Menopause, Secondary Amenorrhoea and HRT

Question 1

describe menopause

Answer 1

• a womans last ever period
• average age is 51
• perimenopause for approx 5 years before
• premature menopause = less than 40 years old

Question 2

what happens during menopause?

Answer 2

• ovarian insufficieny: oestradiol falls, FSH from pituitary rises, stimm some oestriol from conversion of adrenal androgens in adipose tissue
• FSH levels fluctuate in perimenopause - premenopausal level does not exclude perimenopause as a cause for symptoms
• menopausal transition may be natural or sudden following oophorectomy/chemo/radiotherapy

Question 3

menopause symptoms

Answer 3

• vasomotor: hot flushes/night sweats - usually last 2-5 yrs but may be 10+ years
• vaginal dryness/soreness
• low libido
• muscle and joint aches
• mood changes/poor memory - possibly related to vasomotor symptoms affecting sleep
• fractures > osteoporosis

Question 4

menopause symptomatic treatment

Answer 4

Hormone replacement therapy:
- local vaginal HRT oestrogen pessary/ring/cream
- systemic oestrogen transdermal patch/gel or oral transdermal avoids first pass: oestrogen only if no uterus, oestreogen + progestogen if uterus present (progestogen prevents endometrial hyperplasia from unopposed oestrogen)

Question 5

when would cyclical combined 14 days estrogen + 14 days estrogen + progesterone be used?

Answer 5

if there may be some ovarian function to avoid inconvenience of irregular bleeding

Question 6

when would continous combined 28 days estrogen + progestogen oral/patch be used?

Answer 6

use if > 1yr after LMP or age 54+

Question 7

contraindications to systemic HRT

Answer 7

• current hormone-dependent cancer of breast/endometrium
• current active liver disease
• uninvestigated abnormal vaginal bleeding
• seek advice if prev. VTE, thrombophilia, FH VTE
• seek advice if previous breast cancer or BRCA carrier

Question 8

contraindications to vaginal HRT

Answer 8

• avoid for women taking aromatase inhibitor treatment for breast cancer - but may choose to use if symptoms affecting quality of life

Question 9

HRT risks

Answer 9

• breast cancer if combined HRT
• ovarian cancer
• venous thrombosis if oral route
• CVA if oral route

Question 10

what is secondary amenorrhoea?

Answer 10

has hade periods in past but none for 6 months

Question 11

secondary amenorrhoea causes

Answer 11

• pregnancy/breastfeeding
• contraception related
• PCOS
• premature ovarian insufficiency
• hypothalamic - stress, 10% weight change, excess exercise, any severe illness
• thyroid disease/cushings
• raised prolactin
• congenital adrenal hyperplasia
• androgen secreting tumour
• Sheehans syndrome - pituitary failure
• Ashermans syndrome - intrauterine adhesions

Question 12

Secondary amenorrhea exams and tests

Answer 12

• BMI, cushingoid
• acne hirsutism virilised - enlarged clit/deep voice
• abdominal and bimanual exam
• urine pregnancy tests
• bloods: FSH, oestradiol, prolactin, TFTs, testosterone and SHBG, 17 hydroxy progesterone
• pelvic US

Question 13

PCOS management

Answer 13

• weight loss/exercise to BMI 20-25
• increased NIDDM risk even if slim consider GTT
• support and info
• antiandrogen: COCP, spironolactone, elfornithine cream reduces facial hair growth
• endometrial protection: COCP, Mirena IUS, Oral provera
• fertility: clomiphene/metformine for ovulation induction
• underlying cause