Menopause - secondary Amenorrhoea Flashcards
what is menopause?
average age?
a woman’s last ever period
average age 51
what is perimenopause?
occurs for approx 5 years before
Menopause -What happens?
- what falls and what rises?
Ovarian insufficiency -oestradiol falls
Follicle stimulating hormone (FSH) rises
How is there still some oestriol?
from the conversion of adrenal androgens in adipose tissue
when do FSH levels fluctuate?
in perimenopause- a premenopausal level does not exclude perimenopause as a cause for symptoms
Menopausal transition may follow unnaturally after..?
oophorectomy/chemotherapy/radiotherapy
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
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
risk factors for osteoporosis? (9)
: thin/caucasian/smoking/ high EtOH/+ve FH /malabsorption Vit D or Calcium / prolonged low oestrogen amenorrhoea /oral corticosteroids / hyperthyroid
prevention and treatment of osteoporosis? (6)
wt bearing exercise , adequate calcium & Vit D, HRT, bisphosphonates, denosumab -monoclonal antibody to osteoclasts, calcitonin
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
Systemic oestrogen transdermal / oral medications avoids?
first pass- less risk VTE
a/oestrogen only if no uterus
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
What is andropause?
Testosterone falls by 1% a year after 30
DHEAS falls
What is primary amenorrhoea?
- who does this affect?
never had a period
> 14yrs and no 2ndry sexual characteristics
16 years if 2ndry sexual characteristics
Secondary amenorrhoea means?
has had periods in past but none for 6 months
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?
50
first line treatment for osteoporosis prevention?
bisphosphonates
what should you give for vaginal symptoms?
vaginal oestrogen
