Secondary Amenorrhea/Menopause

Question 1

How does menopause occur?

Answer 1

Causes: ovarian insufficiency - oestradiol falls, FSH rises, some oestriol from the peripheral conversion of adrenal androgens in fat.

May be natural or follow oophorectomy/chemotherapy/radiotherapy

Question 2

What effects does menopause have?

Answer 2

Symptoms: vasomotor eg hot flushes, vaginal dryness/dyspareunia, low libido, muscle and joint aches, ?mood changes/poor memory

Silent change is osteoporosis - reduced bone mineral density. Increased risk of fractures. Prevent and treat with exercise, adequate calcium and vitamin D, HRT, bisphosphonates, denosumab

Question 3

How is menopause managed?

Answer 3

Hormone replacement therapy

1. Systemic: transdermal patch or gel. Oestrogen only if no uterus, oestrogen and progesterone if uterus
2. Local: vaginal oestrogen only eg pessary, ring, cream

Selective Estrogen Receptor Modulators (SERMs).

SSRI, SNRI antidepressants eg venlafaxine

Natural eg phytoestrogen (high placebo effect)

Non hormonal vaginal lubricants

Question 4

What are some causes of secondary amenorrhea?

Answer 4

Secondary amenorrhea is when a female has had periods in the past but none for 6mnths.

Causes: pregnancy/breast feeding, contraceptive use, polycystic ovaries, early menopause, thyroid disease/Cushings/any significant illness, raised prolactin, hypothalamic eg stress, weight change, exercise, androgen secreting hormone, sheehans syndrome, ashermans syndrome

Question 5

How is secondary amenorrhea investigated and managed?

Answer 5

Exam: BMI, cushingoid appearance, Androgenic signs, abdominal/bimanual palpation

Testing: urine pregnancy test + dispstick for glucose, bloods (FSH, oestradiol, thyroid function, prolactin, thyroid function, testosterone), pelvic USS

Management: treat specific cause, aim for BMI 20-25. Give contraception unless been through menopause. Offer HRT if primary ovarian insufficiency. Check for fragile X.

Question 6

How is PCOS managed?

Answer 6

Weight loss/exercise
Antiandrogen eg combined hormonal contraception, spirolactone
Endometrial protection eh CHC, progestogens, mirena IUS
Fertility rx eg clomiphene/metformin