Menopause CSGUL

  • Menopause, perimenopause and ovarian failure

  • Hormonal changes associated with menopause

  • Describe signs and symptoms of menopause

  • Identify abnormal symptoms

  • When investigations are necessary

  • Long and short term treatments for menopause

  • Outline risks and benefits of HRT

 

Perimenopause:

  • Phase before menopause when ovaries gradually begin to produce less oestrogen. Irregular periods, erratic bleeding and larger gaps in between periods due to fluctuating hormone levels

  • Psychological symptoms and vasomotor symptoms like hot flushes, dryness and night sweats.

Menopause: 12 months after last menstrual period - loss of ovarian follicular function between 45-55

Premature ovarian failure: menopause under 40 and needs to be investigated and referred

 

Symptoms:

Endocrine system

  • Hot flashes

  • Night sweats

  • Irregular periods

Reproductive system

  • Dryness

  • Decreased libido

  • Breast soreness

Nervous system

  • Mood changes

  • Sleep disturbances

  • Memory issues

Urinary system

  • Frequent urination

  • Recurrent UTIs

  • Prolapse

Musculoskeletal

  • Joint pain

  • Osteoporosis

GI

  • Bloating

  • Digestive changes

 

Menstrual cycle:

  • Hypothalamus produces GnRH to stimulate production of FSH from pituitary gland

  • FSH stimulates follicular development in ovary and promotes ovarian oestrogen production

  • Increases oestrogen suppress FSH and trigger mid cycle LH surge = ovulation

  • End of luteal = no conception then oestrogen drops + progesterone and menstruation happens

 

Perimenopause:

  • Oestrogen fluctuates and decreases = more FSH to be released so more oestrogen is released by ovaries

  • Ovaries become less responsive due to reduced number of follicles

  • FSH 4.7-21.5IU/L

  • LH 1.9-12.5IU/L

  • Oestrogen 30-400pg/ml

 

Menopause:

  • Oestrogen is low as ovaries are producing minimal oestrogen

  • Causing high level of FSH to try and increase stimulation of follicles and oestrogen but there is lack of follicle so oestrogen remains low

 

Role of hormones:

Progesterone

  • Prepares uterus lining for pregnancy

  • Maintains pregnancy by supporting developing foetus

  • Supports breast development for milk

  • Helps maintain bone health

Oestrogen:

  • Regulates menstrual cycle and ovulation

  • Maintains bone density

  • Supports cardiovasc health by maintaining healthy cholesterol levels

  • Promote skin elasticity and moisture

  • Influences mood and cognitive function

  • Supports reproductive tissue e.g., vaginal lubrication, breast development

 

Menopause:

  • Ageing ovary has less ooctyes and is less responsive to gonadotrophins -> oestrogen declines

  • Low oestrogen persisting = stimulate hpa to produce more fsh to make residual oocytes ovulate

  • Ovarian dysfunction is a gradual process -> marked by erratic hormonal changes and sporadic ovulation where FSH levels can fluctuate.

  • By menopause -> complete ovarian failure then there is consistently raised FSH

  • To diagnose menopause -> use clinical hisotry, symptoms and absence of period of 12months, we do not check bloods

  • Check FSH if pt is under 40, 40-45 with menopausal or is over 50 and using POP.

 

Post menopausal risks:

  • Osteoporosis - thinner and weaker bones due to low oestrogen

  • Cardiovasc decline - decreased oestrogen has increased heart disease and stroke

  • Vaginal atrophy - thinner and less elastic so there is increased risk of infection

  • Increased uti - due to thin walls from lack of oestrogen so increased risk of infection

  • Sleep disturbances - decreased oestrogen decreases serotonin

 

Perimenopause diagnosis:

  • Clinical history - cycle info

  • Reduced flow of blood

  • Shorter no. of days

  • Bigger gaps in between periods

 

Red flag:

  • Intermenstrual bleeding

  • Post coital bleeding

  • Menorrhagia

  • Post menopausal bleeding

  • Rule out endometrial cancer - refer to transvaginal ultrasound scan

  • Unexpected weight loss

  • Severe joint pain

  • Persistent fever

 

Non hormonal treatment:

  • Ssri, gabapentin or clonidine to reduce hot flushes and mood swings

  • Balanced diet, reg exercise and stress management to improve overall wellbeing

  • Phytoestrogens, black cohosh and vit E to mimic oestrogen and reduce hot flashes

  • Acupuncture/hypnotherapy for hot flushes

  • Vaginal moisturisers and lubricants to relieve dryness and discomfort

 

HRT:

  • Oestrogen and progesterone

  • Oral tabs, patches, gels and sprays

  • To improve symptoms, bone density and reduce heart disease risk

  • Small risk of breast cancer with combines HRT, oestrogen only has little to no risk

  • Indication: provide relief of menopausal symptoms, prevent osteoporosis, maintain quality of life, premature ovarian failure, surgical or radiation menopause

 

Contraindications to HRT:

  • Current, past or suspected breast cancer

  • Known or suspected oestrogen dependent cancer

  • Undiagnosed vaginal bleeding

  • Untreated endometrial hyperplasia

  • Previous idiopathic or current venous thromoembolism (unless on anticoags)

  • Active liver disease with abnormal lfts

  • Pregnancy

  • Thrombophilic disorder

 

Uterus:

  • Combined HRT -> oestrogen + progesterone. Oral tablets, patches, gels, sprays. Progesterone needed to protect uterine lining from hyperplasia and cancer

  • Sequential combined HRT -> oestrogen and progesterone cyclic - oral tabs and patches with monthly bleeding for perimenopausal women

  • Continuous combined HRT -> oestrogen and progeston oral tabs, patches, gels, sprays no monthly bleeding for post menopausal women

  • Local oestrogen - vaginal symptoms

 

w/o uterus:

  • Oestrogen only

  • Local oestrogen

 

Monitoring HRT:

  • Review after 3 months starting treatment

  • Review annually afterwards

  • Cover symptom control, ongoing indication, side effects and bleeding

  • Check bmi and bp

  • Reinforce healthy lifestyle advice

  • Ensure cervical and breast screening

  • Explain that HRT is not the same as contraception and to change to COC/POP if wants contraception but risk is low due to age

 

Testosterone

  • Topical testosterone used for patients with low sexual desire with menopause

  • Usually if HRT is ineffective

  • Monitor testosterone levels

  • Check for side effects like hair, acne, weight gain, alopecia, voice changes and clitoral enlargement

 

Refer:

  • Severe menopause symptoms

  • Contraindications to HRT

  • Premature ovarian failure

  • Complex medical history

  • Uncertainty of treatment

 

QUESTIONS:
 

Part 1: Single Best Answer (SBA) Questions

1.

A 48-year-old woman presents with a 6-month history of increasingly irregular periods and debilitating hot flushes. What is the most appropriate initial approach to diagnosis?

a) Order an FSH level to confirm she is perimenopausal.

b) Diagnose perimenopause based on her clinical history and symptoms.

c) Refer her for a transvaginal ultrasound scan.

d) Start her on combined HRT immediately and review in 3 months.

Answer:

b) Diagnose perimenopause based on her clinical history and symptoms.

In women over 45, perimenopause is a clinical diagnosis. FSH testing is not routinely indicated as levels fluctuate. Treatment can be discussed, but a diagnosis should be established first.

 

2.

A 52-year-old woman who had a total hysterectomy (for fibroids) 5 years ago presents with severe hot flushes. She has no personal history of breast cancer or VTE. What is the most appropriate form of HRT for her?

a) Sequential combined HRT

b) Continuous combined HRT

c) Oestrogen-only HRT

d) Testosterone gel

Answer:

c) Oestrogen-only HRT

As she has no uterus, there is no risk of endometrial hyperplasia or cancer. Therefore, she does not require the protective progestogen component and can use oestrogen-only HRT, which has a simpler risk profile.

 

3.

Which of the following is an absolute contraindication to initiating HRT?

a) A family history of breast cancer.

b) Controlled hypertension.

c) Undiagnosed post-menopausal bleeding.

d) A history of migraine without aura.

Answer:

c) Undiagnosed post-menopausal bleeding.

Undiagnosed vaginal/post-menopausal bleeding is an absolute contraindication as it must be investigated to rule out endometrial cancer before starting HRT. A family history (a) is not a contraindication. Migraine without aura (d) and controlled hypertension (b) require caution but are not absolute contraindications.

 

4.

A 58-year-old woman, 8 years post-menopause, is on continuous combined HRT. During her annual review, she asks about the risk of breast cancer. What is the most accurate information to give her?

a) All forms of HRT significantly increase the risk of breast cancer from the first year of use.

b) Oestrogen-only HRT carries a significant risk, but combined HRT does not.

c) There is a small increased risk with combined HRT, which is related to the duration of use.

d) HRT actually protects against breast cancer.

Answer:

c) There is a small increased risk with combined HRT, which is related to the duration of use.

The risk of breast cancer is primarily associated with combined HRT (oestrogen and progestogen) and increases with duration of use. The risk reduces after stopping and returns to baseline around 5 years later. Oestrogen-only HRT has little to no increased risk.

 

Part 2: Extended Matching Questions (EMQ)

Questions 5-7:

For each patient scenario, select the MOST appropriate management option.

Options:

A. Recommend lifestyle changes and a trial of a vaginal moisturiser.

B. Prescribe sequential combined HRT.

C. Prescribe continuous combined HRT.

D. Prescribe oestrogen-only HRT.

E. Refer to gynaecology for investigation.

5.

A 49-year-old woman with irregular periods and hot flushes. She has a uterus and her last period was 6 weeks ago.

Answer:

B. Prescribe sequential combined HRT.

She is perimenopausal (irregular periods) and has a uterus. Sequential HRT provides oestrogen with cyclical progestogen to induce a regular withdrawal bleed and protect the endometrium.

6.

A 60-year-old woman who had her last period 10 years ago. She has a uterus and presents with distressing vaginal dryness and hot flushes.

Answer:

C. Prescribe continuous combined HRT.

She is postmenopausal (>1 year since last period) and has a uterus. Continuous combined HRT is appropriate as it should not cause bleeding and provides symptom relief.

7.

A 55-year-old woman presents with a 3-week history of post-menopausal bleeding. She is not on HRT.

Answer:

E. Refer to gynaecology for investigation.

Post-menopausal bleeding is a red flag for endometrial cancer until proven otherwise and requires urgent investigation (e.g., ultrasound, biopsy), not initiation of HRT.

 

Part 3: Clinical Scenarios (OSCE/Patient Style)

Scenario 1: HRT Counselling

A 51-year-old woman with a uterus seeks advice for hot flushes. She is interested in HRT but is worried about the risk of breast cancer, which her mother had. She has no personal history of cancer or VTE.

How do you counsel this patient?

  • Acknowledge Concerns: "It's very understandable to be worried about breast cancer, especially with a family history. It's important to know that for most women, the benefits of HRT outweigh the risks."

  • Explain the Risk Accurately: "The small increased risk of breast cancer is primarily linked to the combined form of HRT (which contains oestrogen and progesterone) and is related to how long you take it. For a woman in her 50s, the absolute risk is small. For example, it might mean a few extra cases per 1000 women after 5+ years of use. This risk decreases after you stop HRT."

  • Discuss Benefits & Alternatives: "HRT is the most effective treatment for your symptoms and also helps prevent osteoporosis. If you're still concerned, we could consider oestrogen-only HRT, which has little to no increased risk, but that's only an option if you've had a hysterectomy. We can also discuss non-hormonal options, though they are less effective."

  • Safety Netting: "We would start you on the lowest effective dose and review you regularly. It's also crucial that you continue with your routine breast screening appointments."

 

Scenario 2: Differentiating Treatments

A 58-year-old postmenopausal woman on continuous combined HRT for 4 years reports that her hot flushes are well controlled, but she is very bothered by persistent vaginal dryness and discomfort during intercourse.

What is the most appropriate management?

  • Assess Current Regimen: "It's great that the HRT patch is controlling your flushes. The vaginal symptoms can sometimes persist even with systemic HRT because the dose needed for the whole body isn't always high enough to fully treat the local tissues in the vagina."

  • Recommend Additional Treatment: "The most effective solution for this is to add a local vaginal oestrogen treatment, such as a cream, pessary, or ring. This delivers a low dose of oestrogen directly to the vaginal area, which is very safe and will effectively treat the dryness without significantly increasing your overall hormone levels."

  • Reassure on Safety: "Using local oestrogen in addition to your existing HRT is safe and is recommended in this situation. It can be used long-term to maintain comfort and vaginal health."

 

Part 4: Prescription & Monitoring

Question 8: Formulation Choice

A 53-year-old woman with a history of hypertension (well-controlled) and a BMI of 35 requests HRT for hot flushes. She has a uterus. Why might a transdermal HRT preparation (patch/gel) be preferred for her over an oral preparation?

Answer:

  • Transdermal HRT is preferred because it is associated with a lower risk of Venous Thromboembolism (VTE). This patient has two additional risk factors for VTE (hypertension and high BMI), so avoiding the VTE risk associated with oral HRT is a prudent safety measure.

Question 9: Contraception Advice

A 48-year-old perimenopausal woman who smokes is started on sequential combined HRT. She is sexually active and does not wish to become pregnant. What advice must you give her regarding contraception?

Answer:

  • "It is very important to know that HRT is not a form of contraception. The hormone doses in HRT do not reliably prevent ovulation. Therefore, you will need to use a reliable contraceptive method until you are confirmed to be post-menopausal (i.e., until you are 55 years old, or have had no natural periods for 2 years if you are under 50). Given that you smoke, a progesterone-only method like the mini-pill, implant, or coil would be suitable, as the combined oral contraceptive pill is contraindicated."