Menopause + Secondary Amenorrhoea

Question 1

Menopause

Answer 1

• LAST EVER PERIOD - can only be determined in retrospect - PERIOD-FREE FOR 12 MONTHS
  
  • AVERAGE AGE ~ 51yrs
  • PERIMENOPAUSE for ~ 5YRS BEFORE
  • PREMATURE MENOPAUSE = ≤ 40YRS

Question 2

Menopause Physiology

Answer 2

• OVARIAN INSUFFICIENCY

	○ OESTRADIOL FALLS
	○ FSH RISES (as pituitary tries to stimulate ovaries to work)
	○ Still SOME OESTRIOL from PERIPHERAL CONVERSION of ADRENAL ANDROGENS in FAT (adipose tissue produces oestrogen)

MENOPAUSE = NATURAL or FOLLOW OOPHORECTOMY/CHEMOTHERAPY/RT

Question 3

Menopause Presentation

Answer 3

• VASOMOTOR SYMPTOMS = HOT FLUSHES, NIGHT SWEATS, SWEATING, FLUSHING, ANXIETY, PALPITATIONS

	○ Usually LAST 2 - 5YRS - COULD LAST 10+YRS
	○ Hot flush triggers = caffeine, alcohol, spicy foods, smoking, thick clothing, high temp., stress/anxiety, some health conditions (e.g. hyperthyroidism, diabetes, TB), some medications, rx for some cancers

* VAGINAL DRYNESS/DYSPAREUNIA (difficult/painful sexual intercourse)
* LOW LIBIDO
* MUSCLE & JOINT ACHES

• MOOD CHANGES/POOR MEMORY

Question 4

Menopause Investigation/diagnosis

Answer 4

• MAINLY CLINICAL DIAGNOSIS

* If PT. has had HYSTERECTOMY = CHECK FSH LVLS

Question 5

Complications of Menopause

Answer 5

• REDUCED BONE DENSITY = # e.g. #hip/#vertebra
- DEXA SCAN + T SCORE

FRAX score risk:
• THIN
• CAUCASIAN
• SMOKER
• ETHANOL
• +FHx
• AMENORRHOEA
• MALABSORPTION
• STEROIDS
• HYPERTHYROID

Prevention + Rx:
• EXERCISE
• ADEQUATE CALCIUM + VITAMIN D
• HRT
• BISPHOSPHONATES
• DENOSUMAB - monclonal antibodies to osteoclasts
• TERIPARATIDE

Question 6

Menopause Management

Answer 6

HRT - systemic + local (vaginal)

• systemic = transdermal patch/gel/oral - oestrogen (+ progesterone), cyclical/continuous
• vaginal = pessary/ring/cream

SERM (selective oestrogen receptor modulators) = tamoxifen, tibolone

SSRI/SNRI antidepressants - side-effects > benefits; not for only vasomotor symptoms

Natural methods e.g. soy, exercise, CBT, hypnotherapy

Non-hormonal vaginal lubricants

Question 7

HRT - CI, risks, benefits, no effect

Answer 7

CI for systemic HRT:

1. CURRENT HORMONE DEPENDENT CANCER = BREAST/ENDOMETRIUM
2. CURRENT ACTIVE LIVER DISEASE
3. UNINVESTIGATED ABNORMAL BLEEDING

4. PREVIOUS VTE, THROMBOPHILIA, FHx VTE = SEEK ADVICE
5. PREVIOUS BREAST CANCER/BRCA CARRIER = SEEK ADVICE

Benefits = vasomotor, local genital symptoms, osteoporosis

Risks = breast cancer, ovarian cancer, VTE, stroke

No effect = Alzheimer’s disease

Question 8

Amenorrhoea Types

Answer 8

Primary = pt. has never had a period (>14yrs + no 2ndary sexual characteristics; >16yrs + 2ndary sexual characteristics)

Secondary = pt. has had a period, but none for past 6 months

Question 9

Secondary Amenorrhoea Aetiology

Answer 9

• PREGNANCY/BREAST-FEEDING
  
  • CONTRACEPTION RELATED - CURRENT USE or for 6 - 9 MONTHS AFTER DEPOPROVERA (depo progesterone shot)
  • POLYCYSTIC OVARIES
  • EARLY MENOPAUSE
  • THYROID DISEASE/CUSHINGS/ANY SIGNIFICANT ILLNESS
  • RAISED PROLACTIN - PROLACTINOMA/MEDICATION RELATED
  • HYPOTHALAMIC - STRESS/WGT. CHANGE/EXERCISE/LOW FSH LVLS (hypothalamus thinks starvation occurring - therefore the body cannot support pregnancy)
  • ANDROGEN SECRETING TUMOUR - TESTOSTERONE > 5mg/L
  • SHEEHAN’S SYNDROME - PITUITARY FAILURE - PPH causng PITUITARY INFARCTION & ∴ HYPOPITUITARISM
  • ASHERMAN’S SYNDROME - INTRAUTERINE ADHESIONS

Question 10

Secondary Amenorrhoea Investigations/diagnosis

Answer 10

• BMI, CUSHINGOID
  
  • ANDROGENIC SIGNS e.g. HIRSUTISM, ACNE, ENLARGED CLITORIS, DEEP VOICE
  • ABDOMINAL/BIMANUAL
  • URINE PREGNANCY TEST + DIPSTICK for GLUCOSE (pregnancy causes amenorrhoea)
  • BLOODS = FSH, OESTRADIOL, PROLACTIN, THYROID FUNCTIONS (TFTs + TSH), TESTOSTERONE
  • PELVIC USS = PCOS MORPHOLOGY

Question 11

Secondary Amenorrhoea Management

Answer 11

• TREAT SPECIFIC CAUSE + AIM for BMI ~ 20 - 25 & CYCLE may BECOME REGULAR AGAIN
  
  • ASSUME FERTILE = needs CONTRACEPTION UNLESS 2YRS AFTER CONFIRMED MENOPAUSE
  • If PREMATURE OVARIAN INSUFFICIENCY = offer HRT til 50YRS + EMOTIONAL SUPPORT (e.g. Daisy network - support network of pt.) + CHECK for FRAGILE X (may affect other family members)

Question 12

PCOS Diagnostic Criteria

Answer 12

1. OLIGO/ANOLVULATION = AMENORRHOEA/INFERTILITY
   
   2. CLINICAL/BIOCHEMICAL HYPERANDROGENISM = HIRSUTISM/ACNE
   3. PELVIC USS = PCOS MORPHOLOGY present - 10 small peripheral follicles/ovarian vol. > 12mL

Question 13

PCOS Complications

Answer 13

• HIGHER RISK DM & CVD - FOR ANY GIVEN BMI
  
  • RISK of ENDOMETRIAL HYPERPLASIA if < 4 PERIODS A YEAR (& NOT ON HORMONES
  • PCOS = DOESN’T CAUSE WGT. GAIN/PAIN - however, if wgt. Is put on it makes symptoms worse as less sex binding globulin hormones is present - higher lvls of oestrogen + testosterone
  • Underlying problem = INSULIN RESISTANCE (increasing insulin lvls results in wgt. gain + ovaries producing too much testosterone - interfere w/ normal ovulation)

Question 14

PCOS Management

Answer 14

• WGT. LOSS/EXERCISE can help all symptoms - difficult to do if pt. self-conscious about body
  
  • ANTI-ANDROGEN = COMBINED HORMONAL CONTRACEPTION, SPIRONOLACTONE, EFLORNITHINE CREAM for FACIAL HAIR
  • ENDOMETRIAL PROTECTION = COMBINED HORMONAL CONTRACEPTION, PROGESTOGENS, MIRENA IUS
  • FERTILITY = CLOMIPHENE/METFORMIN (helps ovulation, not good evidence that it helps androgenic side-effects/wgt. Loss)