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Y3 repro > 2y amenorrhoea and menopause > Flashcards

2y amenorrhoea and menopause Flashcards

1
Q

what is menopause

A

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

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2
Q

what is premature menopause

A

<40y/o

affects 1% women

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3
Q

what happens at menopause - hormones

A

ovarian insufficiency - oestradiol falls
FSH from pituitary rises
still some oestriol from conversion of adrenal androgens in adipose tissue

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4
Q

FSH levels in perimenopause

A

levels fluctuate

one off level doesn’t exclude perimenopause as a cause for symptoms

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5
Q

how does menopausal transition occur

A

may be natural or sudden following oophorectomy/chemotherapy/radiotherapy

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6
Q

menopause symptoms

A

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

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7
Q

osteoporosis in menopause

A

reduced oestrogen - lowered BMD

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8
Q

what is osteoporosis

A

reduced bone mineral density

tested for w/ DEXA scan - T score

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9
Q

problems with osteoporosis following menopause

A

fractured hip/vertebrae
1% women 50-69
significant morbidity and mortality

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10
Q

osteoporosis risk factors

A 
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
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11
Q

prevention and treatment of osteoporosis

A 
wight bearing exercise
adequate Ca and vit D
HRT 
bisphosphonates
denosumab - monoclonal ab to osteoclasts 
calcitonin
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12
Q

HRT for menopausal symptoms

A
  1. local vaginal HRT - oestrogen pessary/ring/cream - minimal systemic absorption, need to use longterm to maintain benefit
  2. 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

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13
Q

why can oestrogen alone not be used if the woman still has a uterus

A

risk of endometrial hyperplasia and endometrial cancer

progesterone has to also be used for protection against this

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14
Q

combined oestrogen and progestogen HRT - women with ovarian function

A

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

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15
Q

combined oestrogen and progestogen HRT - women w/o any likely natural ovarian function

A

continuous combined 28 days E+P oral/patch
expect to be bleed free after 1st 3mths
use if >1yr after LMP or age >54

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16
Q

what combined oestrogen and progestogen HRT can be used for women of any age

A

Mirena LNG IUS 5yrs + daily E

expect to be bleed free

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17
Q

what HRT regime gives contraceptive cover

A

mirena + E

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18
Q

CI to systemic HRT

A

not the same as CI to combined hormonal contraception

  1. current hormone dependent breast/endometrium cancer
  2. current active liver disease
  3. uninvestigated abnormal vaginal bleeding
  4. seek advice if prev VTE, thrombophilia, FH VTE
  5. seek advice if prev breast cancer or BRCA carrier
19
Q

CI to vaginal HRT

A

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

20
Q

treatment for symptoms of menopause

A

HRT
SERMs
clonidine/SSRI/SNRI antidepressants
phytooestrogen herbs e.g. red clover, soya
hypnotherapy/exercise/CBT
non-hormonal lubricants for vaginal dryness

21
Q

SERMs

A

selective oestrogen receptor modulators
E effect on selected organs

e.g. tibolone has E effect on flushes, bones but not endometrium

22
Q

clonidine or SSRI SNRI antidepressants

A

e.g. venlafaxine
NOT recommended for vasomotor symptoms

frequent side effects and few women benefit

23
Q

HRT benefits

A

vasomotor
local genital symptoms
osteoporosis

no effect on alzheimers
no increase in CV risks if start before 60y/o (before significant atherosclerosis develops)

24
Q

risks of HRT

A

breast Ca if combined HRT
ovarian Ca
VTE if oral route
CVA if oral route

25
Q

HRT risks vs benefits

A

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

26
Q

NICE guidance for HRT

A
  • 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
27
Q

andropause - male menopause

A

testosterone falls by 1% a year after 30y/o
DHEAS falls

no sudden change and fertility remains

28
Q

what is 1y amenorrhoea

A 
never had a period 
5%
delayed pubery if: 
>14 and no 2y sexual characteristics
>16 if 2y sexual characteristics
29
Q

what is 2y amenorrhoea

A

has had periods in past but none for 6mths

30
Q

causes of 2y amenorrhoea

A

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
31
Q

contraception related 2y amenorrhoea

A

current use of 6-9mths after depoprovera

32
Q

hypothalamic 2y amenorrhoea

A

stress
10% weight change
XS exercise
any severe illness

33
Q

causes for raised prolactin

A

prolactinoma

medication

34
Q

androgen secreting tumour and 2y amenorrhoea

A

testosterone >5mg/l

35
Q

hx for 2y amenorrhoea

A

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

36
Q

2y amenorrhoea examination and investigation

A

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

37
Q

2y amenorrhoea treatment

A

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)

38
Q

diagnosis of PCOS

A

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

39
Q

risks with PCOS

A

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

40
Q

weight gain and PCOS

A

PCOS DOES NOT cause pain or weight gain

weight gain can worsen PCOS symptoms as reduced SHBG levels so increased free androgen levels

41
Q

US definition of polycystic ovaries

A

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

42
Q

management of PCOS - symptoms

A

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

43
Q

management of PCOS complications

A

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

Y3 repro (47 decks)

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