menopause + amenorrhoea Flashcards
menopause
woman’s last ever period
avg age of menopause
51
perimenopause
for ~5yrs before
premature menopause
40yrs or less
what happens during menopause
ovarian insufficiency: oestradial falls
FSK levels fluctuate during preimenopause
menopausal transition may be natural or sudden following oopherectomy, chemotherapy, radiotherapy
symptoms of menopause
vasomotor symptoms: hot flushes/night sweats vaginal dryness/soreness low libido muscle + joint aches ?mood changes/poor memory
silent change of menopause
osteoporosis
osteoporosis risk factors
thin caucasian smoking high EtOH \+ive FH malabsorption of VitD/Ca oral corticosteroids hyperthyroid
prevention + Rx osteoporosis
weight bearing exercise adequate Ca + VitD HRT bisphosphonates denosumab - monoclonal antibody to osteoclasts calcitonin
symptom treatment of menopause - HRT
local vaginal HRT
systemic oestrogen
combined oestrogen + progestogen HRT
local vaginal HRT
oestrogen pessary/ring/cream
local effects - minimal systemic absorption
need longterm use to maintain benefit
systemic oestrogen HRT
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
combined oestrogen and progestogen HRT: cyclical combined
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
combined oestrogen and progestogen HRT: continuous combined
28 days oestrogen an progestogen oral/patch
bleed free after 3mo
use if >1yr after menopause or age 54+
contraindications to systemic HRT
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
HRT benefits
vasomotor
local genital symptoms
osteoporosis
HRT risks
breast Ca if combined HRT
ovarian Ca
venous thrombosis if oral route
CVA is oral route
HRT use NICE guidlines 2015
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
other symptomatic treatment
selective oestrogen receptor modulators e.g. tibilone
phyoestrogen herbs e.g. red clover
hypnotherapy/exercise/CBT
non-hormonal lubricants for vaginal dryness
andropause
testosterone falls by 1% a year after 30
DHEAS dalls
fertility remains, no sudden change
primary amenorrhoea
never has a period
secondary amenorrhoea
has had periods in past but none for 6mo
secondary amenorrhoea: causes
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
secondary amenorrhoea: exa, and tests
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
secondary amenorrhoea: management
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
PCOS diagnosis: need 2/3 of
oligo/amenorrhoea
androgenic symptoms: excess hair/acne
polycystic ovarian morphology on scan
management PCOS
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
