Menopause and Premature Ovarian Insufficiency Flashcards
Describe 3 features of age-related decline in gonadal function
1) Exhaustion of gametes (females)
2) Sudden fall in fertility (females)
3) Senescent changes in reproductive potential which may precede menopause (females and males)
What is the definition of menopause?
The last menstrual period (LMP) - a retrospective diagnosis after one year of amenorrhea
What are 2 hormonal factors to diagnose menopause?
1) High FSH > 30 (bc not getting feedback from oestrogen as no oocytes left)
2) Oestrodiol low < 203
Above what age are >80% of women thought to be postmenopausal?
54
What is the climacteric (perimenopause)?
The period of time around the LMP
When do you make a diagnosis of menopause?
> 45
How do you make a diagnosis of menopause?
Amenorrhoea for >12 months in women with a uterus (symptoms are based on women without a uterus)
- NO laboratory tests
How do you diagnose perimenopause?
Vasomotor symptoms and irregular bleeding
What makes it harder to diagnose menopause?
If the woman is taking hormone medications to control heavy bleeding e.g. COCP and high dose progesterone
Above what age should a woman not really be on the COCP?
45
Describe what happens during menopause
- Menopause is due to a limited pool of oocytes
- Oocytes decrease, reduction in oestrogen (no ovulation)
- FSH increases (lack of inhibitory feedback from oestrogen)
- This leads to:
1) Anovulatory changes, menstrual irregularities, menorrhagia (v heavy bleeding)
2) Physical changes
3) Psychological changes
Where are the location of (oestrogen) receptors?
Skin, breasts, pro-genital tract, bone, brain, blood vessels
What are symptoms of menopause?
1) Hot flush/night sweat
2) Headaches
3) Palpitations
4) Leg cramps
5) Uro-genital symptoms
6) Reduced libido
7) Mood changes
What scale is used to measure menopause symptoms?
Green (climacteric) scale
What is the average age of menopause?
52
What are possible long term consequences of menopause?
1) Osteoporosis - in adults, oestrogens are crucial for the maintenance of bone mass in both males and females, acting to suppress bone resorption by osteoclasts and to promote bone formation by osteoblasts
2) Cardiovascular disease - CAD, stroke, VTE, PE
3) Vaginal dryness and atrophy
4) Alzheimer’s
What hormones are involved in treatment for menopause?
Oestrogen, progesterone and testosterone
Why is oestrogen needed in HRT?
To reverse the symptoms and effects of low oestrogen
Why is progesterone needed in HRT?
- Necessary to protect the endometrium if the uterus present but not required in women without a uterus
- It counteracts the negative effects of oestrogen on the endometrium
- However, in patients with endometriosis who have had surgical menopause, still give progesterone to protect the still present pockets of endometriosis
Why is testosterone needed in HRT?
To increase overall energy level and enhance sexual desire and arousal
Describe continuous HRT
Should not have breakthrough bleeding bc progesterone keeps the endometrium thick
Describe sequential HRT
Used in the first 1-2 years of menopause bc still have some ovarian function, otherwise will bleed a lot
What are non-hormonal treatment options for menopause?
1) Lifestyle measures
2) Replens - vaginal moisturiser and lubricant
3) Alpha 2 agonists - clonidine (more hot flushes and night sweats)
4) SSRIs (lower dose than for depression/anxiety)
5) Gabapentin (joint problems)
What are the benefits of HRT?
1) Alleviate symptoms
2) Protect bones
3) Reduces incidence of colorectal cancer
4) ?Protect CVD
5) Improves quality of life
What are the risks of HRT?
1) VTE
2) Breast cancer
3) Endometrial cancer
4) ?CVD
When is the best time to start HRT?
At perimenopause, otherwise 5-10 years in the risks of cancer is higher
What are the different forms of HRT preparations?
1) Oral - tablet
2) Transdermal - patches, lower risk of DVT, can be gel (normally start women on this)
3) Implant - testosterone or oestrogen, every 3 months
4) Local - used on vagina or genital areas, v low dose and local, possible for women who have had breast cancer
How do you diagnose premature ovarian insufficiency?
1) Amenorrhoea for 4 months
2) FSH > 30 U/L on two occasions 6 weeks apart
3) < 40 years of age
What is the incidence of POI?
1% in women < 40
What would you do for idiopathic POI?
1) Cytogenetics - to rule out mosaic Turner syndrome
2) FMR1 permutation screening
3) Anti-adrenal and anti-thyroid antibodies
What are the consequences of POI?
1) Heart problems
2) Sex life
3) Psychological
4) Bone problems
How can you treat POI?
1) Hormone replacement (unless someone young has breast cancer)
2) Fertility treatment
3) Psychological support - The Daisy Network
What are the two possible hormone replacement treatments for treatment of POI?
1) HRT - better for bones
2) COCP/patch - for younger people, but take pill back to back otherwise symptoms come back on week off and lose oestrogen they need (also pill is free)
What are possible causes of POI?
1) Cytogenetic abnormality (8-13%) - 50% Turner
2) Autoimmune disease
3) FMR1 premutation
4) Iatrogenic
5) Infection
6) Rare genetic syndromes - Prader Willi
What % of POI is idiopathic?
70%
In what condition to streak ovaries occur?
Turner syndrome
What are streak ovaries?
Some ovarian stroma but no primary oocytes - no chance of pregnancy
What are the possible mechanisms of POI that are different from menopause?
1) Inadequate oogenesis
2) Follicle depletion
3) Follicle dysfunction
What % of women with POI have an unpredictable level of ovarian function?
50%
What % of women with POI achieve lifetime spontaneous pregnancy?
5%
What % of idiopathic POI is familial?
30%
