Menopause: MCCQE1 Preparation Guide

Introduction

Menopause is a physiological event marking the end of reproductive life. For MCCQE1 preparation, it is crucial to understand the definitions, the physiological changes in the Hypothalamic-Pituitary-Ovarian (HPO) axis, and the management of symptoms according to Canadian clinical practice guidelines (primarily SOGC).

Key Definitions

• Perimenopause (Menopause Transition): The period immediately prior to menopause (when endocrinological, biological, and clinical features of approaching menopause commence) and the first year after menopause.
• Postmenopause: The period dating from the final menstrual period (FMP).
• Premature Ovarian Insufficiency (POI): Menopause occurring before age 40.
• Early Menopause: Menopause occurring between ages 40 and 45.

Epidemiology and Physiology

The average age of menopause in Canada is approximately 51.5 years. It is a high-yield topic for the MCCQE1, given the aging Canadian population.

The HPO Axis Transition

As the ovarian follicular pool depletes, the feedback loops in the HPO axis change significantly.

Clinical Presentation

The clinical presentation varies, but symptoms generally fall into three categories. Understanding these helps in ruling out differentials during the MCCQE1 Clinical Decision Making (CDM) portion.

Diagnosis and Investigations

For MCCQE1, knowing when to test is just as important as knowing what to test.

Diagnostic Algorithm

1. Age > 45 years:

   • Diagnosis is Clinical. Based on irregular menses and menopausal symptoms.
   • Do NOT measure FSH/LH. Levels fluctuate wildly during perimenopause and are not diagnostic.

2. Age 40–45 years:

   • Investigate to rule out other causes of amenorrhea (e.g., pregnancy, prolactinoma, thyroid dysfunction).
   • FSH may be used adjunctively but is not definitive.

3. Age < 40 years (Suspected POI):

   • Requires full workup.
   • Required: hCG (pregnancy test), Prolactin, TSH.
   • Confirmatory: FSH > 30-40 IU/L on two occasions at least 4-6 weeks apart.

Differential Diagnosis Checklist

• Pregnancy (Always the first rule out in MCCQE1)
• Thyroid dysfunction (Hyper/Hypothyroidism)
• Hyperprolactinemia
• Uncontrolled diabetes
• Malignancy (Pheochromocytoma, Carcinoid - rare causes of flushing)
• Medication side effects

Management

Management should be individualized, following the CanMEDS role of Health Advocate—engaging in shared decision-making.

Principles of MHT Prescribing

Routes of Administration

Contraindications to Systemic MHT

Canadian Guidelines (SOGC & NAMS)

The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines are the gold standard for the MCCQE1.

1. Bioidentical Hormones: SOGC recommends regulated bioidentical hormones (e.g., 17$\beta$-estradiol, micronized progesterone) over compounded bioidentical hormones due to safety and potency concerns.
2. Breast Cancer Risk: The risk of breast cancer with MHT is rare (< 1 additional case per 1000 women per year of use) and is primarily associated with the combination of estrogen and synthetic progestins (e.g., MPA) used for > 5 years.
   • Micronized progesterone may have a lower risk profile than synthetic progestins.
3. Duration: There is no mandatory “stop date.” Therapy should be reviewed annually.

Key Points to Remember for MCCQE1

• Diagnosis: In women > 45, do not order FSH. Treat clinically.
• Unopposed Estrogen: Never give systemic estrogen alone to a woman with a uterus.
• Vaginal Bleeding: Any postmenopausal bleeding (PMB) is endometrial cancer until proven otherwise. Transvaginal Ultrasound (TVUS) and/or Endometrial Biopsy (EMB) is mandatory.
• GSM Treatment: Vaginal moisturizers/lubricants are first-line. Low-dose vaginal estrogen is second-line and safe for most women (even some breast cancer survivors, in consultation with oncology).
• Contraception: Women are considered fertile until 12 months of amenorrhea (if > 50 years old) or 24 months (if < 50 years old). Continue contraception during perimenopause.

Sample Question

Clinical Scenario

A 53-year-old female presents to your family medicine clinic with a 6-month history of severe hot flashes and night sweats that are disrupting her sleep and work performance. Her last menstrual period was 14 months ago. She has a history of controlled hypertension and had a laparoscopic cholecystectomy 3 years ago. Her BMI is 28. She has an intact uterus. She has tried layering clothing and avoiding caffeine without relief. She is requesting medication.

Which one of the following pharmacologic interventions is most appropriate for this patient?

• A. Oral conjugated equine estrogen alone
• B. Transdermal estradiol patch and oral micronized progesterone
• C. Vaginal estrogen cream
• D. Compounded bioidentical estrogen and progesterone cream
• E. Oral combined estrogen-progestin therapy and check serum FSH

Explanation

The correct answer is:

• B. Transdermal estradiol patch and oral micronized progesterone

Detailed Explanation:

• A is incorrect: This patient has an intact uterus. Administering “unopposed” estrogen (estrogen without progesterone) significantly increases the risk of endometrial hyperplasia and adenocarcinoma.
• B is correct: This is the ideal regimen. The patient has controlled hypertension and a BMI of 28 (overweight). Transdermal estrogen is preferred over oral estrogen in women with hypertension or elevated BMI because it bypasses the liver (first-pass metabolism), resulting in less activation of the coagulation cascade (lower VTE risk) and less effect on blood pressure markers. Micronized progesterone is required to protect the endometrium.
• C is incorrect: Vaginal estrogen is indicated for Genitourinary Syndrome of Menopause (GSM) such as dryness or dyspareunia. It does not provide systemic levels high enough to treat vasomotor symptoms (hot flashes).
• D is incorrect: SOGC guidelines advise against compounded bioidentical hormones due to lack of regulation, inconsistent potency, and lack of safety data regarding endometrial protection.
• E is incorrect: While oral combined therapy is an option, transdermal is safer given her hypertension/BMI. Furthermore, checking serum FSH is unnecessary and not recommended for diagnosis in a woman over 45 with typical symptoms and >12 months of amenorrhea.

References

1. Society of Obstetricians and Gynaecologists of Canada (SOGC). (2021). Guideline No. 422: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle. J Obstet Gynaecol Can. Link to SOGC Guidelines 
2. The North American Menopause Society (NAMS). (2022). The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause.
3. Medical Council of Canada (MCC). Objectives for the Qualifying Examination Part I. MCC Objectives 
4. RxFiles. (2023). Menopause & Hormone Therapy (MHT/HRT). Canadian Academic Detailing.