Secondary Amenorrhoea and Menopause Flashcards
Definition of menopause
When a women aged 45 or over has amenorrhoea for 12 months
Average age of menopause
51
Perimenopause lasts for how long before menopause?
5 years before
What age is classified as premature menopause?
40 years or less
What physiological change occurs during menopause?
Ovarian insuffiency
Ovarian insufficiency of menopause involves….
Oestradiol falls
FSH rises - telling brain to produce more oestrogen
Still some oestradiol from peripheral
Conversion of adrenal androgens in fat (women with more body fat will have fewer hot flushes/sweats)
Causes of menopause
Natural
Follow oophorectomy
Follow chemotherapy
Follow radiotherapy
Symptoms of menopause
Itchy Irritable Sweaty Sleepy Bloated Mood changes Possibly forgetful Vasomotor symptoms - "hot flushes" Vaginal dryness/soreness Low libido Muscle and joint aches Silent change of osteoporosis
Risks of osteoporosis in menopause
Thin Caucasian Smokers EtOH Positive FH of amenorrhoea Malabsorption Oral steroids Hyperthyroid
Prevention/treatment of osteoporosis
exercise adequate calcium + vit D HRT Bisphosphonates Denosumab Teriparatide
What does denosumab do?
It is a monoclonal antibody to osteoclasts
Symptom treatment of menopause
Hormone replacement therapy (HRT)
Selective oestrogen receptor modulators (SERMS)
SSRI SNRI antidepressants
Natural methods e.g. herbs, exercise
Non-hormonal lubricants e.g. Reptes, Sylk
Types of HRT
Local vaginal oestrogen pessary/ring/cream
Systemic transdermal/oral transdermal
Systemic transdermal/oral transdermal HRT - which hormones are indicated?
Oestrogen ONLY if no uterus
Oestrogen AND progesterone if uterus present
Contraindications to HRT
Current hormone dependent cancer of breast/endometrium
Current active liver disease
Uninvestigated abnormal bleeding
Seek advise before giving HRT if….
Previous VTE Thrombophilia FH VTE Previous breast cancer BRCA carrier
Benefits of HRT
Vasomotor
Local genital symptoms
Osteoporosis
Risks of HRT
Breast cancer if combined HRT Ovarian cancer VTE if oral route CVA if oral route after 60 y/o can affect CVS
Natural methods for the treatment of menopause
Phytooestrogen Herbs e.g. red clover Hypnotherapy Exercise CBT - high placebo effect
Testosterone falls by 1% a year after what age in males?
30 y/o
Definition of primary amenorrhoea
Never had a period
Definition of secondary amenorrhoea
Has had periods in the past but none for 6 months
Causes of secondary amenorrhoea
Pregnancy/breast feeding
Contraception related (current use or 6 months after DP)
Polycystic ovaries
Early menopause
Thyroid disease/cushings
Any significant illness
Raised prolactin (prolactinoma, medication related)
Hypothalamic
Androgen screening tumour (testosterone >5mg/l)
Sheehan’s syndrome (pituitary failure)
Asherman’s syndrome (intrauterine adhersions)
Investigations for secondary amenorrhoea
BP BMI Acne Hirsituism Cushingoid Enlarged clitoris/deep voice = virulised Abdominal/bimanual Urine pregnancy test + urine glucose dipstick Bloods (FSH, LH, oestrogen, prolactin, TFTs, testosterone) Pelvic USS for PCO
Treatment for secondary amenorrhoea
treat specific cause
Aim BMI 20-25
Assume fertile and need contraception unless 2 years after confirmed menopause
if premature ovarian insuffiency offer HRT until 50
Emotional support - daisy network
Check for fragile X
Presentation spectrum for polycystic ovarian syndrome (PCOS)
Oligo/Amenorrhoea
Androgenic symptoms; excess hair/acne
Anovulatory fertility
What do polycystic ovaries NOT cause
weight gain
pain
Treatment of polycystic ovarian syndrome (PCOS)
Weight loss/exercise Antiandrogen - combined hormonal contraception (CHC) - Spironolactone - Eflornithine cream facial hair Endometrial protection - CHC - Progesterones - Mirena IUS Fertility treatment - clomiphene/metformin
Definition of polycystic ovaries
Small peripheral ovarian cysts x10/ovary or ovarian volume >12cm3
Perimenopause definition
The time leading up to menopause. Many women experience menopausal symptoms during this
Blood values indicative of menopause
Low oestrogen
High FSH and LH
In order to find the correct HRT regime, what 3 things must be addressed?
- Is there a uterus?
- Is the patient perimenopausal or menopausal?
- Is a systemic or a local effect required?
Is continuous or cyclical HRT recommended in perimenopausal HRT?
Cyclical
Why is systemic oestrogen only HRT not appropriate for women with a uterus?
Increased risk of endometrial cancer
What % of women of reproductive age are affected by PCOS?
5 - 20%
Investigations of PCOS
Pelvic USS (multiple cysts on ovaries)
FSH, LH, prolactin, TSH, testosterone
Glucose tolerance
Diagnostic criteria for PCOS
2/3 out of;
- Infrequent or no ovulation
- Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone
- polycystic ovaries on ultrasonography or increased ovarian volume
What test is done to confirm menopause?
FSH
Describe sheehans syndrome
Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic shock
Features of sheehans syndrome
Agalactorrhoea Amenorrhoea Symptoms of - hypothyroidism - hypoadrenalism
What is ashermans syndrome?
Intrauterine adhesions
What can ashermans syndrome occur after?
Dilatation and curettage
How can ashermans syndrome cause secondary amenorrhea?
Prevent the endometrium responding to oestrogen as it normally would
