Menopause-silent change- Osteoporosis - what is this? - problems that can occur from this?

- reduced bone mass - DEXA scan bone density described as T score - fractured hip / vertebra 1% women 50-69 significant morbidity+mortality

Menopause- symptom treatment Hormone replacement therapy (HRT) - Local vaginal HRT

oestrogen pessary/ring/cream - Local effects -minimal systemic absorption - Need to use longterm to maintain benefit

Combined Estrogen ( E) and Progestogen (P) HRT - how is this combined? - when will there be a withdrawal bleed?

cyclically - 14 days E + 14 days E+P - P use if there may still be some ov function to avoid irregular bleeding

Menopause - secondary Amenorrhoea Flashcards by Sophie C

what is menopause?

average age?

a woman’s last ever period

average age 51

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what is perimenopause?

occurs for approx 5 years before

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Menopause -What happens?

- what falls and what rises?

Ovarian insufficiency -oestradiol falls

Follicle stimulating hormone (FSH) rises

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How is there still some oestriol?

from the conversion of adrenal androgens in adipose tissue

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when do FSH levels fluctuate?

in perimenopause- a premenopausal level does not exclude perimenopause as a cause for symptoms

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Menopausal transition may follow unnaturally after..?

oophorectomy/chemotherapy/radiotherapy

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Menopause-symptoms - vasomotor

hot flushes / night sweats

Vaginal dryness / soreness
Low libido
Muscle and joint aches
Mood changes / poor memory – possibly related to vasomotor symptoms affecting sleep

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Menopause-silent change- Osteoporosis - what is this?

problems that can occur from this?

reduced bone mass
DEXA scan bone density described as T score
fractured hip / vertebra 1% women 50-69 significant morbidity+mortality

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risk factors for osteoporosis? (9)

: thin/caucasian/smoking/ high EtOH/+ve FH /malabsorption Vit D or Calcium / prolonged low oestrogen amenorrhoea /oral corticosteroids / hyperthyroid

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prevention and treatment of osteoporosis? (6)

wt bearing exercise , adequate calcium & Vit D, HRT, bisphosphonates, denosumab -monoclonal antibody to osteoclasts, calcitonin

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Menopause- symptom treatment Hormone replacement therapy (HRT)

Local vaginal HRT

oestrogen pessary/ring/cream

Local effects -minimal systemic absorption
Need to use longterm to maintain benefit

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Systemic oestrogen transdermal / oral medications avoids?

first pass- less risk VTE

a/oestrogen only if no uterus

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Combined Estrogen ( E) and Progestogen (P) HRT

how is this combined?
when will there be a withdrawal bleed?

cyclically - 14 days E + 14 days E+P

P use if there may still be some ov function to avoid
irregular bleeding

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What is andropause?

Testosterone falls by 1% a year after 30

DHEAS falls

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What is primary amenorrhoea?

- who does this affect?

never had a period

> 14yrs and no 2ndry sexual characteristics
16 years if 2ndry sexual characteristics

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Secondary amenorrhoea means?

has had periods in past but none for 6 months

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Secondary amenorrhoea causes (11) - give a few

Pregnancy / Breast feeding
Contraception related- current use or for 6-9 months after depoprovera
Polycystic ovary syndrome
Premature ovarian insufficiency
Thyroid disease/ Cushings/ Any significant illness
Raised prolactin- prolactinoma/ medication related
Congenital adrenal hyperplasia
Hypothalamic- stress/ 10% wt change / excess exercise
Androgen secreting tumour- testosterone >5mg/l
Sheehans syndrome- pituitary failure
Ashermans syndrome- intrauterine adhesions

Secondary amenorrhoea: exam and tests?

BP, BMI, hirsutism, acne , Cushingoid
enlarged clitoris/deep voice =virilised
-abdominal/bimanual

urine pregnancy test   + dipstick for glucose
bloods  FSH oestradiol (menopause)
prolactin
thyroid function    testosterone
17 hydroxy progesterone ( CAH)
pelvic ultrasound-  ?polycystic ovaries

with secondary amenorrhoea you should treat?

BMI aimed for ovulation?

specific cause

Aim BMI >20 <30 for ovulation

If a patient has premature ovarian insufficiency - what should you do?

insufficiency offer HRT till 50

emotional support Daisy network

what do you need to diagnose PCOS - 2 out of 3 criteria

oligo/amenorrhoea
androgenic symptoms: excess hair/acne
Polycystic ovarian morphology on scan

Normal/high oestrogen levels
Increased androgens
? Underlying cause insulin resistance

when do patients have a risk of endometrial hyperplasia?

why do you assume they are fertile?

< 4 periods a year (and not on hormones)

Reduced fertility if not ovulating regularly- BUT assume fertile and use contraception if not plan pregnancy
Reduced fertility if not ovulating regularly- BUT assume fertile and use contraception if not plan pregnancy

endometrial hyperplasia have a higher risk if they have what 2 conditions ?

diabetes & cardiovascular disease even if lean

Polycystic ovaries do NOT cause ? (2)

weight gain or pain.
- Weight gain can worsen PCOS symptoms as ↓SHBG
levels ↑ androgens

Polycystic ovaries – ultrasound scan - what would you see (size)

Small peripheral ovarian cysts x 10/0vary or | - ovarian volume>12cm3

what ovaries are common in adolescents?

Multicystic ovaries

management of PCOS? | - what is there an increase risk of even if they are slim?

Weight loss/exercise to BMI 20-25 - increased NIDDM risk even if slim consider GTT

what does weight loss in PCOS do?

can help all symptoms | - increases SHBG so less free androgens

treatment/management of PCOS?

Antiandrogen - combined hormonal contraception if no CI spironolactone eflornithine cream reduces facial hair growth

what may metformin encourage in PCOS?

- ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss

Fertility Rx for PCOS?

Rx clomiphene / metformin ovulation induction

PCOS - endometrial protection | - what to give if no period

CHC, Mirena IUS | Oral provera 10/90 if no period

When would you use the continuous combined 28 days E+P oral/patch? - when would you expect patients to be bleed free?

use if > 1yr after menopause or age 54+ - ( after 1st 3 months)

Contraindications to Systemic HRT? (3) - what should you seek advice for before prescribing HRT? (2)

1 - Current Hormone dependent cancer breast/endometrium 2 - Current active liver disease 3 - Uninvestigated abnormal bleeding - if prev VTE, thrombophilia, FH VTE - if previous breast cancer or BRCA carrier

Symptom treatment - what should you give? | give an example?

- Selective Estrogen Receptor Modulators (SERMs) | - tibolone

non-pharmalogical treatment ?

hypnotherapy/ exercise / Cognitive behavioural therapy

HRT benefits - can help against? (3)

vasomotor local genital symptoms osteoporosis

HRT risks? things taken the oral route?

breast Ca if combined HRT - ovarian Ca - venous thrombosis if oral route - CVA if oral route

For women with premature ovarian insufficiency HRT benefits outweigh risk until what age?

first line treatment for osteoporosis prevention?

bisphosphonates

what should you give for vaginal symptoms?

vaginal oestrogen