore follicles decreases Oestrodiol production decreases Proportion of anovulatory cycles increases Progesterone production deceases FSH & LH falls because of diminishing negative feedback from oestrogen Signs & Symptoms Vaginal bleeding Irregular periods (due to anovulatory cycles) Endometrial assessment may be required to exclude thee possibility of endometrial carcinoma Menopause can only be assessed 6 months / 1 year after last period Hot Flushes Subjective feeling of warmth in upper part of body lasting around 3 minutes Can be accompanied by nausea, palpitations & sweating Can be worse at night HRT will relieve symptoms in 90% of case Genitourinary atrophy Genital system, urethra and bladder trigone are oestrogen dependent so atrophy Thinning of vaginal skin à dyspareunia and bleeding Loss of vaginal glycogen à raised pH à predisposes to infection Trigone atrophy à urgency of micturition Long term effects Breast cancer Rate of increase of breast cancer risk decreases after menopause Risk double menopause at 50 rather than 40yrs Cardiovascular disease Loss of oestrogens à brings CVS risk equivalent to that of men by age 85 Osteoporosis Bone resorption by osteoclasts is accelerated by menopause Oestrogens stimulate osteoblasts (lost when oestrogens decrease) à increase rate of low impact # esp distal radius, vertebral body and upper femur Higher risk if underweight HRT can reduce rate of resorption Diagnosis Clinical diagnosis – made 6 months / 1 year after LMP Hormonal Therapy Based on oestrogen replacement If have not had hysterectomy should also have progestogen to lessen risk of endometrial cancer Oral preparations More beneficial for lipid profiles but higher thrombotic risk Cyclical preparations used perimenopausally (with withdrawl bleeds) Continuous forms for > 2yrs after LMP Transcutaneous (transdermal patches) Available as cyclical or continuous Can cause local skin reactions such as blisters and hyperaemia Avoids GI and hepatic side effects Subcutaneous implants Usually in lower abdomen, lasts approx 6 months Vaginal preparations Include tablets, ring pessaries and cream – used for atrophic vaginitis Risks and Side effects of hormone treatment General - Nausea & breast tenderness in 5-10% Endometrial Carcinoma - Oestrogen only HRT increases risk of endometrial Ca by 4 – so only used if hysterectomy Can use oestrogen only with mirena coil Breast Cancer - Very slight increase in risk for developing breast cancer Venous Thromboembolic disease - Increased risk in first year Contraindications to HRT Pregnancy, thromboembolic disease, recurrent thromboemboism, liver disease, undiagnosed vagial bleeding Also – in theory – those who have had any female cancer Duration of HRT If for symptomatic treatment – 2-3 years (possibly continue if symptoms recur) Non Hormonal Treatment Clonidine – helps vasomotor symptoms (act on hypothalamus) Other treatments are symptomatic (eg beta blockers, sedatives, hypnotics etc) Post Menopausal Bleeding Hormonal – HRT withdrawl bleed, ovarian activity Vaginal – trauma, prolapse/procidentia Cervical – polyp, carcinoma Uterine – polyp, endometrial hyperplasia, carcinoma Ectopic – rectum, bladder/urethra, vulva Idiopathic Management – should check origin of blood, examine patient, US scan for endometrial thickness, pipelle biopsy if hyperplasia/carcinoma suspected.