MenopauseSecondary Amenorrhoea Flashcards
what is menopause? and when does it happen?
The Menopause is a woman’s last ever period
average age 51
1/3 of UK lifespan after menopause
what is perimenopause?
perimenopause for approx 5 years before
Perimenopause means “around menopause” and refers to the time during which your body makes the natural transition to menopause, marking the end of the reproductive years. Perimenopause is also called the menopausal transition
what is premature menopause?
premature menopause = 40 years or less affects 1% of women
what happens in menopause?
- Ovarian insufficiency - oestradiol falls, Follicle stimulating hormone (FSH) rises, Still some oestriol from conversion of adrenal androgens in adipose tissue
- FSH levels fluctuate in perimenopause- a premenopausal level does not exclude perimenopause as a cause for symptoms
- Menopausal transition may be natural or sudden following oophorectomy/chemotherapy/radiotherapy
whata re the symptoms of menopause?
- Vasomotor symptoms - hot flushes/night sweats - 80% women get them but 45% find them a problem - 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
what is a silent change that may occur in menopause?
osteoprosis
When a woman reaches menopause, her estrogen levels drop and can lead to bone loss. For some women, this bone loss is rapid and severe
what is osteoprosis?
reduced bone mass
DEXA scan bone density described as T score
(picture shows normal and osteoprotic bone)
what are the problems with osteoprosis?
fractured hip/vertebra
1% women 50-69
significant morbidity+mortality
what are the risk factors for osteprosis?
thin/caucasian/smoking/ high EtOH/+ve FH /malabsorption Vit D or Calcium / prolonged low oestrogen amenorrhoea /oral corticosteroids / hyperthyroid
what si the prevention and treatment of osteoprosis?
wt bearing exercise, adequate calcium & Vit D, HRT, bisphosphonates, denosumab -monoclonal antibody to osteoclasts, calcitonin
Menopause- symptom treatment
Hormone replacement therapy (HRT):
how is Local vaginal HRT used?
oestrogen pessary/ring/cream
Local effects - minimal systemic absorption
Need to use longterm to maintain benefit
Menopause- symptom treatment
Hormone replacement therapy (HRT):
how is Systemic oestrogen transdermal / oral used?
transdermal avoids first pass - less risk VTE
a/oestrogen only if no uterus
b/oestrogen + progestogen if uterus present
progestogen oral, transdermal or LNG IUS
progestogen prevents endometrial hyperplasia from unopposed oestrogen
Combined Estrogen ( E) and Progestogen (P) HRT:
how is it used?
cyclical combined - 14 days E + 14 days E+P, expect withdrawal bleed after the P
use if there may still be some ov function to avoid irregular bleeding
continuous combined 28 days E+P oral/patch, expect to b bleed-free (after 1st 3 months), use if >1yr after menopause or age 54+
any age can use Mirena LNG IUS + daily E and expect to be bleed free (and contraceptive cover under age 55)
what are the ocntraindications to systemic HRT?
NOT the same as contraindications to combined hormonal contraception - very few CI
1/ Current Hormone dependent cancer breast/endometrium
2/ Current active liver disease
3/ Uninvestigated abnormal bleeding
4/ seek advice if prev VTE, thrombophilia, FH VTE
5/ seek advice if previous breast cancer or BRCA carrier
what is the treatment of menopause symptoms?
•Selective Estrogen Receptor Modulators (SERMs)
E effect on selected organs (eg tibolone )
- NOT clonidine or SSRI SNRI antidepressants eg venlafaxine common side effects & few benefit
- phytooestrogen herbs eg red clover/soya
- hypnotherapy/exercise/Cognitive behavioural therapy
- Non hormonal lubricants for vaginal dryness Regular eg Replens or Pre sex ‘Sylk’
what are the benefits of HRT?
vasomotor, local genital symptoms, osteoprosis
Not affect Alzheimers
Not increase Cardiovascular risks if start before age 60 ie before atherosclerosis develops
whata re the risks of HRT?
breast cancer risk if combied HRT
ovarian cancer
venous thrombosis if oral route
CVA (storke) if oral route
HRT use NICE guidance 2015
- For treatment of severe vasomotor symptoms, review annually
- For women with premature ovarian insufficiency
HRT benefits outweigh risks till age 50
- Not as first line for osteoporosis prevention / treatment (bisphosphonates instead)
- Vaginal Oestrogen for vaginal symptoms
what is andropause?
- Testosterone falls by 1% a year after 30
- DHEAS falls
- Fertility remains
- No sudden change
? a medical disorder
( different from hypogonadism)
The “male menopause” (sometimes called the andropause) is an unhelpful term sometimes used in the media.
This label is misleading because it suggests the symptoms are the result of a sudden drop in testosterone in middle age, similar to what occurs in the female menopause. This is not true
what is primary amenorrhoea?
- Primary amenorrhoea: never had a period
- Affects 5% girls
>14yrs and no 2ndry sexual characteristics
>16 years if 2ndry sexual characteristics
what is secondary amenorrhoea?
has had periods in past but none for 6 months
what are the causes of secondary amenorrhoea?
- 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
what exmasn and tetss are done for secondary amenorrhoea?
- BP, BMI, hirsutism, acne, Cushingoid
- enlarged clitoris/deep voice = virilised
- abdominal/bimanual
- urine pregnancy test + dipstick for glucose
- bloods - FSH, oestradio (menopause), prolactin, thyroid function, testosterone, 17 hydroxy progesterone ( CAH)
pelvic ultrasound - ?polycystic ovaries
what is the management and treatment of secondary ameorrhoea?
- Treat specific cause
- Aim BMI >20 <30 for ovulation
- Assume fertile and need contraception unless 2 yrs after confirmed menopause
- If premature ovarian insufficiency offer HRT till 50, emotional support, Daisy network, check for Fragile X relatives may wish testing
Polycystic ovary syndrome (PCOS) is a common condition that affects how a woman’s ovaries work
he 3 main features of PCOS are what? (need 2 out of 3 for a diagnosis)
irregular periods – which means your ovaries do not regularly release eggs (ovulation)
excess androgen – high levels of “male” hormones in your body, which may cause physical signs such as excess facial or body hair
polycystic ovaries – your ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs (but despite the name, you do not actually have cysts if you have PCOS)
what are the effects of polycystic ovaries?
- Risk of endometrial hyperplasia if < 4 periods a year (and not on hormones)
- Reduced fertility if not ovulating regularly - BUT assume fertile and use contraception if not plan pregnancy
- ?Higher risk diabetes & cardiovascular disease even if lean
- Polycystic ovaries do NOT cause weight gain or pain. Weight gain can worsen PCOS symptoms as ↓SHBG levels ↑ androgens
Ultrasound appearance polycystic ovaries
Polycystic ovaries- laparoscopy
what is the management of polycystic ovaries?
•Weight loss/exercise to BMI 20-25 can help all symptoms
increases SHBG so less free androgens
- ?increased NIDDM risk even if slim consider GTT
- Support & information– Verity patient support group
- Antiandrogen, combined hormonal contraception if, no CI spironolactone, eflornithine cream reduces facial hair growth
- Endometrial protection, CHC, Mirena IUS, Oral provera 10/90 if no period
- Fertility Rx clomiphene / metformin ovulation induction
- Metformin - may encourage ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss
Menopause & HRT:
•Jane is 48 and has hot flushes and night sweats. She has periods 5/30 cycle but has missed 2 periods in the last year.
what should be done?
- Management
- Information likely perimenopause
- No need to check FSH
- Lifestyle / herbal – red clover /CBT
- HRT
which HRT?
- If HRT needs oestrogen to Rx symptoms
- Has a uterus so needs progestogen
- Has some ovarian function so needs
- Cyclical combined
- OR Mirena + Oestrogen oral/transdermal
Case 2:
- Sheila has had a hysterectomy for menorrhagia when she was 36 18/40 size fibroids.
- Her ovaries were conserved
- She is now 39 and has hot flushes.
- She wonders if she is menopausal?
- Tests: FSH – under 40 and no ‘clue ‘ about menopausal status from bleeding pattern after hysterectomy
FSH level = 73 -menopausal
Which HTR?
- Prem menopause frequent after hysterectomy even if ovaries conserved
- If symptomatic needs oestrogen
- Does not have uterus so not need progestogen
- Age < 50 HRT is only replacing ‘what should be there’ - benefit > risk
- If not want oestrogen suggest DEXA and bisphosphonates if necessary
Case 3:
- Lucy is 55
- Her periods stopped when she was 51. She has vaginal\dryness and soreness
- She is worried about side effects from HRT
- Management
- Examination- vaginal atrophy only- no other pathology
what treatment?
- May prefer to try regular vaginal moisturisers eg ReplensTM and /or lubricants for sex
- If no help needs vaginal oestrogens - pessary/cream used x 2/week, vaginal ring lasts 3 months
- Minimal systemic absorption
- No need additional progestogen
- Try for 3 months - continue indefinitely if helpful
