Menopause and secondary amenorrhea Flashcards
1
Q
Management of PCOS
A
- Weight loss/ exercise to BMI 20-25 (increases SHBG and less free androgens
- Increased risk of non-insulin dependant diabetes (GGT)
- Support and information
- Anti-androgens
- Combined hormonal contraceptive
- Spironolactone
- Eflorithine Crean (reduces facial hair)
- Endometrial protection
- Combined hormonal contraception/ MIRENA IUS
- Oral provera
- Fertility → metformin/ clomiphene
- Treat insulin resistance → metformin
2
Q
Polycystic ovary syndrome
A
- Oligo/ amenorrhea
- Androgenic symptoms (excess hair/ acne)
- Polycystic ovarian morphology (scan)
- Normal/ high oestradiol
- High androgens → acne/ hirsutism
- Underlying cause in insulin resistance
- Risk of endometrial hyperplasia
- Reduced fertility
- Higher risk of diabetes and CVS even with lower BMI
- Worsened symptoms by weight gain
- Can have PCOS without the morphology
3
Q
Treatment of secondary amenorrhea
A
- Treat specific causes
- BMI >20 >30 for ovulation
- Assume fertile and require contraception unless menopausal
- GRT till 50 (premature ovarian insufficiency)
- Emotional support
- Genetic testing (Fragile X)
4
Q
Investigations in secondary amenorrhea
A
- BMI/ cushingoid feature
- Acne/ hirsutism/ enlarged clitoris/ deep voice
- Abdo and bimannial exam (pelvic mass?)
- Urine pregnancy test
- Bloods (FSH, oestradiol, prolactin, TFT, testosterone, SHBG
- Pelvic ultrasound (polycystic ovaries)
5
Q
History in secondary amenorrhea
A
- Possible pregnancy
- Breast feeding
- Medication HX contraceptions, opiates, antipsychotic, metoclopramine)
- Galactorrhoea/ visual changes (high prolactin)
- Acne/ hirsutism/ voice changes (high androgen)
- Weight changes
- Exercise/ stress
- Significant illness
6
Q
Aetiology of secondary amenorrhoea
A
- Breast feeding
- Contraception related → persists for 6-9 months after
- Polycystic ovary syndrome
- Premature ovarian insufficiency
- Hypothalamic - stress/ 10% weight loss/ excess exercise/ severe illness
- Thyroid disease/ bushings
- Raised prolactin → prolactinoma/ medication related
- Congenital adrenal hyperplasia (CAH)
- Androgens secreting tumour → testosterone
- Ashermans syndrome → intrauterine adhesions
- Sheehan’s syndrome → pituitary failure
7
Q
Amenorrhoea
A
- Primary
- Never had a period
- Affects 5% of girls
- Secondary
- Has previously had periods
- None for 6 months
8
Q
Andropause
A
- Fall in testosterone by 1% a year after 40 years
- DHEAS falls too
- Fertility remains
- No sudden change in hormonal levels
- Undefined as a medical disorder and different to hypogonadism
9
Q
Indication for HRT (NICE)
A
- Treating severe vasomotor symptoms
- Women with premature ovarian insufficiency
- Osteoporosis prevention/ treatment (not first line, use bisphosphonates)
- Vaginal dryness use vaginal oestrogen)
10
Q
Risks vs benefits of HRT
A
- Benefit
- Vasomotor symptoms
- Local genital symptoms
- Osteoporosis
- Risks
- Breast and ovarian cancer
- VTE and CVA in oral route
- Unaffected
- Alzheimers
- Cardiovascular risk before 60 years
11
Q
Symptomatic treatment of menopause
A
- Selective estrogen receptor modulators (SERMs)
- Estrogen effect on selected organs but not endometrium
- Clonidine/ SSRI/ SNIR antidepressant → vasomotor symptoms (frequent side effects and few benefits)
- Phytoestrogen herbs (soya and red clover)
- Hypnotherapy/ exercise/ cognitive behavioural therapy
- Non-hormonal lubricant for vaginal dryness
12
Q
HRT contraindications
A
- Current hormone dependant cancer breast/ endometrial
- Active liver disease
- Uninvestigated vaginal bleeding
- History of breast cancer/ BRCA carrier
- Previous VTE/ thrombophilia/ family history of VTE
- Systemic > vaginal (risk factors, minimal systemic absorption)
13
Q
Combined oestrogen and progestogen HRT
A
- Cyclical combined
- 14 days E + 14 days E + P
- For some remaining ovarian function
- Continuous combined
- 28 days E + P
- >1 years after LMP/ 54 years +
- Mirena levonogestrol IUS
- Gives contraceptive cover
14
Q
Hormone replacement therapy
A
- Local vaginal HRT
- Oestrogen pessary/ ring/ cream
- Minimal systemic absorption
- Systemic oestrogen
- Transdermal patch/ gel (avoid FPM and loawerrisk of VTE) or oral
- Oestrogen only (no uterus)
- Oestrogen and progestogen (uterus present, prevents endometrial hyperplasia)
15
Q
Prevention and treatment of osteoporosis
A
- Weight bearing exercises
- Good vitamin D and calcium intake
- Hormone replacement therapy
- Bisphosphonates
- Denosumab → monoclonal antibodies
