Menopause + Amenorrhoea Flashcards
What is the menopause
Last ever period Can be Dx if no period for 12 months Typically age 50 Perimenopause 5 years prior Require contraception for 2 years if <50 and 1 year if >50
What causes menopause
Ovarian insufficiency - natural - surgery - oophorectomy - chemo / RT - autoimmune - Turner's Low oestrogen FSH rises due to low oestrogen
Why do obese people suffer less in menopause
Conversion of androgens in fat stores to oestrogen
When is menopause premature?
<40
Common after hysterectomy
Will have raised FSH and LH
What are the symptoms of menopause?
DUB Vasomotor 'hot flush' Night sweats Atrophy of vagina / myometrial thinning - Vagina dryness - Dyspareunia - Urinary incontinence - Recurrent UTI Low libido Muscle and joint aches Mood changes
What is the silent change of menopause
Osteoporosis
Oestrogen protective of bone mass as it acts on osteoclasts
Reduced bone mass on DEXA
Fractures more likely
When is osteoporosis more likely?
Low BMI Malabsorption Smoker Alcohol FH Steroids Hyperthyroid
When should you always start HRT
If premature
Benefits > risks
Benefits = reduced symptoms and osteoporosis
What is important in the history
LMP
Pattern of bleeding before
How do you Dx menopause
FSH and LH - will be high
DEXA
When do you refer to secondary care
Rx not worked
Ongoing bleeding
Ongoing SE from HRT
What are lifestyle measures
Exercise
Weight loss
Reduce stress
Sleep hygiene
What types of HRT is there
Local oestrogen cream or ring if vaginal symptoms only
Transdermal - less risk VTE
Oral
SERM
When do you give local cream
If only vaginal Sx
What are non-hormonal Rx
CBT Hypnotherapy Lubricant Anti-depressant - SSRI Vaginal E
What are CI to HRT
Hormone dependent breast or endometrial cancer
Liver disease
Abnormal bleeding
What are relative CI to HRT
VTE
Thrombophilia
FH / previous cancer
BRCA
What can HRT cause in breast
Proliferation of breast tissue
Appear dense on mammogram
What can you do for osteoporosis
Weight bearing exercise Ca + vit D Biphosphonates = 1st line Denosumab Teritamide HRT reduce fracture
What is action of denosumab and teritamide
Denosumab - Ab to osteoclast
Teritamide - stimulate PTH
What are risks of HRT
Breast, ovarian and endometrial cancer
VTE
CVS risk if start >60 as may disrupt atherosclerosis
How do you give HRT
Oestrogen only if no uterus
O+P if uterus to prevent hyperplasia of endometrium (but increased risk of breast)
What are SE of HRT
Nausea Breast pain Bleeding Fluid retention / bloating Weight gain Headache
How can O+P be given
Combined / cyclical - 14 days O then 14 days O+P (if perimenopause as gives more predictable bleeds)
Continuous if >1 year from menopause
Mirena + daily E - any age
What is primary amenorrhoea
Never had a period
What triggers menstruation
Fall in progesterone 2 weeks after ovulation if no pregnancy
What can cause primary amenorrhoea
Hypogonadotrophic hypogonadism - hypothalamus / AP not producing LH or FSH
- Hypothyroid
- Hyperprolactin
Hypergonadotrophic hypogonadism - ovaries not producing sex hormones
Turner’s - 45x
Androgen insensitivity
Congential adrenal hyperplasia
Other
Congenital malformation blocking tract - imperforate hymen
What are symptoms of blockage
Pelvic pain
Bloating
When do you investigate primary amenorrhoea
16 if normal 2 sexual characteristic e.g. breast budding
14 if absence of 2
What investigations do you do prior to referral / what do you look for in examination
Examination
- BP / BMI / pelvic USS to ensure structural normal
- Abdo and pelvic exam for structural cause
- Evidence of puberty
Hypothalamic Evidence of eating disorder / chronic disease / exercise / stress Signs of androgen excess Signs of hypothyroid Signs of hyperprolactin
Investigation FSH + LH Oestrogen / Testosterone Prolactin / TFT Pelvic USS
What does low FSH / LH suggest
Hypothalamic cause
What does raised FSH / LH suggest
Ovarian cause
How do you treat primary amenorrhoea
Treat cause Puberty induction Gradual build up of oestrogen Add progesterone when max height reached If persistent / unable to treat then consider treating osteoporosis risk with Ca / vit D / COCP
When do you refer to gynae
Obstruction / malformation
When do you refer to endocrinology
Other
What is a normal period
13-51
30-40ml lasting 4-5 days
Cycle 21-35 days
What are other symptoms of period
Cramps Sore breast Fluid retention Appetite Mood change
What is secondary amenorrhoea
No period for 6 months after having a normal period
What are causes of secondary amenorrhoea
Structural Ovarian Hypothalamic Pituitary Adrenal
What are structural causes
Asherman’s
Fibroids
PCOS
What are ovarian causes
PCOS Premature ovarian failure Menopause Contraception Pregnancy Breast feeding
What are hypothalamic causes
Weight loss
Excessive exercise
Stress
Chronic disease
What are pituitary / endocrine causes
Prolactinoma Piuitary adenoma Cushing's Acromegay Hypothyroid / hyper Sheehan's Contracpetion
What does a prolactinoma do and how d you Rx
Act on hypothalamus to decrease GnRH
Results in hypogonadotrophic hypogonadism
Raised prolactin
Rx = dopamine agonist
What does pituitary adenoma do
Secrete androgen
What is Sheehan
Destruction of gland
What is Asherman’s, what does it cause and how do you Dx
Intrauterine adhesions Usually after dilatation and curettage Leads to - Amenorrhoea - Infertility - Recurrent miscarriage Dx = hysteroscopy
What is adrenal causes
Adrenal hyperplasia
Adrenal tumour
Increased steroid
What investigations do you do and examination
Exclude pregnancy FSH + LH to see if hypothalamic or ovarian cause Androgen - may be raised in PCOS Prolactin / TFT if indicated Pelvic USS Oestrogen / testosterone
Examination
BP
BMI
Abdo / bimanual
What can be raised in PCOS
Testosterone
How do you treat
Treat cause
Weight loss
What must you offer
Contraception
Assume fertile
If premature ovarian
HRT till 50
How do you regulate cycle
COCP
POP
IUS
How do you see if ovulating
Mid literal progesterone
What is Sheehan
Destruction of pituatary gland
Amenorrhoea
Lack of milk
Hypothyroid
What is SSRI used for
Vasomotor symptoms
What is androgen insensitivity syndrome
Body insensitive to androgens e.g. testosterone
Normal male sexual characteristics do not develop
Female phenotype externally
Male genotype 46XY
Internally they have testes and absence of female reproductive hormones
How is it inherited
X-linked
What are complications
Infertile
Risk of testicular cancer
How do you Rx
Raise as female as insensitive to all male hormones
Oestrogen
Orchidectomy
