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Obs & Gynae > Menopause + Amenorrhoea > Flashcards

Menopause + Amenorrhoea Flashcards

1
Q

What is the menopause

A 
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
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2
Q

What causes menopause

A 
Ovarian insufficiency 
- natural
- surgery - oophorectomy 
- chemo / RT  
- autoimmune 
- Turner's 
Low oestrogen 
FSH rises due to low oestrogen
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3
Q

Why do obese people suffer less in menopause

A

Conversion of androgens in fat stores to oestrogen

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4
Q

When is menopause premature?

A

<40
Common after hysterectomy
Will have raised FSH and LH

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5
Q

What are the symptoms of menopause?

A 
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
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6
Q

What is the silent change of menopause

A

Osteoporosis
Oestrogen protective of bone mass as it acts on osteoclasts
Reduced bone mass on DEXA
Fractures more likely

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7
Q

When is osteoporosis more likely?

A 
Low BMI
Malabsorption 
Smoker 
Alcohol 
FH
Steroids 
Hyperthyroid
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8
Q

When should you always start HRT

A

If premature
Benefits > risks
Benefits = reduced symptoms and osteoporosis

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9
Q

What is important in the history

A

LMP

Pattern of bleeding before

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10
Q

How do you Dx menopause

A

FSH and LH - will be high

DEXA

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11
Q

When do you refer to secondary care

A

Rx not worked
Ongoing bleeding
Ongoing SE from HRT

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12
Q

What are lifestyle measures

A

Exercise
Weight loss
Reduce stress
Sleep hygiene

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13
Q

What types of HRT is there

A

Local oestrogen cream or ring if vaginal symptoms only
Transdermal - less risk VTE
Oral
SERM

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14
Q

When do you give local cream

A

If only vaginal Sx

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15
Q

What are non-hormonal Rx

A 
CBT
Hypnotherapy
Lubricant
Anti-depressant - SSRI 
Vaginal E
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16
Q

What are CI to HRT

A

Hormone dependent breast or endometrial cancer
Liver disease
Abnormal bleeding

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17
Q

What are relative CI to HRT

A

VTE
Thrombophilia
FH / previous cancer
BRCA

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18
Q

What can HRT cause in breast

A

Proliferation of breast tissue

Appear dense on mammogram

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19
Q

What can you do for osteoporosis

A 
Weight bearing exercise
Ca + vit D
Biphosphonates = 1st line
Denosumab
Teritamide 
HRT reduce fracture
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20
Q

What is action of denosumab and teritamide

A

Denosumab - Ab to osteoclast

Teritamide - stimulate PTH

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21
Q

What are risks of HRT

A

Breast, ovarian and endometrial cancer
VTE
CVS risk if start >60 as may disrupt atherosclerosis

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22
Q

How do you give HRT

A

Oestrogen only if no uterus

O+P if uterus to prevent hyperplasia of endometrium (but increased risk of breast)

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23
Q

What are SE of HRT

A 
Nausea
Breast pain
Bleeding
Fluid retention / bloating 
Weight gain
Headache
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24
Q

How can O+P be given

A

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

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25
Q

What is primary amenorrhoea

A

Never had a period

26
Q

What triggers menstruation

A

Fall in progesterone 2 weeks after ovulation if no pregnancy

27
Q

What can cause primary amenorrhoea

A

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

28
Q

What are symptoms of blockage

A

Pelvic pain

Bloating

29
Q

When do you investigate primary amenorrhoea

A

16 if normal 2 sexual characteristic e.g. breast budding

14 if absence of 2

30
Q

What investigations do you do prior to referral / what do you look for in examination

A

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
31
Q

What does low FSH / LH suggest

A

Hypothalamic cause

32
Q

What does raised FSH / LH suggest

A

Ovarian cause

33
Q

How do you treat primary amenorrhoea

A 
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
34
Q

When do you refer to gynae

A

Obstruction / malformation

35
Q

When do you refer to endocrinology

A

Other

36
Q

What is a normal period

A

13-51
30-40ml lasting 4-5 days
Cycle 21-35 days

37
Q

What are other symptoms of period

A 
Cramps
Sore breast
Fluid retention
Appetite
Mood change
38
Q

What is secondary amenorrhoea

A

No period for 6 months after having a normal period

39
Q

What are causes of secondary amenorrhoea

A 
Structural
Ovarian
Hypothalamic
Pituitary
Adrenal
40
Q

What are structural causes

A

Asherman’s
Fibroids
PCOS

41
Q

What are ovarian causes

A 
PCOS
Premature ovarian failure
Menopause 
Contraception
Pregnancy
Breast feeding
42
Q

What are hypothalamic causes

A

Weight loss
Excessive exercise
Stress
Chronic disease

43
Q

What are pituitary / endocrine causes

A 
Prolactinoma
Piuitary adenoma
Cushing's 
Acromegay
Hypothyroid / hyper
Sheehan's
Contracpetion
44
Q

What does a prolactinoma do and how d you Rx

A

Act on hypothalamus to decrease GnRH
Results in hypogonadotrophic hypogonadism
Raised prolactin
Rx = dopamine agonist

45
Q

What does pituitary adenoma do

A

Secrete androgen

46
Q

What is Sheehan

A

Destruction of gland

47
Q

What is Asherman’s, what does it cause and how do you Dx

A 
Intrauterine adhesions
Usually after dilatation and curettage 
Leads to
- Amenorrhoea
- Infertility
- Recurrent miscarriage 
Dx = hysteroscopy
48
Q

What is adrenal causes

A

Adrenal hyperplasia
Adrenal tumour
Increased steroid

49
Q

What investigations do you do and examination

A 
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

50
Q

What can be raised in PCOS

A

Testosterone

51
Q

How do you treat

A

Treat cause

Weight loss

52
Q

What must you offer

A

Contraception

Assume fertile

53
Q

If premature ovarian

A

HRT till 50

54
Q

How do you regulate cycle

A

COCP
POP
IUS

55
Q

How do you see if ovulating

A

Mid literal progesterone

56
Q

What is Sheehan

A

Destruction of pituatary gland
Amenorrhoea
Lack of milk
Hypothyroid

57
Q

What is SSRI used for

A

Vasomotor symptoms

58
Q

What is androgen insensitivity syndrome

A

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

59
Q

How is it inherited

A

X-linked

60
Q

What are complications

A

Infertile

Risk of testicular cancer

61
Q

How do you Rx

A

Raise as female as insensitive to all male hormones
Oestrogen
Orchidectomy

Obs & Gynae (23 decks)

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