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MBBS IV - Junior Clerkship WCS > JC 106 (O&G) - Climacteric symptoms > Flashcards

JC 106 (O&G) - Climacteric symptoms Flashcards

1
Q

Define primary and secondary amenorrhea

A

Primary - Absence of menstruation by age 16

Secondary - Absence of menstruation for 6 months in a woman with previous menstruation

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2
Q

6 major groups of causes of amenorrhea

A

Physiological

Disorders of hypothalamus/ CNS

Disorders of pituitary

Disorders of ovary

Disorders of outflow tract and/ or uterus

Androgen insensitivity syndrome (AIS)

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3
Q

List physiological causes of amenorrhea

A

Pre-pubertal
Pregnancy & lactation
Postmenopausal

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4
Q

List CNS/ hypothalamic causes of Amenorrhea

A

CNS effect, e.g. weight loss, over-exercise, stress, eating disorders (e.g. anorexia nervosa)

Kallmann’s syndrome (X-linked/autosomal recessive hypogonadotrphic hypogonadism)

Idiopathic hypogonadotrophic hypogonadism

Tumours, e.g. craniopharyngioma causing growth hormone deficiency

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5
Q

List pituitary causes of amenorrhea

A

Sheehan’s syndrome (severe postpartum hemorrhage causing hypopituitarism)

Prolactinomas (suppress GnRH secretion, inhibit gonadotrophins (FSH, LH)

Non-functioning adenoma

Iatrogenic: surgery, radiotherapy

Other endocrinopathies:
 Hyperprolactinaemia (e.g. prolactinoma)
 Thyroid dysfunction (TRH also regulates the synthesis and release of prolactin)
 Congenital adrenal hyperplasia

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6
Q

List ovary causes of amenorrhea

A

Premature ovarian insufficiency
 Gonadal agenesis/ dysgenesis: chromosomal/ non-chromosomal
 Iatrogenic: surgery (bilateral oophorectomy), radiotherapy to pelvis, chemotherapy
 Autoimmune

Polycystic ovary syndrome (ovaries are working but hormonal disturbance)

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7
Q

Clinical diagnostic criteria for PCOS

A

Rotterdam consensus: 2 out of the 3 criteria

1) Oligo-anovulation
2) Clinical/ biochemical hyperandrogenism

3) Sonographic features of polycystic ovaries:
 Follicle number per ovary of >20; and/or
 An ovarian volume >=10ml

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8
Q

List outflow tract/ uterus causes of amenorrhea

A

Outflow tract obstruction
 Cervical/ vaginal atresia
 Transverse vaginal septum
 Imperforate hymen

Absence of vagina/ uterus

Endometrial destruction:
 TB endometritis
 Asherman’s syndrome (severe intrauterine adhesions, usually following surgery, e.g. suction, evacuation)

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9
Q

Features of Androgen insensitivity syndrome (AIS)

A

Androgen receptor mutation in 46XY:
 Non-virilisation of genitalia - female phenotype
 Undescended gonads
 No axillary/pubic hair
 Some breast development (peripheral conversion of androgen into oestrogen)

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10
Q

Clinical presentation of outflow tract/ uterine obstruction

A
  • primary amenorrhea with cyclical abdominal pain (due to distension)
  • pelvic mass, endometriosis (due to backflow of period)
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11
Q

Approach to primary amenorrhea

  • Indication for investigation
  • Which conditions to rule out
A

Investigate by age 14 if no secondary sexual characteristics (low estrogen levels)

Must rule out:
 Outflow tract obstruction
 Absence of uterus
 Disorder of sex development:
 AIS
 Swyer syndrome (46,XY but mutant SRY)
 All causes of secondary amenorrhoea occuring before first period
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12
Q

Outline history taking questions for amenorrhea

A

 Onset, duration

Menstrual history:
 Previous menstruation (1o or 2o)
 Pubertal development (growth spurt, age, pubic/axillary hair, breast)

Ddx:
 Menopausal symptoms (hot flushes, vaginal dryness, premature ovarian insufficiency)
 Nutrition, stress, weight change (hypothalamic)
 Galactorrhoea, headache, visual disturbance (pituitary)
 Thyroid symptoms (hyper or hypo)
 Hyperandrogenic symptom (acnes, hirsutism, male-pattern balding)
 Family history of genetic diseases

Iatrogenic causes:
 Past medical history (chemotherapy, radiotherapy, surgery)
 Drug history (long-term medications)

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13
Q

Outline P/E for amenorrhea

A

General:
 Body height/ weight, calculate BMI - PCOS risk
 Stigmata of chromosomal abnormalities

Sexual characteristics:
 Hirsutism/ virilisation
 Secondary sexual characteristics
 Genital tract development (observe introitus, external genitalia; imaging if needed)

Associated endocrine dysfunction:
 Goitre
 Galactorrhoea, visual field

Abdominal mass (pregnancy, PCOS, undescended testes)

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14
Q

First-line investigations for amenorrhea

A

Pregnancy test (always rule out pregnancy)

Hormonal profile: FSH, LH, E2, PRL, TFT, testosterone

Progestogen (Provera) challenge test (give a course of progestogen for a week then stop):

  • Positive result (i.e. gets period after): estrogen production is normal in the body giving endometrial thickness
  • Negative result (i.e. no period after progestogen): endometrial lining quite thin, hence low estrogen

USG pelvis

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15
Q

WHO classification of anovulation

Define the hormonal disturbance in each class

A

Class 1 hypogonadotrophic hypogonadism - Hypothalamic/ pituitary causes

  • Low FSH, LH
  • Low Estradiol
  • or high prolactin

Class 2: normogonadotrophic anovulation - Uterine outflow obstruction
- Normal FSH, LH and Estradiol

Class 3: hypergonadotrophic hypogonadism - Ovarian dysfunction

  • High FSH, LH
  • LOW Estradiol
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16
Q

Class 1 anovulation

  • Hormone disturbance
  • Investigations for underlying cause
A

Class 1: hypogonadotrophic hypogonadism

  • Low FSH, LH, Estradiol
  • Or high prolactin

Investigations:
- Visual field perimetry
- MRI to exclude tumour in hypothalamus/ pituitary stalk lesion
- +/- dynamic test: GnRH stimulation test for pituitary function

  • Thyroid function (hypothyroidism, High TSH induce Prolactin)
  • Renal function test (Renal failure = decrease PRL clearance, increase dopamine excretion)
  • Pelvic USG - PCOS
  • Genetic test: PRLR mutation
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17
Q

Class 2 anovulation

  • Hormone disturbance
  • Investigations for underlying cause
A

Class 2: normogonadotrophic anovulation
Normal FSH, LH, Estradiol

Investigations:
- Provera withdrawal test positive - pelvic ultrasound to exclude PCOS

  • Provera withdrawal test negative - endometrial/ outflow tract problems/ anatomical anomalies:
    i) 3D USG/ MRI pelvis
    ii) USG renal tract (common embryonic origin)
    iii) laparoscopy/ hysteroscopy
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18
Q

Class 3 anovulation

  • Hormone disturbance
  • Investigations for underlying cause
A

Class 3: hypergonadotrophic hypogonadism
High FSH, LH but low estradiol

Suspect premature ovarian insufficiency (POI)

  • Confirm diagnosis: FSH >25 IU/L twice over 4 weeks apart

Genetic tests:
i) Karyotype (primary amenorrhoea): Turner syndrome, disorders of sex differentiation (ambiguous genitalia, absent uterus)
ii) Fragile X premutation

Autoimmune screening: anti-thyroid Ab, anti- adrenal Ab vs ovaries

MRI pelvis: Structural lesions (Ovarian cancer, Iatrogenic damage…etc)

DXA scan (risk of osteoporosis)

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19
Q

Investigations for significant virilization/ hirsutism/ raised testosterone

A

Test for androgens:
 SHBG/ sex hormone binding globulin
 17-OH progesterone (if raised = congenital adrenal hyperplasia)

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20
Q

Test for low estrogen levels

A

Negative progestogen challenge/ Estrogen and progesterone withdrawal test

Withdrawal with no bleeding = low endogenous estrogen level

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21
Q

Treatment of amenorrhea: Hypogonadotrophic hypogonadism

A
  1. Hypothalamic functional causes: lifestyle (stress, eating disorder, excessive exercise), reassurance and observe, psychological treatment
  2. Neurosurgery for hypothalamic-pituitary lesions
  3. Estrogen therapy for primary amenorrhea and induce puberty
  4. Maintenance HRT (E+P) against osteoporosis
  5. Exogenous gonadotrophins for fertility issue (e.g. Follitropin, Lutropin a)
22
Q

Treatment of PCOS

A

Weight reduction (restore ovulation + prevent metabolic disorder in long term)

Menstrual regulation to prevent endometrial hyperplasia/CA due to unopposed estrogen:

  • Periodic progestogen for withdrawal bleeding
  • Combined OC pills

Hirsutism:

  • Combined OC pills
  • cosmetic measures (laser, shaving)
  • anti- oestrogens (spironolactone)

Fertility:
 Letrozole (1st line)
 Gonadotrophin
 Laparoscopic ovarian drilling

23
Q

Treatment for premature ovarian insufficiency

A

Primary amenorrhea: estrogen to induce puberty

Maintenance HRT (E+P) against osteoporosis until age 51

Fertility:
Oocyte donation
Adopt children

24
Q

Treatment for hyperprolactinaemia

A

 Dopaminergic drugs e.g. bromocriptine, cabergoline

 Neurosurgery (rarely)

25
Q

Treatment for outflow tract/ uterine obstruction causing amenorrhea

A

Surgical correction of congenital anomalies/ outflow tract obstruction (e.g. vaginal dilation for vaginal atresia)

26
Q

Define climacteric and menopause

A

Climacteric:

  • the years of waning ovarian function
  • Marks the transition from the reproductive to the non-reproductive state

Menopause:

  • a specific event (the final menstrual period)
  • diagnosed retrospectively after cessation of menses for 12 months in previously cyclical women
  • permanent cessation of ovarian function and fertility
27
Q

Define the time period for perimenopause

A

 Begins with the first clinical, biological and endocrinological features of the approaching menopause
 Ends 12 months after the final menstrual period
 Can last for several years

post-menopause = after perimenopause

28
Q

Define 3 clinical types of menopause

A

Natural menopause

  • Clinically diagnosed in retrospect following spontaneous amenorrhoea for 12 months
  • without other obvious pathological/ physiological cause (mean age 51 years)

Artificial/ induced menopause
- Sudden termination of menstrual life due to surgery/ radiotherapy/ chemotherapy

Premature ovarian insufficiency
- Loss of ovarian function before age 40 yrs

29
Q

Hormonal changes at menopause

A

Decline in number of ovarian follicles

  • Decrease Estradiol
  • Decrease inhibins and loss of negative feedback&raquo_space; Increase FSH and LH&raquo_space; stimulates ovarian stroma to produce androgens&raquo_space; peripheral conversion to estrone
30
Q

List 4 major categories of climacteric symptoms

A

Vasomotor symptoms

Psychological symptoms

Sexual dysfunction

Urogenital atrophy

31
Q

List vasomotor symptoms due to menopause

A

 Hot flushes
 Sweating
 Palpitation
 Dizziness

32
Q

List psychological symptoms due to menopause

A 
 Loss of energy and drive
 Loss of concentration
 Irritability
 Anxiety
 Depression
 Mood fluctuations
 Sleep disturbances
33
Q

List sexual dysfunctions due to menopause

A

 Dyspareunia (atrophic change)

 Decreased libido (Can be multifactorial)

34
Q

List urogenital atrophy symptoms due to menopause

A 
Vagina: 
 Dryness
 Burning
 Pruritus
 Dyspareunia
 Prolapse
Urinary: 
 Urgency
 Frequency
 Dysuria
 Urinary tract infection
 Incontinence
 Voiding difficulties
35
Q

Long-term health problems in menopause

A

Cardiovascular disease: loss of estrogen protective effect on vasculature and lipid profile

Postmenopausal osteoporosis: loss of estrogen causing compromised bone strength, fractures

Musculoskeletal degeneration: Laxity of soft tissue, poor muscular strength, Backache, joint pains

Dementia, cognitive decline

36
Q

WHO criteria for osteoporosis severity

Name 1 clinical tool for fracture risk assessment

A

BMC or BMD below the young adult mean for women by:

Normal <1 SD
Low bone mass 1-2.5 SD
Osteoporosis >2.5 SD
Severe osteoporosis >2.5 SD And the presence of >1 fragility fractures

FRAX tool – takes other risk factors of fracture into account in clinical management

37
Q

Clinical definition for diagnosis of menopause

Any tests for onset of menopause?

A

Clinical diagnosis in healthy women >45 years who have amenorrhoea for 12 months

Tests:
No biological marker
High FSH for some years before menopause

38
Q

General lifestyle management for menopause

A 
Lifestyle modification
 Smoking cessation
 Air conditioning
 Dress in layers
 Avoid alcohol and spicy food
 Reduce obesity
 Reduce stress (counseling)
39
Q

Outline management plan for menopause

A 
A. Lifestyle modification
B. Cardiovascular risk assessment and management
C. Cancer screening and prevention
D. Hormone replacement therapy (HRT)
E. Non-hormonal treatments for symptoms
40
Q

Hormone replacement therapy (HRT) for menopause

  • Benefits
  • Risks
A

Benefits
 Effective for severe climacteric symptoms
 Slow progression of atrophic symptoms (topical oestrogen)
 Prevent/ delay bone loss, lower risk of vertebral & non-vertebral fractures

Risks:
 Carcinoma of breast
 Venous thromboembolism
 Stroke
 Gallbladder disease
41
Q

Hormone replacement therapy (HRT) for menopause

  • Dosage
  • Contraindications
A

Use lowest possible dose for shortest possible duration for symptom relief

Contraindications:
 Severe liver disease
 Oestrogen-dependent tumours e.g. breast, uterus
 Deep vein thrombosis, embolism
 Cerebrovascular disease
 Undiagnosed uterine bleeding
42
Q

Regimens of Hormone replacement therapy (HRT) for menopause

A

With uterus: Oestrogen and progestogen (prevent endometrial hyperplasia/CA)

  • Sequential (cyclical) – add Progestogen for 12-14 days/cycle for scheduled bleeding
  • Continuous = non-bleeding regimen (suitable for >2 years post-menopause

Without uterus/ hysterectomy:
- Estrogen only

43
Q

HRT for menopausal women

  • Drug options
A

Oestrogen types:

1) Natural oestrogens (preferred):
- E.g. 17β-oestradiol (Estrofem®), conjugated equine estrogens (Premarin®)
- Preparation: oral, transdermal patch, gel Implant, vaginal ring
2) Phytoestrogens

Progestogen types:

1) Oral progestogen
2) Mirena® - levonorgestrel-releasing intrauterine system (IUCD)

Tibolone
- synthetic compound: converted to metabolites with oestrogenic, progestogenic actions

44
Q

Definite benefit, risks of estrogen only HRT

A

Benefit - reduce hip fracture
Risk - Stroke

Neutral/ conflicting:

  • Venous thromboembolism
  • CRC
  • CHD
  • Invasive breast cancer
45
Q

Definite benefit, risks of combination E+P HRT

A

Benefit:

  • Reduce hip fracture
  • Reduce CRC

Neutral
- Endometrial cancer

Risks:

  • Invasive breast cancer
  • Venous thromboembolism (VTE)
  • Stroke
  • Coronary heart disease (CHD) if administered after age 60-70
46
Q

HRT for menopausal women

  • Withdrawal method
  • SIde effects
A

Withdrawal: Tapering vs. abrupt stop (no proven difference in clinical outcome)

Side effects: breast tenderness, fluid retention, bloating, nausea, headache, irregular bleeding

47
Q

Outline non-hormonal treatments for vasomotor climacteric symptoms

A

 Clonidine, gabapentin
 Relaxation
 Lifestyle modifications

48
Q

non-hormonal treatments for psychological climacteric symptoms

A

 Psychological counselling/ therapy

 Anti-depressants

49
Q

non-hormonal treatments for vaginal atrophy in climacteric symptoms

A

 Lubricants, moisturisers

50
Q

non-hormonal treatments for cardiovascular climacteric symptoms

A

Lifestyle:
 Exercise
 Avoid smoking

Control predisposing factors: HT, DM, hyperlipidaemia, obesity

51
Q

non-hormonal treatments for osteroporosis after menopause

A

Lifestyle:
 Calcium, vit D
 Weight-bearing exercise
 Avoid smoking/ excessive alcohol/ caffeine

Selective estrogen receptor modulator e.g. raloxifene

Bisphosphonates

RANK ligand (denosumab)

MBBS IV - Junior Clerkship WCS (131 decks)

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