Menopause and Secondary Amenorrhoea

Question 1

Define menopause and premature menopause

Answer 1

• Menopause, last ever period (12mth period free)

- Premature menopause, menopause at 40yrs or less

Question 2

UK average age at menopause

Answer 2

51

Question 3

What is perimenopause and how long doe it last for

Answer 3

• Beginning of menopause
• Ovaries begin to produce less oestrogen, therefore less/smaller periods
• ~5 yrs prior to menopause

Question 4

3 iatrogenic causes of menopause

Answer 4

• Oophorectomy
• Chemotherapy
• Radiotherapy

Question 5

2 hormonal changes during menopause

Answer 5

• Oestradiol falls

- Follicle Stimulating Hormone (FSH) rises

Question 6

Symptoms of menopause

Answer 6

• Vasomotor symptoms (hot flushes)
• Vaginal dryness/soreness
• Low libido
• Muscle and joint aches
• ? Mood changes/poor memory

Question 7

“Silent change” of menopause and risk factors for it

Answer 7

Osteoporosis

• Thin
• Smoking and alcohol
• FHx of Amenorrhea
• Malabsorption
• Steroids
• Hyperthyroid

Question 8

Prevention + treatment of osteoporosis

Answer 8

• Weight bearing exercise
• Adequate Ca + Vit D
• HRT
• Bisphosphonates
• Calcitonin
• Monoclonal antibody to osteoclasts (Denosumab)

Question 9

Contraindication for Calcitonin + Denosumab

Answer 9

Low blood calcium levels

Question 10

2 types of HRT

Answer 10

• Local, vaginal oestrogen pessary/ring/cream
• Systemic, transdermal/oral

(?combined? ?E+P?)

Question 11

Benefit of transdermal HRT vs oral

Answer 11

Transdermal avoids first pass metabolism, reducing risk of VTE

Question 12

3 contraindications for HRT

Answer 12

• Current hormone dependent cancer (breast/endometrium)
• Current active liver disease
• Uninvestigated abnormal bleeding

Question 13

When do seek advice before HRT

Answer 13

• Previous/FHx VTE, thrombophilia

- Previous breast cancer or BRCA carrier

Question 14

Risk of HRT

Answer 14

• Breast cancer if combined HRT
• Ovarian cancer
• VTE if oral route
• CVA if oral route

Question 15

NICE guidelines for HRT use

Answer 15

• For severe vasomotor symptoms, review annually
• Premature ovarian insufficiency, HRT benefits outweigh risks till 50yrs
• Not 1st line for osteoporosis prevention/treatment (Bisphosphonates instead)
• Vaginal oestrogen for vaginal symptoms (dryness)

Question 16

Define secondary amenorrhoea

Answer 16

Has had periods in past but none for 6 months

Question 17

Causes of secondary amenorrhoea

Answer 17

• Pregnancy/breast feeding
• Contraceptive use
• Polycystic ovaries
• Early menopause
• Thyroid disease/Cushing’s
• Raised prolactin (Prolactinoma)
• Androgen secreting tumour (testosterone)

Question 18

Exams and investigations for secondary amenorrhoea

Answer 18

• BP + BMI
• Hirsutism, acne, striae
• Enlarged clitoris/deep voice
• Abdo + bimanual exam
• Pelvic US
• Urine dipstick (for glucose) + urine pregnancy test
• FSH
• LH
• Thyroid function tests
• Prolactin
• Oestradiol + Testosterone

Question 19

Treatment for secondary amenorrhoea

Answer 19

• Treat specific cause, aim BMI 20-25

- If premature ovarian insufficiency offer HRT till 50

Question 20

What is a DEXA scan used for and what does it stand for

Answer 20

• Dual Energy X-ray Absorptiometry

- Bone density

Question 21

3 characteristics of polycystic ovary syndrome

Answer 21

• Irregular ovulation so irregular cycle
• Plenty of oestrogen but also high androgens
• Underlying insulin resistance

Question 22

Treatment of Polycystic Ovary Syndrome (PCOS)

Answer 22

• Weight loss/exercise
• Combine hormonal contraception (Antiandrogen)
• Endometrial protection (progesterone, mirena IUS)
• Fertility Rx metformin/clomiphene