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Reproductive > Menopause/secondary amenorrhoea > Flashcards

Menopause/secondary amenorrhoea Flashcards

1
Q

What does menopause mean?

A

Last ever period

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2
Q

What is the average age of menopause?

A

51

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3
Q

When is perimenopause?

A

Approx 5 years before menopause

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4
Q

What counts as premature menopause?

A

40yrs or less

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5
Q

What is the physiology of menopause?

A

Ovarian insufficiency
- Oestradiol falls
- FSH rises
Still some oestriol from peripheral conversion of adrenal androgens in fat

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6
Q

Apart from naturally, when else might menopause occur?

A

Following oophroectomy, chemotherapy or radiotherapy

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7
Q

What are the symptoms of menopause?

A 
Vasomotor: hot fluses
Vaginal dryness/dyspareunia
Low libido
Muscle and joint aches
?Mood changes/poor memory
Osteoporosis
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8
Q

How long can vasomotor symptoms like hot flushes be a problem in menopause?

A

Usually last 2-5yrs

Some cases 10yrs+

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9
Q

What is osteoporosis?

A

Reduced bone mineral density

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10
Q

What are the tests for osteoporosis?

A

DEXA scan w/ T score

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11
Q

What scoring system can determines risk of fracture?

A

FRAX score

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12
Q

What is the prevention/treatment for osteoporosis?

A 
Exercise
Adequate calcium and vit D
Bisphosphonaes
Denosumab
Teriparatide
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13
Q

What are symptom treatments for menopause?

A 
Hormone replacement therapy (HRT)
Selective estrogen receptor modulators (SERMs)
SSRI SNRI antidepressants
Natural methods phytoestrogens
Non-hormonal vaginal lubricants
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14
Q

How can HRT be delivered?

A

Systemic transdermal patch or gel/oral

Locally, vaginal oestrogen only, pessary/ring/cream

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15
Q

What does transdermal HRT avoid and what risk factor does it reduce?

A

First pass metabolism

Less risk VTE

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16
Q

When would the HRT be oestrogen only?

A

If no uterus

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17
Q

When would the HRT be oestrogen and progesterone?

A

If uterus present to prevent endometrial hyperplasia

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18
Q

How is progesterone given in HRT?

A

Oral, transdermal patch or LNG IUS

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19
Q

What are the benefits of vaginal eostrogen?

A

Minimal absorpton so no increased VTE/Breast Ca risk

No need progesterone for endometrial protection

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20
Q

What are the contraindications to systemic HRT?

A 
Current hormone dependent cancer breast/endometrium
Current active liver disease
Uninvestigated abnormal PV bleeding
?Prev VTE/thrombophilia, FHx VTE
?Prev Ca breast or BRCA carrier
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21
Q

What cancer risk reduces on combined estrogen and progesterone HRT?

A

Endometrial cancer

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22
Q

If on combined HRT when are women typically bleed free?

A

After 3mo

23
Q

What is likely is still some ovarian function (perimenopause) and on continuous combined HRT?

A

Breakthrough bleeding

24
Q

What is a way to have HRT without bleeding problems?

A 
Cyclical combined:
14days E
14days E+P
Withdrawal bleed after stop P
(Mirena LNG IUS + daily E)
25
Q

What are natural methods of HRT?

A

Phytooestrogen e.g. red clover & soy, black cohosh
Hynotherapy
Exercise
CBT

26
Q

What are the benefits of HRT?

A

Vasomotor
Local genital symptoms
Osteoporosis

27
Q

What are the risk of HRT?

A

Breast Ca (combined)
Ovarian Ca
VT (oral)
CVA (oral)

28
Q

Does HRT increase CVS risks?

A

Not if start before 60yrs

29
Q

When is there excess risk of breast cancer on HRT?

A

5-10yrs after HRT

30
Q

When does HRT benefits outweigh risks with premature ovarian insufficiency ?

A

Till age 50

31
Q

What is first line for osteoporosis prevention/treatment?

A

Biphosphonates

32
Q

What is first line for vaginal symptoms?

A

Vaginal oestrogen

33
Q

Case I: Woman, 48yo, hot flushes, night sweats. Periods 5/3- cycle but missed 2 periods in last years.
What are differentials?

A

TB/thyroid/lymphoma
Likely perimenopause
Lifestyle - red clover
HRT

34
Q

Case I: Woman, 48yo, hot flushes, night sweats. Periods 5/3- cycle but missed 2 periods in last years.
Which HRT should be recommended and why?

A

Vasomotor symptoms = oestogen
Has uterus = progesterone
Some ovarian function = cyclical combined

OR Mirena + oestrogen oral/transfermal

35
Q

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. Could she be menopausal?

A

Yes, ovaries can stop sooner if hysterectomy

36
Q

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. What are the investigations to see if she is menopausal?

A

FSH

37
Q

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. What HRT treatment could she be started on?

A

If symptomatic = oestrogen

No uterus = no progesterone

38
Q

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. Why is there more benefit than risk to be on HRT due to her age?

A

<50 so HRT only replacing ‘what should be there’

39
Q

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. What is she does not want to be started on oestrogen?

A

Check FRAX score
DEXA scan
Bisphosphonates if necessary
May accept vaginal HRT if symptomatic

40
Q

Case III: Woman, 55yo. Periods stopped when 51, attends for route cervical cytology, more uncomfortable than before, mentions she has vaginal dryness and dyspareunia. Tried non hormonal vaginal moisturisers and lubricants but still has symptoms. Which HRT and why?

A

Uterus and >2yrs postmenopausal
Significant atrophy = oestrogen

Vaginal oestrogen - pessary/cream/ring

41
Q

What is andropause?

A

‘Male menopause’
Testosterone falls by 1% a year after 30
DHEAS (hormone) also falls

Fertility remains
No sudden change

42
Q

What is primary amenorrhoea?

A

Never had a period

43
Q

When is it primary amenorrhoea?

A

> 14yes and no 2ndry sexual characteristics

>16yrs with 2ndry sexual characteristics

44
Q

What is secondary amenorrhoea?

A

Had periods in past but none for 6mo

45
Q

What are some causes of secondary amenorrhoea?

A

Pregnancy/breast feeding
Contraception related -current or after Depo-provera
Polycystic ovaries
Early menopause
Thyroid/Cushing’s/sign illness
Raised prolactin - prolactinoma/medication-related
Hypothalamic - stress/wt change/exercise
Androgen secreting tumour - testosterone
Sheehans syndrome - pituitary failure
Ashermans syndrome - intrauterine adhesions

46
Q

What are the exams/investigations for secondary amenorrhoea?

A 
BMI
Cushingoid signs
Androgenic signs
Abdominal/bimanual exam
Urine pregnancy test
Dipstick glucose
Bloods: FSH, oestradiol, prolactin, thyroid, testosterone
Pelvis US ?PCOS
47
Q

What are androgenic signs?

A

Hirsutism
Acne
Enlarged clitoris
Deep voice

48
Q

What is the management of secondary amenorrhoea?

A

Treat specific cause

49
Q

What is the treatment for premature ovarian insufficiency?

A

HRT till 50
Emotional support
Check if Fragile X carrier

50
Q

When can you diagnosis polycystic ovary syndrome?

A

2 out of 3 of:

  • PCO morphology on scan (x10 small peripheral follicles or ov volume >12ml)
  • clinical or biochemical hyperandrogenism - hirsutism/acne
  • oligo or an ovulation - amenorrhoea or infertility
51
Q

What are the risks of PCOS?

A

Higher risk diabetes/CVS disease

Risk endometrial hyperplasia if <4 periods a year

52
Q

What is the management for PCOS?

A

Weight loss/exercise
can help symptoms
Increase SHBG so less free androgens
- AntiandrogensL CHC, spironolactone, eflornithine cream facial hair
- Endometrial protection: CHC, progestogens, Mirena IUS

53
Q

What are the fertility treatments that can help PCOS?

A

Clomiphene

Metformin

54
Q

What does metformin do for fertility?

A

Helps ovulation

Reproductive (20 decks)

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