secondary amenorrhoea and menopause Flashcards
what is the menopause?
last ever period a female has
when does the menopause usually occur?
51 years
early: <40 years old
how long is the perimenopause?
5 years before the menopause occurs
what is the physiology of the menopause?
ovarian insufficiency
- oestradiol falls
- FSH rises
(still some oestriol from conversion of adrenal androgens in adipose tissue)
what may trigger the menopause?
- naturally/spontaneously
- oophorectomy, chemotherapy or radiotherapy
what are the ‘seven dwarves’ of menopause?
- itchy
- bitchy
- sweaty
- sleepy
- bloated
- forgetful
- psycho
what are the symptom of menopause?
vasomotor symptoms: hot flushes, night sweats
vaginal symptoms: dryness/soreness, low libido
more: muscle/joint aches, mood changes, poor memory
what silent change can occur with the menopause?
osteoporosis: reduced bone mineral density
detected with DEXA scan - described as T score
what is there significant risk of in osteoporosis?
fractured hip/ vertebra
what are the risk factors for osteoporosis?
heavy: smokers, steroids
health: hyperthyroidism, amenorrhoea, malabsorption
history: caucasian, thin, family history
how can osteoporosis be prevented and managed?
exercise: weight bearing
supplements: calcium and vitamin D
medical: HRT, bisphosphonates, denosumab (monoclonal antibody to osteoclasts), teriparatide
how can HRT be administered for menopause
locally: vaginal oestrogen (pessary, ring or cream)
systemically: transdermal or oral
what combination of HRT can be given?
- oestrogen only, if no uterus
- oestrogen + progesterone, if uterus present (progesterone can be oral, transdermal of LNG IUS)
what are the contraindications to HRT?
breast/endometrium cancer: hormone dependent
liver disease
abnormal bleeding
what are the features of the cyclical combined oestrogen and progesterone HRT?
use if still some ovarian function (perimenopause)
14 days of O and 14 days of O+P
what are the features of the continuous combined oestrogen and progesterone HRT?
use if no ovarian function (>1 year after menopause or age 54+)
28 days of O+P
who can use Mirena LNG IUS and daily oestrogen?
any age
what OTHER menopause symptomatic treatments are there?
SERM: selective oestrogen receptor modulators
SSRI/SNRI antidepressants: venlafaxine or clonidine
natural methods: phytoestrogen/ herbs/ hypnotherapy/ exercise/ CBT, lubricants
what are the benefits of HRT?
- effect on vasomotor symptoms
- effect on local genital symptoms
- decreases risk of osteoporosis
what are the risks of HRT use?
- breast/ovarian cancer
- VTE/CVA if oral rote
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when should HRT be used in menopause according to NICE guidelines?
treatment of:
- severe vasomotor symptoms
- premature ovarian insufficiency
what occurs in andropause?
testosterone falls after the age of 30
DHEAS falls
fertility remains and no sudden change occurs in the male
what is primary amenorrhoea?
never having had a period
when can primary amenorrhoea be diagnosed?
> 14 years with no secondary sexual characteristics
<16 years if secondary sexual characteristics present
what is secondary amenorrhoea?
there has been periods in the past but nothing for the past 6 months
what are the causes of secondary amenorrhoea?
pregnancy, breast feeding, premature ovarian insuffiency, PCOS
medications: contraceptions
hypothalamic: weight, exercise, stress
thyroid,: cushings, prolactinoma, CAH, tumours (androgen secreting), sheehanS/ashermans syndrome
how is secondary amenorrhoea investigated?
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
how should secondary amenorrhoea be treated?
treat specific cause
if premature ovarian insufficiency offer HRT till 50
how can polycystic ovary syndrome present?
oligo/amenorrhoea
androgenic symptoms: excess hair/acne
what risks are there with polycystic ovary syndrome?
- diabetes
- cardiovascular disease
- reduced fertility
- endometrial hyperplasia
what do polycystic ovaries NOT cause?
weight gain or pain
what are polycystic ovaries?
small peripheral ovarian cysts
ovary x10 or ovarian volume >12cm^3
how is polycystic ovary syndrome managed?
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
what role does metformin play in PCOS?
treats underlying cause - insulin resistance
encourages ovulation
