2y amenorrhoea and menopause Flashcards
what is menopause
a woman’s last ever period
~51y/o
1/3 of UK lifespan after menopause
perimenopause 3-5yrs before final period, can have menopausal symptoms during this
what is premature menopause
<40y/o
affects 1% women
what happens at menopause - hormones
ovarian insufficiency - oestradiol falls
FSH from pituitary rises
still some oestriol from conversion of adrenal androgens in adipose tissue
FSH levels in perimenopause
levels fluctuate
one off level doesn’t exclude perimenopause as a cause for symptoms
how does menopausal transition occur
may be natural or sudden following oophorectomy/chemotherapy/radiotherapy
menopause symptoms
vasomotor - hot flushes/night sweats, 80% women affected, 45% significant problem, usually last 2-5yrs, may be >10yrs
vaginal dryness/soreness
low libido
muscle and joint aches
mood changes/poor memory - possibly related to vasomotor symptoms affecting sleep
osteoporosis in menopause
reduced oestrogen - lowered BMD
what is osteoporosis
reduced bone mineral density
tested for w/ DEXA scan - T score
problems with osteoporosis following menopause
fractured hip/vertebrae
1% women 50-69
significant morbidity and mortality
osteoporosis risk factors
thin caucasian smoker high alcohol intake (EtOH) \+ve FHx esp male or younger age malabsorption vit D and Ca prolonged low oestrogen before menopause and amenorrhoea oral corticosteroids hyperthyroid
prevention and treatment of osteoporosis
wight bearing exercise adequate Ca and vit D HRT bisphosphonates denosumab - monoclonal ab to osteoclasts calcitonin
HRT for menopausal symptoms
- local vaginal HRT - oestrogen pessary/ring/cream - minimal systemic absorption, need to use longterm to maintain benefit
- systemic oestrogen transdermal patch/gel or oral - transdermal avoids 1st pass + less risk VTE
oestrogen only if no uterus
oestrogen and progesterone is uterus present - progestogen oral, patch or LNG IUS
why can oestrogen alone not be used if the woman still has a uterus
risk of endometrial hyperplasia and endometrial cancer
progesterone has to also be used for protection against this
combined oestrogen and progestogen HRT - women with ovarian function
for women who still have some ovarian function to avoid inconvenience of irregular bleeding
cyclical combined HRT - 14 days E, 14 days E+P
expect withdrawal bleed after P
combined oestrogen and progestogen HRT - women w/o any likely natural ovarian function
continuous combined 28 days E+P oral/patch
expect to be bleed free after 1st 3mths
use if >1yr after LMP or age >54
what combined oestrogen and progestogen HRT can be used for women of any age
Mirena LNG IUS 5yrs + daily E
expect to be bleed free
what HRT regime gives contraceptive cover
mirena + E
CI to systemic HRT
not the same as CI to combined hormonal contraception
- current hormone dependent breast/endometrium cancer
- current active liver disease
- uninvestigated abnormal vaginal bleeding
- seek advice if prev VTE, thrombophilia, FH VTE
- seek advice if prev breast cancer or BRCA carrier
CI to vaginal HRT
avoid for women taking aromatase inhibitor treatment for breast cancer - but may choose to use if symptoms affecting QOL
no other CI as minimal systemic absorption
treatment for symptoms of menopause
HRT
SERMs
clonidine/SSRI/SNRI antidepressants
phytooestrogen herbs e.g. red clover, soya
hypnotherapy/exercise/CBT
non-hormonal lubricants for vaginal dryness
SERMs
selective oestrogen receptor modulators
E effect on selected organs
e.g. tibolone has E effect on flushes, bones but not endometrium
clonidine or SSRI SNRI antidepressants
e.g. venlafaxine
NOT recommended for vasomotor symptoms
frequent side effects and few women benefit
HRT benefits
vasomotor
local genital symptoms
osteoporosis
no effect on alzheimers
no increase in CV risks if start before 60y/o (before significant atherosclerosis develops)
risks of HRT
breast Ca if combined HRT
ovarian Ca
VTE if oral route
CVA if oral route
HRT risks vs benefits
no overall increased mortality for HRT users - suggests reduced mortality but not certain enough to recommend for all women
XS breast Ca risk returns to baseline as for never users after 5yrs off HRT
NICE guidance for HRT
- treatment of severe vasomotor symptoms, review annually
- premature ovarian insufficiency, HRT benefits > risks until 50y/o
- not as 1st line for osteoporosis prevention/treatment (bisphosphonates instead)
- use vaginal oestrogen if vaginal symptoms
- no absolute upper age limit of max duration of HRT use
andropause - male menopause
testosterone falls by 1% a year after 30y/o
DHEAS falls
no sudden change and fertility remains
what is 1y amenorrhoea
never had a period 5% delayed pubery if: >14 and no 2y sexual characteristics >16 if 2y sexual characteristics
what is 2y amenorrhoea
has had periods in past but none for 6mths
causes of 2y amenorrhoea
pregnancy/BF
contraception related
PCOS
premature ovarian insufficiency hypothalamic thyroid disease, cushings raised prolactin congenital adrenal hyperplasia androgen secreting tumour Sheehan's syndrome - pituitary failure Asherman's syndrome - IU lesions
contraception related 2y amenorrhoea
current use of 6-9mths after depoprovera
hypothalamic 2y amenorrhoea
stress
10% weight change
XS exercise
any severe illness
causes for raised prolactin
prolactinoma
medication
androgen secreting tumour and 2y amenorrhoea
testosterone >5mg/l
hx for 2y amenorrhoea
possibility of pregnancy
BF
medications - contraception, opiates, antipsychotics, metoclopramide
galactorrhoea/visual change (increased prolactin)
acne, hirsutism, voice change (increased androgen)
weight change
exercise/stress
significant illness
2y amenorrhoea examination and investigation
BMI
Cushing’s features
acne, hirsutism, virilised - enlarged clitoris, deep voice
abdo and bimanual exam - pelvic mass, pregnant uterus, ovarian cyst
urine pregnancy test
bloods - raised FSH, low oestadiol (menopause); prolactin, TFTs, testosterone and SHBG (free androgen index), 17 hydroxy progesterone (CAH)
pelvic US - PCOS
2y amenorrhoea treatment
treat specific cause
BMI >20 <30 ideal for ovulation
assume fertile and need contraception unless 2yrs after confirmed menopause
if premature ovarian insufficiency - offer HRT until 50, emotional support (incl Daisy network), check for fragile X (also relatives)
diagnosis of PCOS
need 2/3 of:
oligo/amenorrhoea
androgenic symptoms - XS hair/acne (or increased levels on testing)
PCO morphology on scan
- can have PCOS with normal looking ovaries
normal/high oestrogen levels
increased androgens - acne/hirsutism
? underlying cause is insulin resistance
risks with PCOS
risk of endometrial hyperplasia if <4 periods a year (and not on hormonal contraception)
reduced fertility if not ovulating regularly - assume fertile and use contraception if not planning pregnancy
higher risk DM and CVD even w/ BMI <25
weight gain and PCOS
PCOS DOES NOT cause pain or weight gain
weight gain can worsen PCOS symptoms as reduced SHBG levels so increased free androgen levels
US definition of polycystic ovaries
small peripheral ovarian cysts x10/ovary or ovarian volume >12ml
20% women have this on scan but not other features e.g. not PCOS
multicystic ovaries common in adolescents and not associated w/ PCOS - don’t diagnose PCOS until late teens
management of PCOS - symptoms
weight loss/exercise to BMI 20-25 can help with all symptoms - increases SHBG so less free androgens
increased NIDDM risk even if slim - consider GTT
support and info - Verity support group
antiandrogen - combined hormonal contraception if no CI, spironolactone, eflornithine cream to reduce facial hair growth
management of PCOS complications
endometrial protection - CHC, mirena IUS, oral provera 10 days every 90 days if no period to cause withdrawal bleed
fertility Rx clomiphene/metformin usually effective for ovulation induction
underlying cause - insulin resistance, metformin may encourage ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss
