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Year 3 - Reproduction > Menopause and Secondary Amenorrhoea > Flashcards

Menopause and Secondary Amenorrhoea Flashcards

1
Q

What is menopause?

A

Menopause mean last ever period

Can be natural or follow oophorectomy/chemotherapy/ radiotherapy

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2
Q

What is the average age of menopause?

A

51 years old

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3
Q

What is perimenopause?

A

Approx 5 years before menopause

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4
Q

What is premature menopause?

A

> 40 years old

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5
Q

What causes menopause?

A

Can be natural or follow oophorectomy/chemotherapy/ radiotherapy

Ovarian insufficiency:

  • Oestradiol falls
  • FSH rises
  • Still some oestriol from peripheral
    - Conversion of adrenal androgens in fat
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6
Q

What are the symptoms of menopause?

A

1) Vasomotor symptoms ‘hot flushes’ 80% women 45% find them a problem usually last 2-5 yrs, may be 10 years+
2) Vaginal dryness / dyspareunia
3) Low libido
4) Muscle and joint aches
5) Mood changes / poor memory
6) Osteoporosis

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7
Q

How are the symptoms of menopause managed?

A

1) Hormone replacement therapy
2) Local vaginal oestrogen only pessary/ring/cream
3) Selective estrogen receptor modulators (SERMs).
4) SSRI SNRI antidepressants
5) Natural methods phytooestrogen
6) Non hormonal vaginal lubricants

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8
Q

Contraindications to systemic hormone replacement therapy?

A

1) Current Hormone dependent cancer breast/endometrium
2) Current active liver disease
3) Uninvestigated abnormal bleeding
4) Seek advice if previous VTE, thrombophilia, FH VTE
5) Seek advice if previous CA breast or BRCA carrier

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9
Q

How are the symptoms of menopause managed - HRT?

A

1) Hormone replacement therapy:
- Systemic transdermal patch
- Gel/oral transdermal avoids first pass- less risk VTE
- a/oestrogen only if no uterus
- b/oestrogen + progestogen if uterus present to prevent
- Endometrial hyperplasia
- Progestogen oral
- Transdermal patch
- LNG IUS

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10
Q

How are the symptoms of menopause managed - Local vaginal oestrogen only pessary/ring/cream?

A

Local vaginal oestrogen only pessary/ring/cream. Minimal absorption-no increased VTE/breast Ca risk –no need progestogen for endometrial protection

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11
Q

How are the symptoms of menopause managed - combined oestrogen and progesterone HRT?

A

Combined Estrogen and Progestogen HRT:
- Continuous combined HRT ie E+P taken daily

 - Lower endometrial cancer risk
 - Bleed free after 3 months or so
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12
Q

How are the symptoms of menopause managed - combined oestrogen and progesterone HRT what if bleeding still occurs?

A

Need Cyclical combined 14 days E + 14 days E+P

Withdrawal bleed after stop P

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13
Q

How are the symptoms of menopause managed - example of a SERM?

A

Tibolone

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14
Q

How are the symptoms of menopause managed - example of a SSRI SNRI antidepressant?

A

Venlafaxine or Clonidine

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15
Q

How are the symptoms of menopause managed - example of a natural methods phytooestrogen?

A 
> Red clover & soy 
> Black cohosh   
> Hypnotherapy
> Exercise 
> CBT   
> High placebo effect
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16
Q

Risks of hormonal replacement therapies?

A

1) Breast cancer if combined HRT
2) Ovarian Ca
3) Venous thrombosis if oral route
4) CVA if oral route
5) Fracture

6)

17
Q

Benefits of hormonal replacement therapies?

A

1) Vasomotor
2) Local genital symptoms
3) Osteoporosis

18
Q

Jane is 48 and has hot flushes and night sweats. She has periods 5/30 cycle but has missed 2 periods in the last year.

  • What should you consider?
  • What is the most likely diagnosis?
  • How can you manage?
A

1) Consider TB/ thyroid/ lymphoma
2) Information likely perimenopause
3) Lifestyle changes / Red clover / Hormone replacement therapy

19
Q

Jane is 48 and has hot flushes and night sweats. She has periods 5/30 cycle but has missed 2 periods in the last year. Which HRT should be used.

1) Vasomotor symptoms
2) Has a uterus
3) Has some ovarian function

A

1) Vasomotor symptoms need oestrogen
2) Has a uterus so needs progestogen

3) Has some ovarian function so needs cyclical combined
OR
Mirena + Oestrogen oral/transdermal

20
Q

Sheila had a hysterectomy for menorrhagia when she was 36 18/40 size fibroids. Her ovaries were conserved. She is now 39 and has hot flushes.

1) She wonders if she is menopausal?
2) Tests?
3) Management?

A

1) Menopause frequent after hysterectomy even if ovaries conserved

2) - Follicle stimulating hormone = FSH.
- FRAX score/DEXA scan

3) If symptomatic oestrogen, can use vaginal HRT for vaginal symptoms.
(Does not have uterus so does not require progesterone)

21
Q

What is andropause?

A

Drop in testosterone and DHEAS

22
Q

What is the normal fall of testosterone each year after 30?

A

1% a year after 30 years old

23
Q

What happens to fertility with andropause?

A

Fertility remains

24
Q

What is primary amenorrhoea?

A

Never had a period

25
Q

How many girls affected by primary amenorrhoea?

A

5%

26
Q

What is secondary amenorrhoea?

A

Has had periods in the past but none in the last 6 months

27
Q

Causes of secondary amenorrhoea?

A

1) Pregnancy / Breast feeding
2) Contraception related- current use or for 6-9 months after depoprovera
3) Polycystic ovaries
4) Early menopause
5) Thyroid disease/ Cushings/ Any significant illness
6) Raised prolactin- prolactinoma/ medication related
7) Hypothalamic- stress/ wt change / exercise
8) Androgen secreting tumour- testosterone >5mg/l
9) Sheehans syndrome- pituitary failure
10) Ashermans syndrome- intrauterine adhesions

28
Q

Which exams and tests would you perform for secondary amenorrhoea?

A

> BMI,, Cushingoid

> Androgenic signs eg hirsutism, acne, enlarged clitoris, deep voice

> Abdominal/bimanual

> Urine pregnancy test + dipstick for glucose

> Bloods = FSH, oestradiol, prolactin, thyroid function, testosterone

> Pelvic ultrasound - polycystic ovary morphology

29
Q

What percentage of woman will have polycystic ovaries on scan but no symptoms?

A

25% of women will have polycystic ovaries on scan but NO other symptoms

30
Q

How is polycystic ovary syndrome diagnosed?

A

Diagnose PCO Syndrome if 2 out of 3 of:

1) PCO morphology on scan (x 10 small peripheral follicles or ov volume >12ml)
2) Clinical or biochemical hyperandrogenism- hirsute/acne
3) Oligo or anovulation – amenorrhoea or infertility

31
Q

Polycystic ovary syndrome - presentation spectrum?

A

1) Higher risk diabetes & cardiovascular disease for any given BMI
2) Risk of endometrial hyperplasia if < 4 periods a year (and not on hormones)
3) Polycystic ovaries do NOT cause weight gain or pain
4) Underlying problem is increased insulin resistance

32
Q

How is polycystic ovaries managed?

A

1) Weight loss/exercise can help all symptoms
- Increase SHBG so less free androgens
- Increased NIDDM risk even if slim GTT

2) Antiandrogen
- Combined hormonal contraception ( CHC)
- Spironolactone
- Eflornithine cream facial hair

3) Endometrial protection:
- CHC
- Progestogens
- Mirena IUS

4) Fertility Rx:
- Clomiphene
- Metformin - helps ovulation but not good evidence that help androgenic SE or weight loss

Year 3 - Reproduction (25 decks)

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