Secondary Amenorrhoea and Menopause Flashcards
What is the menopause?
The last ever period a female has
When does the menopause usually occur?
- Average age is 51
- Menopause is considered early when it occurs in women <40 years old
How long is the perimenopause?
Occurs for approximately 5 years before the menopause occurs
What is the physiology of the menopause?
Ovarian insufficiency
- Oestradiol falls
- FSH rises
- Still some oestriol from periphery
- Conversion of adrenal androgens in fat
What may trigger the menopause?
Can occur naturally/spontaneously or following 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 including hot flushes
- Vaginal dryness/soreness
- Low libido
- Muscle and joint aches
- Mood changes/poor memory
What silent change can occur with the menopause?
Osteoporosis
How can osteoporosis be detected?
Reduced bone mass
- DEXA scan
- T score
What is there significant risk of in osteoporosis?
Fractured hip/ vertebra leading to significant morbidity and mortality
What are the risk factors for osteoporosis?
- Thin
- Caucasian
- Smokers
- EtOH
- Family history
- Amenorrhoea
- Malabsorptioon
- Steroids
- Hyperthyroidism
How can osteoporosis be prevented and managed?
- Exercise
- Adequate calcium and vitamin D
- HRT
- Bisphosphonates
- Denosumab (monoclonal antibody to osteoclasts)
- Teriparatide
How can HRT be administered for menopaus?
- Locally: vaginal oestrogen in the form of pessary, ring or cream
- Systemically: transdermal or oral (transdermal avoids first pass so less risk of VTE)
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?
- Current Hormone dependent cancer breast/endometrium
- Current active liver disease
- Uninvestigated abnormal bleeding
- Seek advice if prev VTE, thrombophilia, FH VTE
- Seek advice if previous CA breast or BRCA carrier
What are the features of the cyclical combined oestrogen and progesterone HRT?
- 14 days of O and 14 days of O+P
- Get withdrawal bleed
- Use if still some ovarian function (perimenopause)
What are the features of the continuous combined oestrogen and progesterone HRT?
- 28 days of O+P
- Bleed free after 3 months
- Use if no ovarian function (>1 year after menopause or age 54+)
Who can use Mirena LNG IUS and daily oestrogen?
Any age
What OTHER menopause symptomatic treatments are there?
- Selective oestrogen receptor modulators (SERM), Oestrogen effect on selected organs (tibolone)
- SSRI/SNRI antidepressants (venlafaxine or Clonidine, NOT helpful side effects and few benefits
- Natural methods phytoestrogen/ herbs/ hypnotherapy/ exercise/ CBT
- Non hormonal 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?
- Risk of breast cancer if combined HRT
- Risk of ovarian cancer
- VTE if oral route
- CVA if oral rote
When does the risk of breast cancer correct following HRT use?
Excess breast cancer risk as for never users after 5 years off HRT
When should HRT be used in menopause according to NICE guidelines?
- For treatment of severe vasomotor symptoms, review annually
- For women with premature ovarian insufficiency HRT benefits outweigh risks till age 50
- Not as first line for osteoporosis prevention / treatment (bisphosphonates instead)
- Vaginal Oestrogen for vaginal symptoms
What occurs in andropause?
- Testosterone falls by 1% a year 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?
When there has been periods in the past but nothing for the past 6 months
What are the causes of secondary amenorrhoea?
- Pregnancy / Breast feeding
- Contraception related- current use or for 6-9 months after depoprovera
- Polycystic ovaries
- Early menopause
- Thyroid disease/ Cushings/ Any significant illness
- Raised prolactin- prolactinoma/ medication related
- Hypothalamic- stress/ wt change / exercise
- Androgen secreting tumour- testosterone >5mg/l
- Sheehans syndrome- pituitary failure
- Ashermans syndrome- intrauterine adhesions
How is secondary amenorrhoea investigated?
Examination
- BP, BMI, hirsutism, acne, Cushingoid
- Enlarged clitoris/deep voice= virilised
- Abdominal/bimanual exam
Investiagtions
- Urine pregnancy test and glucose dipstick
- Bloods including: FSH, LH, oestradiol, prolactin, TFTs, testosterone
- Pelvic ultrasound (PCO)
How should secondary amenorrhoea be treated?
- Treat specific cause
- Aim for BMI 20-25
- Assume fertile and need contraception unless 2 yrs after confirmed menopause
- If premature ovarian insufficiency offer HRT till 50, emotional support , Daisy network, check for Fragile X
How can polycystic ovary syndrome present?
- Oligo/amenorrhoea
- Androgenic symptoms: excess hair/acne
- Anovulatory infertility
What risks are there with polycystic ovary syndrome?
- Higher risk diabetes & cardiovascular disease for any given BMI
- Risk of endometrial hyperplasia if < 4 periods a year ( not on hormones)
What do polycystic ovaries NOT cause?
Weight gain or pain
What are the features of polycystic ovary syndrome?
- Irregular ovulation so irreg cycle
- Plenty oestrogen but also high androgens
- Underlying insulin resistance
What are polycystic ovaries?
- Small peripheral ovarian cysts x10/ovary or ovarian volume>12cm^3 seen on scan
- 20% have this with no other features (no PCOS)
- Multicystic ovaries are common in adolescents and often have no implications
How is polycystic ovary syndrome managed?
- Weight loss/exercise to help symptoms as less free androgens
- Anti-androgen (CHC, spironolactone, eflonithine cream facial hair
- Endometrial protection (CHC, progresterones, mirena IUS)
- Fertilityr treatment clomiphene/metformin
What role does metformin play in PCOS?
Helps ovulation and therefore fertility
