menopause + amenorrhoea

Question 1

menopause

Answer 1

woman’s last ever period

Question 2

avg age of menopause

Answer 2

51

Question 3

perimenopause

Answer 3

for ~5yrs before

Question 4

premature menopause

Answer 4

40yrs or less

Question 5

what happens during menopause

Answer 5

ovarian insufficiency: oestradial falls

FSK levels fluctuate during preimenopause

menopausal transition may be natural or sudden following oopherectomy, chemotherapy, radiotherapy

Question 6

symptoms of menopause

Answer 6

vasomotor symptoms: hot flushes/night sweats
vaginal dryness/soreness
low libido 
muscle + joint aches
?mood changes/poor memory

Question 7

silent change of menopause

Answer 7

osteoporosis

Question 8

osteoporosis risk factors

Answer 8

thin 
caucasian 
smoking 
high EtOH 
\+ive FH 
malabsorption of VitD/Ca
oral corticosteroids
hyperthyroid

Question 9

prevention + Rx osteoporosis

Answer 9

weight bearing exercise
adequate Ca + VitD
HRT
bisphosphonates
denosumab - monoclonal antibody to osteoclasts
calcitonin

Question 10

symptom treatment of menopause - HRT

Answer 10

local vaginal HRT
systemic oestrogen
combined oestrogen + progestogen HRT

Question 11

local vaginal HRT

Answer 11

oestrogen pessary/ring/cream

local effects - minimal systemic absorption

need longterm use to maintain benefit

Question 12

systemic oestrogen HRT

Answer 12

transdermal/oral
(transdermal avoids first pass - less risk VTE)

oestrogen only in no use

oestrogen + progestogen if uterus present: prevent endometrial hyperplasia from unapposed oestrogen

Question 13

combined oestrogen and progestogen HRT: cyclical combined

Answer 13

14days oestrogen and 14 days oestrogen + progestogen

expect withdrawal bleed after progestogen

use if there may still be some ovarian function to avoid irregular bleeding

Question 14

combined oestrogen and progestogen HRT: continuous combined

Answer 14

28 days oestrogen an progestogen oral/patch

bleed free after 3mo

use if >1yr after menopause or age 54+

Question 15

contraindications to systemic HRT

Answer 15

current hormone dependent cancer breast/endometrium

current active liver disease

un-investigated abnormal bleeding

seek advice if prev VTE, thombophilia, FH VTE, prev breast Ca or BRCA carrier

Question 16

HRT benefits

Answer 16

vasomotor
local genital symptoms
osteoporosis

Question 17

HRT risks

Answer 17

breast Ca if combined HRT
ovarian Ca
venous thrombosis if oral route
CVA is oral route

Question 18

HRT use NICE guidlines 2015

Answer 18

for treatment for severe vasomotor symptoms, annual review

women with premature ovarian insufficiency HRT benefits outweigh risk until 50

not as first line for osteoporosis prevention/treatment (bisphosphonates instead)

vaginal oestrogen for vaginal symptoms

Question 19

other symptomatic treatment

Answer 19

selective oestrogen receptor modulators e.g. tibilone

phyoestrogen herbs e.g. red clover

hypnotherapy/exercise/CBT

non-hormonal lubricants for vaginal dryness

Question 20

andropause

Answer 20

testosterone falls by 1% a year after 30

DHEAS dalls

fertility remains, no sudden change

Question 21

primary amenorrhoea

Answer 21

never has a period

Question 22

secondary amenorrhoea

Answer 22

has had periods in past but none for 6mo

Question 23

secondary amenorrhoea: causes

Answer 23

pregnancy/breast feeding 
contraception related
PCOS
premature ovarian insufficiency 
thyroid disease/Cushing's/any signif illness
raised prolactin
congenital adrenal hyperplasia 
hypothalamic- stress, weight change, excess exercise
androgen secreting tumour
Seehan's syndrome
Asherman's syndrome

Question 24

secondary amenorrhoea: exa, and tests

Answer 24

BP, BMI, hirsutuism, Cushing’s
enlarged clitoris/deep voice - virilised
abdominal/bimanual

urine preg test + dipstick for glucose

• FSH, oestradiol
• prolactin
• thyroid function
• testosterone
• 17 hyroxy progesterone

pelvic USS

Question 25

secondary amenorrhoea: management

Answer 25

treat specific cause
aim BMI<20 (<30 for ovulation)
assume fertile and need contraception unless 2yrs after confirmed menopause

if premature ovarian insufficiency offer HRT until 50

Question 26

PCOS diagnosis: need 2/3 of

Answer 26

oligo/amenorrhoea
androgenic symptoms: excess hair/acne
polycystic ovarian morphology on scan

Question 27

management PCOS

Answer 27

weight loss/exercise to BMI 20-25

anti-androgen: COC, spironolactone, eflornithine cream

endometrial protection: CHC, Mirena IUD
oral provera 10/90 if no period

fertility rx

• clomiphene/metformin
• ovulation induction