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Reproductive System > Secondary Amenorrhea + Menopause + PCOS > Flashcards

Secondary Amenorrhea + Menopause + PCOS Flashcards

1
Q

define premature menopause and perimenopause

A

preimenopause: having menopausal symptoms but still menstruating, usually 5 years before menopause
premature menopause: menopause at < 40 yrs (affects 1% UK women)

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2
Q

what is the hormone level like in menopause?

A

decreased estrogen –> increased FSH

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3
Q

can high FSH be used to measure perimenopausal stage?

A

no, because FSH fluctuates a lot during that time

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4
Q

symptoms of menopause (5)

A
  1. vasomotor (80%): hot flushes + night sweats
  2. vaginal dryness
  3. low libido + mood swings/poor memory (?)
  4. muscle and joint aches
  5. osteoporosis
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5
Q

causes of osteoporosis (7)

A
  • FH (esp if younger)
  • prolonged low estrogen amonorrhea
  • vit D/calcium deficiency, malabsorption
  • hyperthyroidism
  • oral corticoids
  • thin, Caucasian
  • high alcohol intake
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6
Q

management of osteoporosis (6)

A
  • Bisphosphonate
  • Denusimab
  • HRT
  • weight-bearing exercise
  • vit D/calcium supplements
  • calcitonin
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7
Q

what are the treatment for the symptoms of menopause? (8)

A
  1. local vaginal HRT (E)
  2. systemic estrogen
  3. combined systemic E+P HRT
  4. SERMS (selective estrogen receptor modulator)
  5. clonidine, SSRI/SNRI
  6. phytoestrogen herbs
  7. hypnotherapy, cognitive behavioral therapy, exercise
  8. nonhormonal lubricants for vaginal dryness
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8
Q

what benefit does transdermal HRT have over oral?

A
  • avoid first pass metabolism (more absorption)

- reduces VTE risk

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9
Q

benefits (4) and risks (4) or HRT?

A

benefits:
1. solves vasomotor symptoms
2. solves genital symptoms
3. decreased osteoporosis
4. decreased colon cancer
risks:
1. increased breast cancer (esp with combined HRT compared to E alone)
2. increased ovarian cancer risk
3. VTE risk (avoided by transdermal over oral HRT)
4. CVS risk (esp if started > 60 yrs)

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10
Q

what are some of the downsides of vaginal estrogen? (2)

A
  1. low systemic absorption and therefore long term application is needed
  2. contrainidicated in those receiving AI for breast cancer, but will proceed if severe
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11
Q

if the woman still has a uterus, should we prescribe them systemic estrogen or combined HRT?

A

should be offered E + P, because unopposed E will result in endometrial cancer risk

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12
Q

what are the 3 regimes for combined HRT? When and who are suitable for each of these regimes?

A
  1. 14 days E + 14 days (E+P) - in those who still retain some natural ovarian function.
    • withdrawal bleeding after P use
  2. 28 days (E+P) - in those with no ovarian function or > 54 yrs, or > 1 yr LMP
    • irregular bleeding for the first 3 months, then bleed free thereafter
  3. mirena levonogestrel IUS 5 yrs + daily E - suitable for all age
    • the ONLY regime that provides contraceptive cover until 55 yrs
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13
Q

how are SERMS different from systemic E? Give an example of 1 SERM

A

ex) tibolone
- targets certain organs and not all
- helps with hot vasomotor symptoms, but not with breast and endometrium –> still Ca chance for these 2

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14
Q

contraindications for systemic HRT (5)

A
  1. current hormone dependent breast/endometrial cancer
  2. current liver disease
  3. unexplained vaginal bleeding
  4. previous breast cancer, BRCA carrier
  5. FH or previous VTE, thrombophilia
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15
Q

what are the 2 hormones that go down during andropause?

A
  1. testosterone (-1% annually after 30 yrs)

2. DHEAS (dehydroepiandrosterone sulfate)

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16
Q

some NICE guidelines to keep in mine about HRT use (5)

A
  1. in severe vasomotor symptoms, annual checks are done to see if HRT is still needed
  2. in premature ovarian insufficiency, HRT benefits outweigh the risks until 50
  3. HRT should not be the first line treatment for osteoporosis (due to increased cancer risk)
  4. there is no absolute limit of max use of HRT
  5. vaginal estrogen should e used in local vaginal symptoms
17
Q

how many girls are affected by primary amenorrhea, and when are they considered to have delayed puberty (in terms of period)?

A

5% girls affected
delayed puberty if:
- > 14 yrs with not secondary sexual characteristic and no period
- > 16 yrs with secondary sexual characteristics and no period

18
Q

causes of secondary amenorrhea (7)

A
  1. physiological: pregnancy, breastfeeding
  2. medications
  3. PCOS
  4. premature ovarian insufficiency
  5. endocrine disorders
  6. hypothalamic causes: illness, excess exercise, > 10% weight loss
  7. asherman’s syndrome (intrauterine adhesions from D&C and ablation)
19
Q

what are some of the detectable hormonal changes that might be the cause of secondary amenorrhea (6 hormones)

A
  1. thyroid disease
  2. increased cortisol (cushings)
  3. increased testosterone
  4. increased prolactin (prolactinoma, mediation-related)
  5. pituitary failure (ischemia from Sheehan’s syndrome)
  6. congenital adrenal hyperplasia (CAH)
20
Q

investigations for secondary amenorrhea

A
  • bloods: different hormone levels, FSH, SHBG, free androgen index
  • urine pregnancy test
  • pelvic USS - pregnancy, PCOS, etc.
21
Q

treatment for secondary amenorrhea

A

treat based on the cause:

- aim for 20

22
Q

what are some of the medications that can cause secondary amenorrhea? (4)

A
  1. depo provera (injectable progesterone)
  2. opiates
  3. antipsychotics
  4. metoclopramide (prokinetic agent that speeds up gastric emptying)
23
Q

name the 3 diagnostic criteria for PCOS (>2/3 to diagnose)

A
  1. oligo/amenorrhea
  2. increased testosterone and androgenic symptoms
  3. PCOS morphology on USS
24
Q

presentation of PCOS?

A
  • normal or elevated E
  • increased testosterone, low SHBG, and androgenic symptoms (deep voice, hirtuism, acne)
  • if < 4 periods/yr, high E, and not on hormonal contraception –> high risk of endometrial hyperplasia
  • high DM and CVS risk even if BMI < 25
  • decreased fertility
25
Q

investigation for PCOS (GOLD standard) and its findings.

A

USS scan = must show > 10 small peripheral cysts or volume > 12 cm3

  • 20% women without PCOS have this, so it might come along with PCOS symptoms
  • multicystic ovary is common in adolescent and will not be diagnosed with PCOS until late teens
26
Q

management of PCOS, which is the GOLD standard method?

A
  1. weight loss exercise - aim for BMI 20-25 (GOLD standard) –> will reduce all androgenic symptoms
  2. lower OGTT threshold (because they are more susceptible to T2DM)
  3. antiandrogen
  4. endometrial protection from unopposed E
  5. infertility treatment (induce ovulation with clomiphene, metformin)
  6. treat underlying insulin resistance - metformin
27
Q

how does weight gain worsen the androgenic symptoms?

A

weight gain –> decreased SHBH –> increased free androgens –> worsen androgenic symptoms
(hence weight loss exercise is the best treatment)

28
Q

what are some of the antiandrogens used in PCOS treatment?

A
  1. CHC
  2. spironolactone
  3. eflornithine cream (for hair growth)
29
Q

what are the first and second line management for endometrial protection from E?

A

1st line: CHC, mirena IUS
2nd line: oral provera 10 days every 3 months/90 days, safe to use in amenorrhea because otherwise will cause withdrawal bleed.

Reproductive System (7 decks)

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