Menopause and Secondary Amenorrhea

Question 1

What is menopause?

Answer 1

• Menopause is woman’s last ever period.
• Average age 51.
• Perimenopause for approx. 5 years before.

Question 2

What is the cause of menopause?

Answer 2

Ovarian insufficiency
• Fall in oestradiol, increase in FSH
• FSH fluctuates in perimenopause

Question 3

What are the symptoms of menopause?

Answer 3

• Vasomotor –> Hot flushes/night sweats
• Vaginal dryness/soreness
• Low libido
• Muscle and joint aches
• Mood changes/poor memory

Question 4

What is the main worry with menopause?

Answer 4

Osteoporosis

Question 5

What are the two modes of management for menopause?

Answer 5

Local

Systemic

Question 6

What is the local management of menopause?

Answer 6

• HRT pessary, ring, cream

* Need to use longterm for benefit

Question 7

What is the systemic management for menopause?

Answer 7

• If no uterus: Oestrogen

* If uterus: Oestrogen + Progesterone (oral or transdermal)

Question 8

Why do you have to add progesterone to oestrogen when there’s a uterus?

Answer 8

Progestogen prevents endometrial hyperplasia from unopposed oestrogen

Question 9

What are the contraindications for HRT?

Answer 9

• Current hormone dependent breast/endometrial cancer
• Current active liver disease
• Uninvestigated abnormal bleeding
• Seek advice for thrombophilia
• Seek advice if previous breast cancer or BRCA carrier

Question 10

What are the causes of secondary amenorrhea?

Answer 10

• Pregnancy/breast feeding
• Contraception related
• Ovary: PCOS, premature ovarian insufficiency
• Endocrine: Thyroid disease, cushings, prolactinoma, hypothalamic, androgen secreting tumour
• Kidney: Congenital adrenal hyperplasia
• Syndromes: Sheehan’s, Asherman’s syndrome

Question 11

What is Sheehan’s syndrome?

Answer 11

Can occur when women lose a life-threatening amount of blood or have severe low BP during/after childbirth.

Can deprive the pituitary gland of oxygen.

Question 12

What is Asherman’s syndrome?

Answer 12

Acquired uterine condition that occurs when scar tissue forms inside the uterus and/or the cervix.

Question 13

What are the investigations for secondary amenorrhea?

Answer 13

• BP
• BMI
• Urine pregnancy test + dipstick for glucose
• FSH, oestradiol, prolactin, TFTs, testosterone
• Hirsutism, acne, Cushingoid
• Enlarged clitoris/ deep voice (virilised –> more male)
• Abdominal/bimanual palpation
• Pelvic USS

Question 14

What is the management for secondary amenorrhea?

Answer 14

• Treat specific cause
• BMI >20, <30
• Offer HRT until 50 if premature ovarian insufficiency

Question 15

What is polycystic ovarian syndrome?

Answer 15

It’s a hormonal and metabolic disorder, often in younger women. The cysts are a sign of the disease and not the cause.

Question 16

What is the name of the diagnostic criteria for PCOS?

Answer 16

Rotterdam criteria

Question 17

What is the Rotterdam criteria?

Answer 17

If you have 2/3 of these:
• Oligo/amenorrhoea
• Androgenic symptoms
• Positive scan findings

Question 18

What are other less main symptoms of PCOS?

Answer 18

• Increased oestrogen

* Weight gain can worsen PCOS symptoms.

Question 19

What complications can PCOS give rise to?

Answer 19

• T2DM
• High BP
• CVS
• Uterine issues - e.g. endometrial hyperplasia
• INFERTILITY

Question 20

What is the management for PCOS?

Answer 20

• Lifestyle changes with aim of healthy BMI.
• COCP, Mirena, POP
• Principle of treating and monitoring underlying cause/