Premenstrual Syndrom; Menopause; Premature ovarian Insufficiency Flashcards
Describe what is meant by a PMS [2]
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.
When does PMS resolve? [1]
The symptoms of PMS resolve once menstruation begins.
How do you differentiate between PMS and menarche, pregnancy or after menopause? [1]
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.
What causes PMS? [2]
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.
What is premenstrual dysphoric disorder? [1]
When features are severe and have a significant effect on quality of life
How do you diagnose PMS? [2]
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.
How do you treat PMS? [4]
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.
What can you use to treat breast pain in PMS? [2]
Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist.
[] may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.
Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.
How do you treat menorrhagia:
- if the patient does not want contraception? [2]
- accepts contraception [3]
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)
Define menopause, perimenopause and postmenopause [3]
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.
What is premature menopause? [1]
Premature menopause: in some women, menopause occurs early for a myriad of reasons. If it occurs prior to 40 it is termed premature menopause.
Describe the physiology and hormonal changes that occur in menopause [+]
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.
Describe the features of the perimenopause [+]
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
Menopause:
A lack of oestrogen increases the risk of certain conditions [4]
- Cardiovascular disease and stroke
- Osteoporosis
- Pelvic organ prolapse
- Urinary incontinence
NICE guidance advises menopause can be diagnosed in healthy women over the age of 45 with: [3]
- 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
Why do people use HRT throughout the menopause? [1]
HRT has been shown to help with vasomotor symptoms, mood changes and urogenital symptoms that may occur secondary to menopause.
Describe the different types of HRT that exist [2]
How do you decide which you give? [1]
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
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?
Women with a uterus:
- combined oestrogen and progesterone HRT
Women with a without uterus:
- oestrogen-only HRT.
Why is oestrogen only HRT not used in women with a uterus? [1]
- Oestrogen-only HRT increases the risk of endometrial cancer so should never be used in women with a uterus.
Describe the benefits [1] and risks [4] of HRTs
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
How long can you be fertile for if you are under / over 50? [2]
Under 50: at least two years after their last period
Over 50: at least one year after their last period
What can you specifically give to treat urogenital atrophy? [1]
vaginal oestrogen should be offered including to patients on systemic HRT.
NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis of menopause in which cases? [2]
Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
