Menopause and secondary amenorrhoea

Question 1

Why might you prescribe HRT?

Answer 1

Hormonal replacement therapy can be used to improve symtpms experienced during menopause.
These symptoms include:
Vasomotor- hot flushes and night sweats
Local genital symtpoms e.g. vaginal dryness
Osteoporosis

HRT is only prescribed in severe vasomotor symptoms or if premature ovarian insuffiency as the benefits then outweight risks until 50 years old.

Question 2

What are the potential risks of HRT?

Answer 2

Increased risk of breast Ca if cobined HRT
Increased risk of ovarian cancer
Increased risk of venour thrombosis if oral estrogen
Increased risk of cardiovasuclar disease if oral route

Question 3

When would vaginal HRT pessary, ring or cream be used?

Answer 3

If local/vaginal symtpoms only

Question 4

What are contraindications to systemic HRT?

Answer 4

Curent breast or endometrial cancer
Current active liver disease
Uninvestigated abnormal vaginal bleeding

Question 5

What is cyclical combined HRT and when is it used?

Answer 5

14 days of estrogen only then 14 days of oestrogen+progesterone

This is used in women who still have some ovarian function so are bleeding irregularly, this makes the bleeding regular so is less inconvient.

Question 6

When is continous combines HRT used?

Answer 6

If
>1 year after LMP
or
Age 54+

will be bleed free after 1st 3 months

Question 7

Define secondary amenorrhoea

Answer 7

Has previously had periods but none in last 6 months.

Question 8

Causes of secondary amenorrhea?

Answer 8

Pregnancy/breast feeding
Polycystic ovarian syndrome
Premature ovarian insufficiency
Stress
Thyroid disease
Prolactinoma
Cognential adrenal hyperplasia
Androgen secreting tumour
Contraception

Question 9

what other symtpoms may be seen if prolactinoma cause?

Answer 9

Galactorrhoea

Visual change

Question 10

What other symptoms may be seen if a androgen secreting tumour was the cause of secondary amenorrhea?

Answer 10

Acne
Hirsutism
Voice change

Question 11

Investigations done in secondary amenorrhea?

Answer 11

TFT's
Blood FSH, prolactin, testosterone ect
Urine pregnancy test
Abdominal and pelvic examination
Pelvic ultrasound

Question 12

How is secondary amenorrhea treated?

Answer 12

Treat specific cause
e.g. weightloss, treatment of thyroid disease

If premature ovaian insufficiency, HRT, counselling and IVF if not yet completed family.

Question 13

What is polycystic ovary (ovarian) syndrome?

Answer 13

Need 2 out of 3:
-oligo/amenorrhoea (in frequent or absecnt periods)
-andrigenic symptoms e.g. excess hair/acne
Polycystic ovarian morphology on scan

Will also have:
normal/high oestrogen levels
Increased androgens

On ultrasound 10 or more small peripheral ovarian cysts per ovary or ovarian volume >12cm3

Question 14

How is PCOS managed?

Answer 14

Weightloss

Incresed risk of diabetes so lower thresholded for OGTT

Support

Antiandrogen e.g. combine hormonal contraception, spironolactone

Elfornithine cream (antiandrogen) - reduces facial hair

Clomiphene or metformin can be used to induce ovulation to increase fertility.