Menopause/Secondary Amenorrhoea Flashcards
What is the menopause?
Ceasing of menstruation
What is the average age of menopause?
51
For how long does perimenopause typically occur?
Approximately 5 years before menopause
What is premature menopause?
Menopause 40 years or younger
What is the cause of menopause?
Ovarian insufficiency
- oestradiol falls
- FSH rises
Menopause may be natural or may follow oophorectomy, chemotherapy or radiotherapy
What are the symptoms of menopause?
Vasomotor symptoms - hot flushes Vaginal dryness/soreness Low libido Muscle and joints aches Mood changes Poor memory
What percentage of women are affected by hot flushes?
80% affected
45% find them a problem
How long can a woman experience hot flushes for?
Usually last 2-5 years
Can be 10+ years
What are the features of osteoporosis due to menopause?
Reduced bone mass
Fractured hip/vertebra in 1% of women 50-69 with significant morbidity/mortality
How can you detect osteoporosis?
DEXA scan, T score will compare BMD to rest of population
What are the risks for osteoporosis due to menopause?
Thin Caucasian Smoker Heavy drinking \+ve FH Amenorrhoea Malabsorption Steroids Hyperthyroid
What is the prevention and treatment of osteoporosis due to menopause?
Weight bearing exercise
Adequate calcium and vitamin D
HRT
Bisphosphonates - calcitonin, strontium, denosumab
What is the symptomatic treatment of menopause?
Hormone replacement therapy (HRT)
Selective oestrogen receptor modulators
Ospemifene - dyspareunia
Tibolone - synthetic steroid for hormone treatment
Natural methods e.g. phytoestrogen, herbs, hypnotherapy, exercise, CBT
Non-hormonal lubricants if symptoms of vaginal dryness only
What are the modes of HRT?
Local - vaginal oestrogen pessary/ring/cream
Systemic - transdermal or oral, transdermal avoids first pass metabolism and carries less risk of VTE
Oestrogen - oestrogen only in women who have had a hysterectomy as this will be the only hormone missing
Oestrogen and progestogen if uterus present
Progestogen oral, transdermal or LNG IUS
What are the contraindications for HRT?
Current hormone dependent cancer of breast/endometrium
Current active liver disease
Uninvestigated abnormal bleeding
Seek advice if previous VTE or thrombophilia, or FH of VTE
Seek advice if previous breast cancer or BRCA carrier
What are the benefits and risks of HRT?
Benefits
- vasomotor symptoms
- local genital symptoms
- osteoporosis
Risks
- breast Ca if combined HRT
- ovarian Ca
- venous thrombosis if oral route
- CVA if oral route
HRT carries no cardiovascular risk if started before what age?
60
When does the excess risk of breast cancer become the same as never-users after HRT treatment?
After 5 years off treatment
According to NICE Guidance, 2015, when is HRT indicated?
For treatment of severe vasomotor symptoms - review annually
For women with premature ovarian insufficiency, HRT benefits > risks until age 50
Not as first line for osteoporosis prevention/treatment - bisphosphonates
Vaginal oestrogen for vaginal symptoms
What are the features of combined oestrogen and progesterone HRT?
Cyclical combined 14 days oestrogen and 14 days oestrogen and progestogen
Get a withdrawal bleed
Use if there is still some ovary function e.g. peri menopause
or
Continuous combined 28 days oestrogen and progestogen
Will settle to amenorrhoea
Use if > 1 year after menopause or > 54 years old
What age group can use Mirena LNG IUS and daily oestrogen?
Any age group
What is andropause?
"male menopause" Testosterone falls by 1% a year after 30 Fertility remains No sudden change DHEAS falls
What is primary amenorrhoea?
A female who has never had a period - 16 or older with secondary sexual characteristics
What percentage of girls are affected by amenorrhoea?
5%;
> 14 years and no secondary sexual characteristics
> 16 years if secondary sexual characteristics
What is secondary amenorrhoea?
No periods in a female who has had periods in the past but has had none for 6 months
What are the causes of secondary amenorrhoea?
Pregnancy
Breast feeding
Contraception related
Polycystic ovaries
Early menopause
Thyroid disease/Cushing’s/any significant illness
Raised prolactin e.g. prolactinoma, medication-related
Hypothalamic - stress, weight change, exercise
Androgen-secreting tumour
Sheehan’s syndrome
Asherman’s syndrome
What are the examinations and investigations for amenorrhoea?
BP BMI Hirsutism Acne Cushingoid features Enlarged clitoris/deep voice Abdominal/bimanual pelvic examination Urine pregnancy test Urine dipstick Bloods - FSH, LH, oestradiol, prolactic, thyroid function, testosterone Pelvic ultrasound
What are the treatments for secondary amenorrhoea?
Treat the specific cause
Aim for BMI 20-25
Assume fertile and need contraception unless 2 years after confirmed menopause
If premature menopause, offer HRT until age 50 and emotional support
Check for fragile X
What is the presentation spectrum for polycystic ovary syndrome?
Higher risk of diabetes and cardiovascular disease for any given BMI
Risk of endometrial hyperplasia if < 4 periods per year and not on hormones
Polycystic ovaries do not cause pelvic pain or weight gain
Oligo/amenorrhoea
Androgenic symptoms - facial hair, acne
Anovulatory infertility
First trimester miscarriage
Diabetes
Cardiovascular disease
Irregular ovulation so irregular menstrual cycle
Plenty of oestrogen but also high androgens
Underlying insulin resistance
What are the features of polycystic ovaries?
Small peripheral ovarian cysts - 10 per ovary or ovarian volume > 12 call me asap^3
20% of women will have this on scan but no other features - this is not PCOS
Multicystic ovaries are common in adolescents and often settle down without implications
What is the management of polycystic ovary syndrome?
Weight loss/exercise can help all symptoms and increase sex hormone binding globulins so less free androgens
May be increased NIDDM risk so may need to offer glucose tolerance test
Anti-androgen - combined hormonal contraception, spironolactone, eflornithine cream for facial hair
Endometrial protection - combined hormonal contraception, progestogens, Mirena IUS
Fertility treatment with clomiphene/metformin
Metformin helps ovulation but no good evidence that it helps androgenic side effects or weight loss
