2ndary Amenorrhea + Menopause Flashcards
What is menopause? What is the average age of menopause?
- Last ever period
- 51
What is perimenopause?
Menopausal symptoms for approx 5 years before
What causes menopause?
- Ovarian insufficiency
- oestrodial falls
- FSH rises
- still some oestrodial from peripheral conversion of adrenal androgens into fat
- Menopause may be natural or follow suddenly post surgery
What are the symptoms of menopause?
- [itchy, bitchy, sweaty, sleepy, bloated, forgetful, psycho]
- Vasomotor symptoms ‘hot flushes’, 80% women 45% find them a problem, usually last 2-5 yrs- may be 10 years+
- Vaginal soreness/dryness
- Low libido
- Muscle/joint aches
What are unoticeable changes (silent changes) that occur post menopause? Risks of these changes?
- Reduced bone mass, DEXA scan and T score
- Fractured hip/vertebra: 1% of women 50-69
- Above has high risks of morbidity + mortality
RF for silent changes in menopause?
- thin/caucasian/smokers/EtOH/+ve FH/ amenorrhoea/malabsorption/steroids/hyperthyroid
How can we treat and prevent these silent changes?
- Exercise
- Adequate calcium and Vit D
- HRT
- Bisphosphonates
- Denosumab -monoclonal antibody to osteoclasts,teriparatide
How can we treat the symptoms of menopause?
Locally?
Systemically?
Hormone replacement therapy:
- Local: vaginal oestrogen pessary/ring/cream
- Systemic: transdermal, oral [transdermal reduces risk of VTE]
When do we give only oestrogen versus oestrogen + progesterone?
- Oestrogen only if no uterus
- Oestrogen and progesterone if uterus present
What are the contraindications to HRT?
- Currently have a hormone dependent cancer: breast/endometrium
- Currently have active liver disease
- Univestigated abnormal bleeding
- Seek advice if previous VTE
- Seek advice if previous CA breast or BRCA carrier
What is the drug routine if there is still some ovary function?
- Cyclical combined
- 14 days E + 14 days E+P
- will get a withdrawal bleed
What is the HRT routine for someone with no ovarian function >1yr or gone through menopause.
- Continuous combined
- 28 days E+P
- bleed free after 3 months
Another treatment for menopause (not as commonly used)?
- Selective Estrogen receptor Modulators (SERMs)
- E effect on selected organs (eg tibolone )
What are the risks and benefits of HRT? Who is not effected?
Benefit
- Vasomotor
- Aids Local genital symptoms
- Helps with osteoperosis
Risk
- breast cancer if combined HRT
- Ovarian cancer
- Venous thrombosis if oral route
Not effected
- Alzeimers
- Not increase Cardiovascular risks if start before age 60 ie before atherosclerosis develops
Risk of breast cancer due to HRT?
- 32/1000 50-65 no HRTC
- Extra 8/1000 if 5yr combined HRT
- Fewer 4 /1000 if 5yr E only HRT
What is the ovarian cancer risk due to HRT?
- 2/1000 per 5 yrs age 50/59
- extra 1/1000 if 5 yrs oral HRT
Risk of VTE due to HRT?
- 11/1000 50-69 no HRT
- extra 13/1000 if 5yr oral HRT
- no change if transdermal route
Fracture femur risk due to HRT?
- 10/1000 50-69 no HRT
- 4/1000 fewer if 5 yr HRT
Colon cancer risk due to HRT?
- 11/1000 50-69 no HRT
- 4/1000 fewer if 5 yr HRT
What are some things to note about the risks of HRT in general?
- Excess breast Ca Risk as for never users after 5years off HRT
NICE guidance regarding HRT ?
- If treating severe vasomotor symptoms need to review annually
- For women with premature ovarian insufficiency HRT benefits outweigh risks till age 50
- Not to be used as first line for osteoperosis prevention/treatment (biphosphates used instead)
- Vaginal oestrogen for vaginal symptoms
What is andropause?
- Testosterone falls 1% a year after 30
- DHEAS (male sex hormone) also falls
- Fertility remains
- Not a sudden change
- (kinda like menopause for men but completely different as very gradual and rare to get symptoms)
What are some causes of secondary amenorrhea?
- Preggers
- Contraception related (current use or for 6-9 months after depoprovera)
- Early menopause
- Polycystic ovaries
- Thyroid disease
- Raised prolactin
- Hypothalamic stress
- Androgen secreting tumour (testosteron > 5mg/l)
- Sheehans syndrome - pituitary failure
What can be found on examination with someone with seconary amenorrhea? What investigations do we do?
- Enlarged clitoris
- Deep voice
- Hirsutism
- Acne
- Urine test, pregnancy test
- Bloods, FSH, LH, oestrodial, prolactin, thyroid function, testosterone
How do we treat secondary amenorrhea?
- Treat the specific cause
- Assume fertile and need contraception unless 2 yrs after confirmed menopause
- If premature ovarian insufficiency offer HRT till 50
How do people present with polycystic ovary syndrome?
- acne
- overweight or obesity
- hypertension
- scalp hair loss
Presence of risk factors:
- Female or reproductive age
- Irregular menstruation
- Infertility
What are the associated risks of polycystic ovary syndrome?
- Higher risk of diabetes and CVS disease for any given BMI
- Risk of endometrial hyperplasia if less than 4 periods per year
What are the features seen in the ovaries in PCO?
- Small peripheral ovarian cysts x 10/ovary or ovarian volume>12cm3
- NB 20% women have this on scan but no other features ie not pco syndrome
- NB Multicystic ovaries common in adolescents- no implications
What is management of Polycystic ovary disease?
If currently infertile and desiring fertility
- line: weight loss
- line: metformin
or
- line: clomifene
- line: metformin
If currently infertile but not seeking fertility
- line: Oral contraceptive pill
- line: metformin
or
- line: anti-androgen therapy
- line: metformin
