HRT and Amenorrhea Flashcards
PRIMARY AMENORRHEA - PUBERTY
i) what is it defined as? (2)
ii) when does normal puberty start in girls and boys? how long does it usually take
iii) what happens first second third in girls?
iv) what is hypogonadism? what are the two types of hypogonadism and what happens in each?
i) not starting menstruation by 13yrs when no other evidence of pubertal dev or by 15 years when there are other signs of puberty eg breast bud dev
ii) normally starts 8-14 in girls and 9-15 in boys and takes 4 years
girls start earlier than boys
iii) girls have breast bud dev > pubic hair > menstrual periods
iv) hypogonad = lack of sex hormones oes and tesos which can cayse a delay in puberty
hypogonadotropic = defic of LH and FSH
hypergonadotrophic = lack of response to LH and FSH by gonads eg ovaries
HYPOGONADISM
i) what LH and FSH levels are seen in hypo? what is this a result of?
ii) name five things that can cause hypo hypo
iii) what LH and FSH levels are seen in hyper? what sex hormone eg oestrogen levels are seen? name three causes of hyper
iv) what type of hyppogonad is seen in kallman syndrome?
i) hypo = low LH and FSH
result of abnormal func of hypothal or pit gland
ii) hypopit, damage to hypothal or pit, chronic conds eg CF, excessive dieting, constitutional delay in growth and dev, kallman
iii) hyper = high LH and FSH due to lack of neg feedback from oestrogen
caused by damage to gonads eg torsion, cancer
congenital absence or ovaries or turners syndrome
iv) kallman - hypo
CONGENITAL ADRENAL HYPERPLASIA
i) what is there a deficiency in? what does this lead to?
ii) what is the inheritance pattern? what two things may be seen in neonate if severe
iii) name four typical features that present later
iv) what phenotype does androgen insensitivty syndrome result in? what sex are the pelvic organs?
v) name three structural things that can cause primary amenorrhea
i) defic in 21 hydroxylase enzyme > underproduction of cortisol and aldo and overproduction of androgens
ii) auto recessive
if severe - electrolyte disturbance and hypoglycaemia
females can px later with tall for age, facial hair, absent periods, deep voice, early puberty
iv) AIS - female pheno with male internal organs eg testes
v) imperforate hymen, transverse vaginal septae, vaginal agenesis, absent uterus, FGM
ASSESSMENT OF PRIMARY AMENORRHEA
i) what is the threshold to initiate ix?
ii) what can show whether its hypo or hyper? what can be used to screen for GH defic?
iii) what imaging can be done to look for constituitional delay? name two other imaging
iv) who may be treated with pulsatile GnRH? what may this induce? what other option os there?
v) what can be given to induce regular menstruation and prevent symptoms of oes defic?
i) no evidence of pubertal change at 13 yrs
ii) FSH and LH to diff between hypi ad hyper
IGF1 to screen for GH deficiency
iii) xray of wrist > bone age > dx of cons delay
can also do pelvic US and MRI brain (pit pathol)
iv) pulsative GnRH if hypo eg hypopit, kallman
may induce fertility
if dont want fertility can use COCP
v) COCP
SECONDARY AMENNORHEA
i) what is it defined as? when should investigation be started? (2)
ii) name six causes? name two pituitary causes
iii) what prolactin levels may cause it? why?
iv) what blood test should be done first?
v) what does high FSH point to? what LH and FSH levels are seen in PCOS?
i) defined as no menstruation for more than three months after previous regular periods
investigate after 3-6m or 6-12m if previously infrequent
ii) pregnancy is most common, menopause/POI, hormonal contraception, hypothal or pit pathology, PCOS, ashermans, thyroid, hyperPRL
pit - pit tumour eg prolactinoma or pit failure
iii) hyper PRL can cause it due to prevention of GnRH release > no LH/FSH release > hypo hypodonadism
most common cause of hyper PRL is pit adenoma
iv) do beta HCG first to rule out pregnancy
v) high FSH - primary ovarian failure
high LH or LH:FSH ratio suggests PCOS
MX OF SECONDARY AMENNORHEA
i) what may induce menstruation/improve symptoms?
ii) how frequently do women with PCOS require a withdrawal bleed? why?
iii) what hormone level is low in these patients? what bone pathology does this increase the risk of? what can therefore be given
i) replacement hormones eg hormonal contraceptives
ii) PCOS - withdrawal bleed every 3-4m to reduce the risk of endometrial hyperplasia and endometrial cancer
iii) low oestroegn > osteoporosis
ensure adequate vitamin D and calcium intake
HRT or COCP
HRT
i) who is it given to? what is given? what also needs to be given to women who have a uterus? why?
ii) name five non hormonal tx for menopausal symptoms?
iii) what is the action of clonidine? what effect does it have on BP and HR? which symptoms of menopause does this help?
iv) name four indications for HRT
v) under which age do benefits usually outweight the risks? name five risks of HRT? name two ways these can be mitigated?
i) given to perimenopausal and post menopausal women to alleviate symptoms
give exogenous oestrogen - if uterus also give progesterone to preevnt endometrial hyperplas/cancer due to unopposed oes
ii) lifestyle change, CBT, clonidine, SSRI anti deps, venlafaxine, gabapentin
iii) clonidine - alpha 2 adrenergic R agonist
lowers BP and HR > helps vasomotor symptoms and hot flushes
SE - dry mouth, headache, dizzy, fatigue
iv) replacing hormones in POI, reduces vasomotor symp eg hot flush and night sweat, improve symptoms such as low mood, decreased libido, poor sleep, reducing risk of osteoporosis in women under 60
v) under 60 benefits > risks
risks - inc risk of breast and endometrial cancer, inc risk of VTE, inc risk of stroke and CAD
add progesterone if uterus to reduced endo ca
use patch rather than pills to reduce risk of VTE
HRT 2
i) name five contraindications?
ii) what type of tx is given for local symptoms? for systemic symptoms?
iii) what is given to women with no uterus? with a uterus? what is given if no period in past 12m? or period in last 12m? (perimeno)
iv) which two ways can oestrogen be given?
v) when is progesterone given? which patterns can it be given in (2) name three ways of deliverying proges
i) undx abnormal bleeding, endometrial hyperplas or cancer, breast cancer, uncontrolled HTN, VTE, liver disease, MI, pregnant
ii) local - topical tx eg oestrogen cream
systemic - systemic tx
iii) no uterus = oes only
uterus = combined HRT (with progesterone)
perimeno - cyclical combined HRT
post meno - continuous combined HRT
iv) oes in tablet or transdermal (patch or gel)
v) give proges when woman has a uterus to reduce risk of endometrial hyperplasia and cancer
give either cyclical (10-14d) if period in last 12m
or continuous
deliver by oral, transdermal or interuterine eg mirena coil
HRT 3
i) what type of HRT is tibolone?
ii) when should pt be followed up after initiating HRT? how long does it take to gain full effects? when should oes containing contraeptives be stopped before major sx?
iii) does HRT act as conrtaception? name three oestrogen and progesterone side effects
i) synthetic steroud that stim oes and proges receptors - continous combined HRT for women post meno with a uterus
ii) follow up 3 months after initiating, see full effects in 3-6m
stop 4 weeks before major surgery
iii) doesnt act as contraception - consider mirena coil or POP in addition to HRT
oes SE - nausea, bloating, breast swell and tender, headache, leg cramp
proges SE - mood swing, bloating, fluid retention, weight gain, acne and greasy skin
