secondary amenorrhoea and menopause

Question 1

what is the menopause?

Answer 1

last ever period a female has

Question 2

when does the menopause usually occur?

Answer 2

51 years

early: <40 years old

Question 3

how long is the perimenopause?

Answer 3

5 years before the menopause occurs

Question 4

what is the physiology of the menopause?

Answer 4

ovarian insufficiency
- oestradiol falls
- FSH rises
(still some oestriol from conversion of adrenal androgens in adipose tissue)

Question 5

what may trigger the menopause?

Answer 5

• naturally/spontaneously

- oophorectomy, chemotherapy or radiotherapy

Question 6

what are the ‘seven dwarves’ of menopause?

Answer 6

• itchy
• bitchy
• sweaty
• sleepy
• bloated
• forgetful
• psycho

Question 7

what are the symptom of menopause?

Answer 7

vasomotor symptoms: hot flushes, night sweats

vaginal symptoms: dryness/soreness, low libido

more: muscle/joint aches, mood changes, poor memory

Question 8

what silent change can occur with the menopause?

Answer 8

osteoporosis: reduced bone mineral density

detected with DEXA scan - described as T score

Question 9

what is there significant risk of in osteoporosis?

Answer 9

fractured hip/ vertebra

Question 10

what are the risk factors for osteoporosis?

Answer 10

heavy: smokers, steroids
health: hyperthyroidism, amenorrhoea, malabsorption
history: caucasian, thin, family history

Question 11

how can osteoporosis be prevented and managed?

Answer 11

exercise: weight bearing
supplements: calcium and vitamin D
medical: HRT, bisphosphonates, denosumab (monoclonal antibody to osteoclasts), teriparatide

Question 12

how can HRT be administered for menopause

Answer 12

locally: vaginal oestrogen (pessary, ring or cream)
systemically: transdermal or oral

Question 13

what combination of HRT can be given?

Answer 13

• oestrogen only, if no uterus

- oestrogen + progesterone, if uterus present (progesterone can be oral, transdermal of LNG IUS)

Question 14

what are the contraindications to HRT?

Answer 14

breast/endometrium cancer: hormone dependent

liver disease

abnormal bleeding

Question 15

what are the features of the cyclical combined oestrogen and progesterone HRT?

Answer 15

use if still some ovarian function (perimenopause)

14 days of O and 14 days of O+P

Question 16

what are the features of the continuous combined oestrogen and progesterone HRT?

Answer 16

use if no ovarian function (>1 year after menopause or age 54+)

28 days of O+P

Question 17

who can use Mirena LNG IUS and daily oestrogen?

Answer 17

any age

Question 18

what OTHER menopause symptomatic treatments are there?

Answer 18

SERM: selective oestrogen receptor modulators

SSRI/SNRI antidepressants: venlafaxine or clonidine

natural methods: phytoestrogen/ herbs/ hypnotherapy/ exercise/ CBT, lubricants

Question 19

what are the benefits of HRT?

Answer 19

• effect on vasomotor symptoms
• effect on local genital symptoms
• decreases risk of osteoporosis

Question 20

what are the risks of HRT use?

Answer 20

• breast/ovarian cancer

- VTE/CVA if oral rote

Question 21

1

Answer 21

1

Question 22

when should HRT be used in menopause according to NICE guidelines?

Answer 22

treatment of:

• severe vasomotor symptoms
• premature ovarian insufficiency

Question 23

what occurs in andropause?

Answer 23

testosterone falls after the age of 30

DHEAS falls

fertility remains and no sudden change occurs in the male

Question 24

what is primary amenorrhoea?

Answer 24

never having had a period

Question 25

when can primary amenorrhoea be diagnosed?

Answer 25

> 14 years with no secondary sexual characteristics

<16 years if secondary sexual characteristics present

Question 26

what is secondary amenorrhoea?

Answer 26

there has been periods in the past but nothing for the past 6 months

Question 27

what are the causes of secondary amenorrhoea?

Answer 27

pregnancy, breast feeding, premature ovarian insuffiency, PCOS

medications: contraceptions
hypothalamic: weight, exercise, stress

thyroid,: cushings, prolactinoma, CAH, tumours (androgen secreting), sheehanS/ashermans syndrome

Question 28

how is secondary amenorrhoea investigated?

Answer 28

examination

• BMI, cushingoid
• acne, hirsutism, virilised (enlarged clitoris/deep voice)
• abdominal/bimanual exam: pelvic mass, uterus/ovarian cyst

investigations

• urine pregnancy test
• bloods: FSH, oestradiol, prolactin, TFTs, testosterone, SHBG (free androgen index), 17-hydroxy progesterone (CAH)
• pelvic ultrasound: polycystic ovaries

Question 29

how should secondary amenorrhoea be treated?

Answer 29

treat specific cause

if premature ovarian insufficiency offer HRT till 50

Question 30

how can polycystic ovary syndrome present?

Answer 30

oligo/amenorrhoea

androgenic symptoms: excess hair/acne

Question 31

what risks are there with polycystic ovary syndrome?

Answer 31

• diabetes
• cardiovascular disease
• reduced fertility
• endometrial hyperplasia

Question 32

what do polycystic ovaries NOT cause?

Answer 32

weight gain or pain

Question 33

what are polycystic ovaries?

Answer 33

small peripheral ovarian cysts

ovary x10 or ovarian volume >12cm^3

Question 34

how is polycystic ovary syndrome managed?

Answer 34

weight loss/exercise
- increases shbg -> less free androgens

anti-androgens
- CHC, spironolactone, eflonithine cream

endometrial protection
- CHC, mirena IUS, oral provera

fertility treatment
- clomiphene/metformin

Question 35

what role does metformin play in PCOS?

Answer 35

treats underlying cause - insulin resistance

encourages ovulation