Menopause Flashcards
Define menopause
After 1 year has passed since a woman’s last period
What is the average age of menopause?
51
What is perimenopause?
5 years or so before menopause where the woman undergoes hormonal and psychological changes and are experiencing symptoms
Define premature menopause
Menopause at 40 or before 40
Why does menopause occur?
Ovarian insufficiency
Reduced no. of functional follicles/reduced sensitivity of remaining follicles to FSH and LH –> oestradiol falls, GnRH, FSH and LH rise (but their secretion becomes very erratic) –> symptoms of perimenopause
Where can some oestradiol still come from in the body?
Peripheral conversion of adrenal androgens in fat
Menopause can occur naturally, how else may it occur?
After oophorectomy, chemo or radiotherapy
What are the symptoms of menopause?
Muscle/joint aches Hot flushes Vaginal dryness Low libido Mood changes/memory problems Osteoporosis
Define osteoporosis
Reduced in bone mineral density
How do you monitor osteoporosis?
DEXA scan, T score, FRAX score
What is the issue with osteoporosis?
Woman at increased risk of fractures
What things would lead to a high FRAX score?
Thin, Caucasian, smoker, alcohol use, +ve FH, steroids, malabsorption, hyperthyroidism
How can prevent/treat osteoporosis?
Exercise, vit D/calcium supplements, bisphosphonates, denosumab (monoclonal Ab against osteoclasts), teriparatide
How can you treat menopause?
HRT Selective oestrogen receptor modulators SSRI/SNRI antidepressants Natural methods Non-hormonal vaginal lubricants
What are the two forms of HRT you can use?
- SYSTEMIC
Patch (avoids first pass met –> less VTE risk), oral, gel
Oestrogen only if no uterus
Oestrogen and progesterone if uterus - LOCAL
Vaginal oestrogen only (pessary/ring/cream)
Minimal absorption so no increased VTE/breast ca risk
Why must you give progesterone to someone in systemic HRT who has a uterus?
Unopposed oestrogen has a proliferative effect on the endometrium so may lead to endometrial hyperplasia
What are the different ways you can give progesterone as HRT?
LNG IUD, transdermal patch, POP
What are the contraindications to HRT?
Current hormone dependent cancer of breast/endometrium, current active liver disease, uninvestigated abnormal vaginal bleeding
Seek advice about prev. VTE, thrombophilia, FH VTE, prev. breast ca/BRCAn carrier
Why might we not do continuous combined HRT?
What is the alternative?
Despite it being assoc. w lower endometrial cancer risk, may lead to inconvenient breakthrough bleeding if still some ovarian function
Can do cyclical combined - 14 days oestrogen 14 days oestrogen and progesterone (withdrawal bleed after stopping progesterone)
NB any age can use mirena and daily oestrogen
What are SERMs?
Have oestrogen effect on selective organs
Used to treat vasomotor symptoms assoc. with menopause
What natural methods can you use for menopause symptom treatment?
Phytooestrogen (red clover, soy, black cohosh)
Hypnotherapy, CBT, exercise
What are the benefits of HRT?
Improves vasomotor and local genital symptoms
Reduces risk of osteoporosis and bowel cancer
What are the risks of HRT?
Breast Ca if combined HRT (and BMI >30, or >14u EtOH/wk & returns to normal after 5y of cessation), ovarian cancer
VTE and CVA if oral route
What are the HRT use NICE guidelines?
Rx of severe vasomotor symptoms - review annually
For woman with premature ovarian insufficiency - HRT benefits outweigh risks until 50
Not first line Rx for osteoporosis - use bisphosphonates
Vaginal oestrogen for vaginal symptoms
What is andropause?
Testosterone decreases by 1% every year after 20
Fertility remains and no sudden change
What is primary amenorrhoea?
Never having had a period
>14y + no secondary sexual characteristics
>16y + secondary sexual characteristics
Define secondary amenorrhoea
Has had periods in past but none for last 6m
What are the causes of secondary amenorrhoea?
Pregnancy/breast feeding Contraception related Polycystic ovaries Early menopause Thyroid/cushings dx/any serious illness Raised prolactin - prolactinoma/medication related Hypothalamic - wt change/stress/exercise Androgenic secreting tumour Sheenan's syndrome Asherman's syndrome
What is sheenan’s syndrome?
Pituitary failure
What is asherman’s syndrome?
Intrauterine adhesions
What tests would you do/signs would you look for in examination of someone with secondary amenorrhoea?
BMI/Cushingoid
Androgenic signs - hirtuism, enlarged clitoris, deep voices, acne
Pregnancy test/dipstick for glucose
FSH, oestradiol, thyroid function tests, prolactin, testosterone
Pelvic USS to check for polycystic ovaries
How do you treat secondary amenorrhoea?
Direct at cause
Aim for BMI 20-25
Check for fragile X
If premature ovarian insufficiency offer HRT until 50, emotional support, daisy network
Can someone still be fertile if they have secondary amenorrhoea?
Assume fertile and need contraception until 2 years after confirmed menopause
How do you diagnose PCOS?
2/3 are present:
PCO morphology on USS (x10 small peripheral follicles/volume >12ml)
Clinical/biochemical hyperandrogenism - hirtuism/acne
Oligo/anovulation - amenorrhoea/infertility
What are people with PCOS at risk of if they are not on hormones?
Endometrial hyperplasia if <4 periods a year and not on hormones
What do half of PCOS patients have?
Metabolic syndrome (obesity, insulin resistance and hypercholesterolaemia)
What is the underlying aetiology of PCOS?
Reduced insulin sensitivity –> hyperinsulinaemia (insulin receptors on theca cells - this is thought to lead to increased LH secretion)
Increased LH leads to increased production of androgens which the granulosa cells can’t convert all of into oestrogen –> imbalance between androgen precursors and oestrogen produced by granulosa cells
–> low FSH and improper follicle maturation, LH so high there is no surge –> anovulation
Increased circulating androgens –> virilization and increase in oestrogen production in adipose tissue
Inhibited production of sex hormone binding globulin in liver –> increased free androgens and oestrogens
What does hyperinsulinaemia result in (apart from increased androgens)?
Obesity, acanthosis nigricans
What would the blood tests of someone with PCOS show?
Increased testosterone, LH increased LH:FSH ratio
Oestrogen normal/raised
What is involved in the management of PCOS?
Wt loss/exercise
Increase SHBG so reduced free androgens
Antiandrogens - COCP, spironolactone, elfornithine cream
Endometrial protection - COCP, POP, mirena
Fertility Rx - clomiphene/metformin
How does metformin work in treating PCOS?
Helps ovulation
How does clomiphene work in treating PCOS?
Inhibits hypothalamic oestrogen receptors –> increased production of GnRH and therefore FSH/LH which stimulates ovulation
What can cause premature ovarian insufficiency?
Idiopathic or genetic causes, e.g. Turner’s syndrome, or post-chemo
What is the mechanism behind premature ovarian insufficiency?
Impaired follicular development –> reduced oestrogen –> loss of feedback inhibition of oestrogen on FSH and LH –> FSH and LH rise
What age is a woman required to be for it to be considered premature ovarian insufficiency?
Before age or 40
