Secondary Amenorrhea + Menopause + PCOS Flashcards
define premature menopause and perimenopause
preimenopause: having menopausal symptoms but still menstruating, usually 5 years before menopause
premature menopause: menopause at < 40 yrs (affects 1% UK women)
what is the hormone level like in menopause?
decreased estrogen –> increased FSH
can high FSH be used to measure perimenopausal stage?
no, because FSH fluctuates a lot during that time
symptoms of menopause (5)
- vasomotor (80%): hot flushes + night sweats
- vaginal dryness
- low libido + mood swings/poor memory (?)
- muscle and joint aches
- osteoporosis
causes of osteoporosis (7)
- FH (esp if younger)
- prolonged low estrogen amonorrhea
- vit D/calcium deficiency, malabsorption
- hyperthyroidism
- oral corticoids
- thin, Caucasian
- high alcohol intake
management of osteoporosis (6)
- Bisphosphonate
- Denusimab
- HRT
- weight-bearing exercise
- vit D/calcium supplements
- calcitonin
what are the treatment for the symptoms of menopause? (8)
- local vaginal HRT (E)
- systemic estrogen
- combined systemic E+P HRT
- SERMS (selective estrogen receptor modulator)
- clonidine, SSRI/SNRI
- phytoestrogen herbs
- hypnotherapy, cognitive behavioral therapy, exercise
- nonhormonal lubricants for vaginal dryness
what benefit does transdermal HRT have over oral?
- avoid first pass metabolism (more absorption)
- reduces VTE risk
benefits (4) and risks (4) or HRT?
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)
what are some of the downsides of vaginal estrogen? (2)
- low systemic absorption and therefore long term application is needed
- contrainidicated in those receiving AI for breast cancer, but will proceed if severe
if the woman still has a uterus, should we prescribe them systemic estrogen or combined HRT?
should be offered E + P, because unopposed E will result in endometrial cancer risk
what are the 3 regimes for combined HRT? When and who are suitable for each of these regimes?
- 14 days E + 14 days (E+P) - in those who still retain some natural ovarian function.
- withdrawal bleeding after P use
- 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
- mirena levonogestrel IUS 5 yrs + daily E - suitable for all age
- the ONLY regime that provides contraceptive cover until 55 yrs
how are SERMS different from systemic E? Give an example of 1 SERM
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
contraindications for systemic HRT (5)
- current hormone dependent breast/endometrial cancer
- current liver disease
- unexplained vaginal bleeding
- previous breast cancer, BRCA carrier
- FH or previous VTE, thrombophilia
what are the 2 hormones that go down during andropause?
- testosterone (-1% annually after 30 yrs)
2. DHEAS (dehydroepiandrosterone sulfate)
some NICE guidelines to keep in mine about HRT use (5)
- in severe vasomotor symptoms, annual checks are done to see if HRT is still needed
- in premature ovarian insufficiency, HRT benefits outweigh the risks until 50
- HRT should not be the first line treatment for osteoporosis (due to increased cancer risk)
- there is no absolute limit of max use of HRT
- vaginal estrogen should e used in local vaginal symptoms
how many girls are affected by primary amenorrhea, and when are they considered to have delayed puberty (in terms of period)?
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
causes of secondary amenorrhea (7)
- physiological: pregnancy, breastfeeding
- medications
- PCOS
- premature ovarian insufficiency
- endocrine disorders
- hypothalamic causes: illness, excess exercise, > 10% weight loss
- asherman’s syndrome (intrauterine adhesions from D&C and ablation)
what are some of the detectable hormonal changes that might be the cause of secondary amenorrhea (6 hormones)
- thyroid disease
- increased cortisol (cushings)
- increased testosterone
- increased prolactin (prolactinoma, mediation-related)
- pituitary failure (ischemia from Sheehan’s syndrome)
- congenital adrenal hyperplasia (CAH)
investigations for secondary amenorrhea
- bloods: different hormone levels, FSH, SHBG, free androgen index
- urine pregnancy test
- pelvic USS - pregnancy, PCOS, etc.
treatment for secondary amenorrhea
treat based on the cause:
- aim for 20
what are some of the medications that can cause secondary amenorrhea? (4)
- depo provera (injectable progesterone)
- opiates
- antipsychotics
- metoclopramide (prokinetic agent that speeds up gastric emptying)
name the 3 diagnostic criteria for PCOS (>2/3 to diagnose)
- oligo/amenorrhea
- increased testosterone and androgenic symptoms
- PCOS morphology on USS
presentation of PCOS?
- 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
investigation for PCOS (GOLD standard) and its findings.
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
management of PCOS, which is the GOLD standard method?
- weight loss exercise - aim for BMI 20-25 (GOLD standard) –> will reduce all androgenic symptoms
- lower OGTT threshold (because they are more susceptible to T2DM)
- antiandrogen
- endometrial protection from unopposed E
- infertility treatment (induce ovulation with clomiphene, metformin)
- treat underlying insulin resistance - metformin
how does weight gain worsen the androgenic symptoms?
weight gain –> decreased SHBH –> increased free androgens –> worsen androgenic symptoms
(hence weight loss exercise is the best treatment)
what are some of the antiandrogens used in PCOS treatment?
- CHC
- spironolactone
- eflornithine cream (for hair growth)
what are the first and second line management for endometrial protection from E?
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.
