Menopause and premature ovarian insufficiency Flashcards
What is menopause
Retrospective diagnosis
When a woman has not had any periods for 12 months
Permanent end to menstruation
What age on average do women experience the menopause?
51yrs
What is postmenopause
From 12 months after the final period onwards
What is perimenopause
Time around the menopause - time leading up to the last menstrual period and the 12 months afterwards
At what age do most women start experiencing perimenopause
45 onwards
What is premature menopause
Menopause <40yrs
What is premature menopause caused by?
Premature ovarian insufficiency
What causes the menopause?
Lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle
What happens to oestrogen and progesterone due to the menopause?
Low
What happens to LH and FSH due to the menopause
High - in response to an absence of negative feedback from oestrogen
Describe the physiology of the menopause
Decline in the development of the ovarian follicles
Without the growth of follicles, reduced production of oestrogen. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced
As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland and increasing levels of LH and FSH
The failing follicular development means ovulation does not occur, resulting in irregular menstrual cycles.
Without oestrogen the endometrium does not develop leading to amenorrhoea.
Low oestrogen levels also cause perimenopausal symptoms
List some perimenopausal symptoms
Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier/lighter periods Vaginal dryness and atrophy Reduced libido
What does a lack of oestrogen increase the risk of?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
How is a diagnosis of perimenopause made
Women >45yrs with symptoms, without performing investigations
FSH to help diagnose women <40 yrs with suspected perimenopause and women 40-45 with menopausal symptoms or a change in the menstrual cycle
What happens to fertility after age 40?
Declines gradually, however women should still consider themselves fertile
How long do women need to use effective contraception for when they think they are going through perimenopause
2 years after LMP in women <50 and 1 year after LMP in women >50
Describe the effect of hormonal contraceptives on menopause
Do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms - makes diagnosing menopause more difficult
List some good contraceptive options (UKMEC1) for women approaching the menopause
Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (<45yrs) Sterilisation
Name a UKMEC2 contraceptive method used during perimenopause and describe how long it can be used for and which versions are the best for this population
COCP - norethisterone or levonorgestrel in women >40 due to lower risk of VTE
Can be used <50 yrs if no other CIs
What are the two key side effects of the progesterone depot injection?
Weight gain
Reduced bone mineral density
Which women is the progesterone depot unsuitable in?
Women >45yrs
How long do the vasomotor symptoms of perimenopause last for?
2-5 years without treatment
Describe the management of perimenopausal symptoms
No treatment
HRT
Tibolone - acts as continuous combined HRT
Clonidine
CBT
SSRIs - fluoxetine or citalopram
Vaginal oestrogen - vaginal dryness and atrophy, used alongside systemic HRT
Testosterone - treat reduced libido
Vaginal moisturisers - sylk, replens, YES
What is premature ovarian insufficiency
Menopause before age 40
What is premature ovarian insufficiency a result of?
Decline in the normal activity of the ovaries at an early age
Presents with early onset of the typical symptoms of menopause
Hypergonadotropic hypogonadism
Describe hypergonadotropic hypogonadism
Under activity of the gonads means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins
What will hormonal analysis of premature ovarian failure show?
Raised LH and FSH
Low oestrogen
What are the causes of premature ovarian insufficiency
Idiopathic
Iatrogenic - chemo, radiotherapy, surgery
Autoimmune - Coeliac disease, adrenal insufficiency, T1DM, Thyroid disease
Genetic - FH, turners syndrome
Infections - Mumps, TB or CMV
Describe the presentation of premature ovarian insufficiency
Irregular menstrual periods
Lack of menstrual periods
Symptoms of low oestrogen levels - hot flushes, night sweats and vaginal dryness
Describe the diagnosis of premature ovarian insufficiency
Woman <40yo
Typical menopausal symptoms
Elevated FSH (persistently raised on 2 occasions separated by more than 4 weeks apart)
When are FSH levels difficult to interpret?
Women taking hormonal contraception
What is premature ovarian insufficiency associated with?
CVD Stroke Osteoporosis Cognitive impairment Dementia Parkinsonism
Describe the management of premature ovarian insufficiency
HRT until at least age 50
Describe the benefits of HRT
Reduces CVD, osteoporosis, cognitive and psychological risks
Why is contraception needed in women with premature ovarian failure?
Small risk of pregnancy
Describe the two options for HRT in women with Premature ovarian insufficiency
Traditional hormone replacement
Combined oral contraceptive pill
Why is HRT a better option than the COCP in people with premature ovarian insufficiency?
Lowers BP
Why is COCP better than HRT in women with premature ovarian insufficiency?
Less stigma - more socially accepted
Acts as a contraception
Describe HRT and the risk of breast cancer
Not considered to increase the risk as women would ordinarily produce the same hormones at this age
How can the risk of VTE in women <50 on HRT be reduced?
Transdermal methods
