Premenstrual Syndrom; Menopause; Premature ovarian Insufficiency

Question 1

Describe what is meant by a PMS [2]

Answer 1

Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation.

Question 2

When does PMS resolve? [1]

Answer 2

The symptoms of PMS resolve once menstruation begins.

Question 3

How do you differentiate between PMS and menarche, pregnancy or after menopause? [1]

Answer 3

The symptoms of PMS resolve once menstruation begins

Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history.

Question 4

What causes PMS? [2]

Answer 4

Premenstrual syndrome is though to the caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle.

The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA.

Question 5

What is premenstrual dysphoric disorder? [1]

Answer 5

When features are severe and have a significant effect on quality of life

Question 6

How do you diagnose PMS? [2]

Answer 6

Diagnosis is made based on a symptom diary spanning two menstrual cycles.

The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation.

A definitive diagnosis may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve.

Question 7

How do you treat PMS? [4]

Answer 7

RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin)
- Drospironone as some antimineralocortioid effects, similar to spironolactone
- Continuous use of the pill, as opposed to cyclical use, may be more effective.

Continuous transdermal oestrogen (patches) can be used to improve symptoms
- Progestogens are required for endometrial protection against endometrial hyperplasia when using oestrogen. This can be in the form of low dose cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil.

GnRH analogues can be used to induce a menopausal state.
- reserved for severe cases due to the adverse effects (e.g. osteoporosis)

Hysterectomy and bilateral oophorectomy
- can be used to induce menopause where symptoms are severe and medical management has failed. Hormone replacement therapy will be required, particularly in women under 45 years.

Question 8

What can you use to treat breast pain in PMS? [2]

Answer 8

Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist.

Question 9

[] may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.

Answer 9

Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.

Question 10

How do you treat menorrhagia:
- if the patient does not want contraception? [2]
- accepts contraception [3]

Answer 10

When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with:

• Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
• Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Management when contraception is wanted or acceptable:
* Mirena coil (first line)
* Combined oral contraceptive pill
* Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)

Question 11

Define menopause, perimenopause and postmenopause [3]

Answer 11

Menopause: is the point at which menstruation stops.
Perimenopause: occurs prior to menopause and is characterised by an irregular menstrual cycle and vasomotor symptoms.
Postmenopause: describes the time after periods have ceased for 12 months.

Question 12

What is premature menopause? [1]

Answer 12

Premature menopause: in some women, menopause occurs early for a myriad of reasons. If it occurs prior to 40 it is termed premature menopause.

Question 13

Describe the physiology and hormonal changes that occur in menopause [+]

Answer 13

As the supply of oocytes falls, follicular activity falls.
- This results in a marked reduction in oestrogen and inhibin.
- As a result, negative feedback on the pituitary is alleviated resulting in increased levels of LH and FSH.

The decrease in oestrogen also results in the development of vasomotor symptoms including flushing and sweats and further disruption of the normal cycle.
- As anovulatory cycles occur estradiol (an oestrogen hormone) production fails, preventing thickening of the endometrial lining and resulting in amenorrhoea.

These changes result in a permanently lowered level of oestrogen and high levels of both FSH and LH.

Question 14

Describe the features of the perimenopause [+]

Answer 14

A lack of oestrogen in the perimenopausal period leads to symptoms of:
* Hot flushes
* Emotional lability or low mood
* Premenstrual syndrome
* Irregular periods
* Joint pains
* Heavier or lighter periods
* Vaginal dryness and atrophy
* Reduced libido

Question 15

Menopause:
A lack of oestrogen increases the risk of certain conditions [4]

Answer 15

• Cardiovascular disease and stroke
• Osteoporosis
• Pelvic organ prolapse
• Urinary incontinence

Question 16

NICE guidance advises menopause can be diagnosed in healthy women over the age of 45 with: [3]

Answer 16

• Perimenopause based on vasomotor symptoms and irregular periods
• Menopause in women who have not had a period for at least 12 months and are not using hormonal contraception
• Menopause based on symptoms in women without a uterus

Question 17

Why do people use HRT throughout the menopause? [1]

Answer 17

HRT has been shown to help with vasomotor symptoms, mood changes and urogenital symptoms that may occur secondary to menopause.

Question 18

Describe the different types of HRT that exist [2]
How do you decide which you give? [1]

Answer 18

HRT may be given as ‘unopposed’ oestrogen or as a combination of oestrogen and progesterone
- The choice is dictated by the presence or absence of a uterus

Question 19

HRT may be given as ‘unopposed’ oestrogen or as a combination of oestrogen and progesterone. They can be offered in an oral or transdermal form.

The choice is dictated by the presence or absence of a uterus.

What do you offer for women with [1] or without [1] a uterus?

Answer 19

Women with a uterus:
- combined oestrogen and progesterone HRT

Women with a without uterus:
- oestrogen-only HRT.

Question 20

Why is oestrogen only HRT not used in women with a uterus? [1]

Answer 20

• Oestrogen-only HRT increases the risk of endometrial cancer so should never be used in women with a uterus.

Question 21

Describe the benefits [1] and risks [4] of HRTs

Answer 21

Benefits:
- Reduces the risk of osteoporosis and fragility fractures

Risks:
- combined HRT (oestrogen and progesterone) is associated with an increased risk of breast cancer
- there appears to be a relatively small increased risk of ovarian cancer from HRT
- VTE
- Stroke

Question 22

How long can you be fertile for if you are under / over 50? [2]

Answer 22

Under 50: at least two years after their last period
Over 50: at least one year after their last period

Question 23

What can you specifically give to treat urogenital atrophy? [1]

Answer 23

vaginal oestrogen should be offered including to patients on systemic HRT.

Question 24

NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis of menopause in which cases? [2]

Answer 24

Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Question 25

**TOM TIP:** It is worth making a note and remembering two key side effects of the **progesterone depot injection (e.g. Depo-Provera).** What are they? [2]

Answer 25

**Weight gain** and **reduced bone mineral density** (**osteoporosis**). These side effects are **unique** to the **depot** and do not occur with **other forms of contraception**. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

Question 26

What can you use to treat reduced libido? [1]

Answer 26

**Testosterone** can be used to treat reduced libido (usually as a gel or cream)

Question 27

What are contraindications for HRT? [4]

Answer 27

* Current or past breast cancer * Any oestrogen-sensitive cancer * Undiagnosed vaginal bleeding * Untreated endometrial hyperplasia

Question 28

How can you manage vasomotor symptoms of menopause in without HRT? [2]

Answer 28

Exercise Fluoxetine, citalopram or venlafaxine

Question 29

Define premature ovarian insufficiency [1]

Answer 29

**Premature ovarian insufficiency is defined as menopause before the age of 40 years**. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause.

Question 30

Describe the pathophysiology of POI [2] What will hormonal analysis show?

Answer 30

**Premature ovarian insufficiency** is characterised by **hypergonadotropic hypogonadism.** **Under-activity of the gonads** (hypogonadism) means there is a **lack of negative feedback** on the **pituitary** **gland**, resulting in an excess of the gonadotropins (**hypergonadotropism**). **Hormonal analysis will show:** * **Raised LH and FSH levels** (gonadotropins) * **Low oestradiol levels**

Question 31

What is the the cause for 50% of POI? [1] What are other causes? [4]

Answer 31

* **Idiopathic** (the cause is unknown in more than 50% of cases) * **Iatrogenic**, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) * **Autoimmune**, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease * **Genetic**, with a positive family history or conditions such as Turner’s syndrome * **Infections** such as mumps, tuberculosis or cytomegalovirus

Question 32

NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed if women have what [3]?

Answer 32

NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed in **women younger than 40 years with typical menopausal symptoms plus elevated FSH.** - The **FSH level needs to be persistently raised (more than 25 IU/l)** on **two consecutive samples** separated by **more than four weeks** to make a **diagnosis**. - The results are difficult to interpret in women taking hormonal contraception.

Question 33

How do you manage POI? [2]

Answer 33

Management involves **hormone replacement therapy** (**HRT**) until at least the age at which women typically go through menopause - **associated** with a **lower blood pressure** compared with the combined oral contraceptive pill OR **Combined oral contraceptive pill**