Menopause/secondary amenorrhoea Flashcards
What does menopause mean?
Last ever period
What is the average age of menopause?
51
When is perimenopause?
Approx 5 years before menopause
What counts as premature menopause?
40yrs or less
What is the physiology of menopause?
Ovarian insufficiency
- Oestradiol falls
- FSH rises
Still some oestriol from peripheral conversion of adrenal androgens in fat
Apart from naturally, when else might menopause occur?
Following oophroectomy, chemotherapy or radiotherapy
What are the symptoms of menopause?
Vasomotor: hot fluses Vaginal dryness/dyspareunia Low libido Muscle and joint aches ?Mood changes/poor memory Osteoporosis
How long can vasomotor symptoms like hot flushes be a problem in menopause?
Usually last 2-5yrs
Some cases 10yrs+
What is osteoporosis?
Reduced bone mineral density
What are the tests for osteoporosis?
DEXA scan w/ T score
What scoring system can determines risk of fracture?
FRAX score
What is the prevention/treatment for osteoporosis?
Exercise Adequate calcium and vit D Bisphosphonaes Denosumab Teriparatide
What are symptom treatments for menopause?
Hormone replacement therapy (HRT) Selective estrogen receptor modulators (SERMs) SSRI SNRI antidepressants Natural methods phytoestrogens Non-hormonal vaginal lubricants
How can HRT be delivered?
Systemic transdermal patch or gel/oral
Locally, vaginal oestrogen only, pessary/ring/cream
What does transdermal HRT avoid and what risk factor does it reduce?
First pass metabolism
Less risk VTE
When would the HRT be oestrogen only?
If no uterus
When would the HRT be oestrogen and progesterone?
If uterus present to prevent endometrial hyperplasia
How is progesterone given in HRT?
Oral, transdermal patch or LNG IUS
What are the benefits of vaginal eostrogen?
Minimal absorpton so no increased VTE/Breast Ca risk
No need progesterone for endometrial protection
What are the contraindications to systemic HRT?
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
What cancer risk reduces on combined estrogen and progesterone HRT?
Endometrial cancer
If on combined HRT when are women typically bleed free?
After 3mo
What is likely is still some ovarian function (perimenopause) and on continuous combined HRT?
Breakthrough bleeding
What is a way to have HRT without bleeding problems?
Cyclical combined: 14days E 14days E+P Withdrawal bleed after stop P (Mirena LNG IUS + daily E)
What are natural methods of HRT?
Phytooestrogen e.g. red clover & soy, black cohosh
Hynotherapy
Exercise
CBT
What are the benefits of HRT?
Vasomotor
Local genital symptoms
Osteoporosis
What are the risk of HRT?
Breast Ca (combined)
Ovarian Ca
VT (oral)
CVA (oral)
Does HRT increase CVS risks?
Not if start before 60yrs
When is there excess risk of breast cancer on HRT?
5-10yrs after HRT
When does HRT benefits outweigh risks with premature ovarian insufficiency ?
Till age 50
What is first line for osteoporosis prevention/treatment?
Biphosphonates
What is first line for vaginal symptoms?
Vaginal oestrogen
Case I: Woman, 48yo, hot flushes, night sweats. Periods 5/3- cycle but missed 2 periods in last years.
What are differentials?
TB/thyroid/lymphoma
Likely perimenopause
Lifestyle - red clover
HRT
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?
Vasomotor symptoms = oestogen
Has uterus = progesterone
Some ovarian function = cyclical combined
OR Mirena + oestrogen oral/transfermal
Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. Could she be menopausal?
Yes, ovaries can stop sooner if hysterectomy
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?
FSH
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?
If symptomatic = oestrogen
No uterus = no progesterone
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?
<50 so HRT only replacing ‘what should be there’
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?
Check FRAX score
DEXA scan
Bisphosphonates if necessary
May accept vaginal HRT if symptomatic
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?
Uterus and >2yrs postmenopausal
Significant atrophy = oestrogen
Vaginal oestrogen - pessary/cream/ring
What is andropause?
‘Male menopause’
Testosterone falls by 1% a year after 30
DHEAS (hormone) also falls
Fertility remains
No sudden change
What is primary amenorrhoea?
Never had a period
When is it primary amenorrhoea?
> 14yes and no 2ndry sexual characteristics
>16yrs with 2ndry sexual characteristics
What is secondary amenorrhoea?
Had periods in past but none for 6mo
What are some causes of secondary amenorrhoea?
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
What are the exams/investigations for secondary amenorrhoea?
BMI Cushingoid signs Androgenic signs Abdominal/bimanual exam Urine pregnancy test Dipstick glucose Bloods: FSH, oestradiol, prolactin, thyroid, testosterone Pelvis US ?PCOS
What are androgenic signs?
Hirsutism
Acne
Enlarged clitoris
Deep voice
What is the management of secondary amenorrhoea?
Treat specific cause
What is the treatment for premature ovarian insufficiency?
HRT till 50
Emotional support
Check if Fragile X carrier
When can you diagnosis polycystic ovary syndrome?
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
What are the risks of PCOS?
Higher risk diabetes/CVS disease
Risk endometrial hyperplasia if <4 periods a year
What is the management for PCOS?
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
What are the fertility treatments that can help PCOS?
Clomiphene
Metformin
What does metformin do for fertility?
Helps ovulation
