Menopause and Secondary Amenorrhoea Flashcards
What is the definition of the menopause?
Women’s last period
Average is age 51 years
What happens during the menopause?
Ovarian insufficiency - oestradiol falls
FSH from pituitary rises
Still some oestriol from conversion of adrenal androgens in adipose tissue
What can cause menopausal transition?
Can be natural or sudden following oophorectomy/ chemotherapy/ radiotherapy
What are the symptoms of menopause?
Vasomotor - hot flushes/ night sweats
Vaginal dryness, low libido, muscle and joint aches and mood changes/ poor memory
What problems can occur when osteoporosis develops during menopause?
Fractured hip/ vertebrae
What are the risk factors for osteoporosis?
Thin, Caucasian, smoker, high EtOH, malabsorption vit D or calcium, prolonged low oestrogen amenorrhoea, oral corticosteroids and hyperthyroidism
What is the prevention and treatment of osteoporosis?
Weight bearing exercises, adequate calcium and vit D, HRT, bisphosphates, denosumab and calcitonin
What is used for symptom treatment for menopause?
Hormone replacement therapy - HRT
Local vaginal HRT
Systemic oestrogen transdermal patch/ gel/ oral
Describe local vaginal HRT
Oestrogen pessary, ring or cream
Minimal systemic absorption
Need to use long term to maintain benefit
Describe systemic oestrogen transdermal
Patch, gel or oral
Less risk of VTE
Oestrogen only if no uterus
Oestrogen and progesterone if uterus present
Progesterone oral, patch or LNG IUS
What does progesterone prevent in HRT?
Endometrial hyperplasia from unopposed oestrogen
Describe cyclical combined oestrogen and progesterone HRT
14 days oestrogen and 14 days combined
Expect withdrawal bleed after progesterone
Use if there may still be some ovarian function to avoid inconvenience of irregular bleeding
Describe continuous combined oestrogen and progesterone HRT
28 days oestrogen and progesterone gel/ patch
Expect to be bleed free
Use if more than one year after LMP or age 54+
What HRT regime gives contraceptive cover?
Mirena plus oestrogen
What are the contraindication to systemic HRT?
Current hormone dependant cancer breast/ endometrium
Current active liver disease
Un-investigated abnormal vaginal bleeding
Advise if previous VTE, thrombophilia, breast cancer or BRCA carrier
What are the contraindications for vaginal HRT?
Avoid for women taking aromatase inhibitor treatment for breast cancer - may choose if symptoms are affecting QoL
What other treatments are used for the menopause?
SERMs - oestrogen effect on selected organs (tibolone)
Clonidine or SSRI/ SNRI antidepressants
Phytoestrogen herbs - red clover/ soya
Hypnotherapy, exercise and cognitive behaviour therapy
Non hormonal lubricants - Replens or Sylk
What antidepressant is not recommended during menopause?
Venlafaxine not recommended for vasomotor symptoms
Frequent side effects and few women benefit
What are the benefits of HRT?
Vasomotor
Local genital symptoms
Osteoporosis
What are the risks of HRT?
Breast cancer if combined HRT
Ovarian cancer
Venous thrombosis if oral route
CVA if oral route
What is andropause?
Testosterone falls by 1% a year after 30
DHEAS falls
Fertility remains and no sudden change
What is primary amenorrhoea?
Never had a period and affects 5% of girls
Delayed puberty if more than 14 with no sexual characteristics or over 16 if secondary characteristics
What is secondary amenorrhoea?
Has had periods in past but none for 6 months
What are some causes of secondary amenorrhoea?
Pregnancy/ breastfeeding, PCOS, premature ovarian insufficiency, hypothalamic, thyroid disease, raised prolactin, CAH, androgen secreting hormone, Sheehans syndrome and Ashermans syndrome
What are signs of an androgen increase?
Acne, hirsutism and voice change
What examinations and tests are done for secondary amenorrhoea?
BMI, acne hirsutism virilised, bimanual exam, pregnancy test, bloods (FSH, oestradiol, thyroid, prolactin, testosterone and 17 hydroxy progesterone) and US
What is the management for secondary amenorrhoea?
Treat specific cause and BMI less than 30
Assume fertile and needs contraception
If premature ovarian insufficiency offer HRT till 50
What is polycystic ovary syndrome?
Need 2 out of 3 for diagnosis -
Amenorrhoea, androgenic symptoms and polycystic ovarian morphology on scan
There is normal/ high oestrogen levels and increased androgens
When is there a risk of endometrial hyperplasia in PCOS?
If less than 4 periods a year and not on hormonal contraception
What are the risks of PCOS?
Reduced fertility
Higher risk of diabetes and CVD
Does not cause pain or weight gain
Weight gain can worsen PCOS symptoms as decreased SHBG levels so increased free androgen levels
What is the US definition of polycystic ovaries?
Small peripheral ovarian cysts x 10/ovary or ovarian volume less than 12cm3
20% women have this
Multicystic ovaries are common in adolescent so wait till late teens
What is the management for PCOS?
Weight loss/ exercise to BMI 25-30
Increase SHBG
Support and information
Antiandrogen - combined hormonal contraception, spironolactone and eflornithine cream
What is used for endometrial protection in PCOS?
CHC, Mirena IUS
Oral provera 10 days every 90 days if no period
What is used for fertility treatment in PCOS?
Clomiphene metformin is effective for ovulation induction
