Menopause and Secondary Amenorrhoea

Question 1

What does menopause mean

Answer 1

• Last ever period
• Perimenopause approx 5 years before

Question 2

What is the average age of menopause

Answer 2

• Women in 51
• 1/3 of life in menopause

Question 3

When is it classed as premature menopause

Answer 3

• <40

Question 4

What occurs in ovarian insufficiency

Answer 4

• Oestradiol falls
• FSH rises
• Still some oestriol from peripheral conversion of adrenal organs in fat

Question 5

What causes menopause

Answer 5

• Natural
• Follow oophorectomy, chemo, radiotherapy

Question 6

What are the symptoms of menopause

Answer 6

• Vasomotor symptoms - ‘hot flushes’
  
  • 80% women, 45% find a problem
  • Last 2-5 years - can be 10+
  • Extreme tiredness as hard to sleep
• Vaginal dryness/dyspareunia
• Low libido
• Muscle and joint ache
• Mood changes/poor memory

Question 7

What are the risks for osteoporosis

Answer 7

• Thin
• Caucasian
• Smoker
• Alcohol
• Positive family history
• Amenorrhoea
• Malabsorption
• Steroids
• Hyperthyroid

Question 8

What can be used to prevent and treat osteoporosis

Answer 8

• Exercise
• Adequate calcium & vitamin D
• HRT
• Biphosphates
• Denosumab - monoclonal antibody to osteoclasts
• Teriparatide

Question 9

What is systemic HRT treatment

Answer 9

• Patch or gel/oral - transdermal avoid first pass - less risk of VTE
  
  • Oestrogen only if no uterus
  • oestrogen + progesterone if uterus to avoid endometrial hyperplasia

Question 10

What is local HRT treatment

Answer 10

• Vaginal oestrogen only - pessary/ring/cream
• Minimal absorption - no increased risk of VTE/breast cancer
• No need for progesterone

Question 11

What is combined HRT

Answer 11

• Taken daily
• Lowers endometrial cancer risk
• Bleed free after 3 months
  
  • If still some ovarian function e.g. perimenopause likely to have breakthrough bleeding
• Cyclical combination - 14 days E + 14 days E+P
• Mirena LNG IUS + daily E

Question 12

What treatment other than HRT for menopause

Answer 12

• Selective oestrogen receptor modulators (SERMs)
  
  • E effect in selected organs
• SSRI SNRI antidepressants e.g. venlafaxine or clonidine
  
  • Not for vasomotor symptoms alone
  • Side effects and few benefit
• Natural methods phytoestrogen e.g. red cover & soy/black cohosh/hyponotherapy/exercise/CBT
  
  • High placebo
  • Cost
• Non-hormonal vaginal lubricants
  
  • ‘Replens’, ‘Sylk’

Question 13

Benefits of HRT

Answer 13

• Vasomotor
• Local genital symptoms
• Osteoporosis
• Doesn’t increase CV risk if started <60 (before atherosclerosis)
• Not affect alzeheimers

Question 14

Risks of HRT

Answer 14

• Breast cancer if combined
  
  • but less than if BMI>30 or >14 units a week
• Ovarian cancer
• Venous thrombosis if oral
• CVA if oral

Question 15

Contraindications to HRT

Answer 15

• Not same as OCP
• Hormone dependent cancer - breast/endometrium
• Current active liver disease
• Un-investigated abdominal bleeding
• Advice if previous VTE, thrombophilia, FH VTE
• Advice if previous CA breast or BRCA carrier

Question 16

NICE guidance for HRT

Answer 16

• For treatment of severe vasomotor symptoms, review annually
• Women with premature ovarian insufficiency HRT benefits outweigh risks till age 50
• Not first line for osteoporosis prevention/treatment
• Vaginal oestrogen for vaginal symptoms - only works whilst using, not long term effects

Question 17

What is the andropause

Answer 17

• Menopause in men

Question 18

What happens in the andropause

Answer 18

• testosterone falls by 1% a year after age 30
• DHEAS falls
• Fertility remains
• No sudden change
• Different from hypogonadism

Question 19

What is primary amenorrhoea

Answer 19

• Never had a period
• Affects 5% of girls
  
  • >14 and so sexual characteristics
  • >16 secondary characteristics

Question 20

What is secondary amenorrhoea

Answer 20

• Has had periods before but not in 6 months

Question 21

Causes of amenorrhoea

Answer 21

• Pregnancy/breast feeding
• contraception related
• PCOS
• Early menopause
• Thyroid disease/Cushing’s/significant illness
• Raised prolactin - prolactinoma/medication related
• Hypothalamic - stress/weight change/exercise
• Androgen secreting tumour - testosterone >5mg/l
• sheehan’s syndrome - pituitary failure
• Asherman’s syndrome - intrauterine adhesions

Question 22

Investigations of amenorrhoea

Answer 22

• BMI, Cushingoid
• Androgenic signs - hirstruism, acne, enlarged clitoris, deep voice
• Abdominal/bimanual
• Urine - pregnancy test + glucose
• Bloods
• Pelvis USS - PCOS

Question 23

Blood tests for amenorrhoea

Answer 23

• FSH
• Oestradiol
• Prolactin
• Thyroid function
• Testosterone

Question 24

Treatment of amenorrhoea

Answer 24

• Treat specific cause - e.g. BMI
• Assume fertile and need contraception unless 2 years after confirmed menopause
• If premature ovarian insufficiency offer HRT till 50
• Emotional support - daisy network
• Check for fragile X - may affect other family members

Question 25

What % women have poly cystic ovaries

Answer 25

• 25% on scan but no other symptoms

Question 26

Diagnosis criteria for PCOS

Answer 26

2 out of

• PCO morphology on scam (x10 small peripheral follicles or ovary volume >12ml)
• Clinical or biochemical hyperandrogenism - hirsute/acne
• Oligo or anovulation - amenorrhoea of infertility

Question 27

Presentation/risks of PCOS

Answer 27

• Higher risk of diabetes and cardiovascular disease for any given BMI
• Risk of endometria hyperplasia of <4 periods a year (and not on hormones)
• Do not cause weight gain or pain
  
  • Weight gain may make symptoms worse
• Underlying problem is increase insulin resistance

Question 28

Treatment of PCOS

Answer 28

• Weight loss/exercise can help all symptoms
  
  • Increase SHBG so less free androgen
  • Increased NIDDM risk even if slim
• Antiandrogen
  
  • Combine contraception
  • Spironolactone
  • Eflornithine cream facial hair
• Endometrial protection
  
  • CHC
  • Progesterone
  • Mirena US
• Fertility treatment
  
  • Clomiphene
  • Metformin (reduced androgen production)