Secondary Amenorrhoea and Menopause

Question 1

What does menopause refer to?

Answer 1

A woman’s last ever period

Question 2

What is the average age for menopause globally?

Answer 2

51

Question 3

When can perimenopause start?

Answer 3

5 years prior to menopause

Question 4

When is menopause considered premature?

Answer 4

If it occurs before the age of 40

Question 5

What are the symptoms of menopause?

Answer 5

• Vasomotor symptoms- hot flushes, night sweats etc
• Vaginal dryness/dyspareunia
• Low libido
• Muscle and joint aches
• Mood changes/poor memory (may be due to lack of sleep caused by hot flushes)

Question 6

Why is osteoporosis more common in post-menopausal women?

Answer 6

Due to a decreased bone density

Question 7

How can osteoporosis be prevented or treated in post-menopausal women?

Answer 7

• Exercise
• Adequate calcium and vitamin D
• HRT
• Bisphosphonates
• Denosumab
• Teriparatide

Question 8

What is the main medical management used to reduce the symptoms of menopause?

Answer 8

Hormone replacement therapy

Question 9

How can hormone replacement therapy be given?

Answer 9

systemically orally, as a transdermal patch (preferable as avoids first pass so reduces risk of VTE) or as a gel. Oestrogen can be given alone if there is no uterus present, but progesterone should also be given if there is a uterus present to prevent endometrial hyperplasia. Vaginal oestrogen can also be given locally using a pessary/ring/cream. As there is minimal absorption there is no increased risk of VTE or breast cancer and so protective progesterone is not required

Question 10

What are the contraindications to systemic HRT?

Answer 10

• 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

Question 11

What are the pros of combined oestrogen and progesterone HRT?

Answer 11

Lower risk of endometrial cancer

Patients should be bleed free by around three months of treatment

Question 12

How is HRT given in perimenopause?

Answer 12

If there is still some ovarian function such as in perimenopause then patients will need cyclical treatment of 14 days on oestrogen alone followed by 14 days on oestrogen and progesterone. There will be a withdrawal bleed when the progesterone is stopped

Question 13

What other medications can be used to treat the symptoms of menopause?

Answer 13

• Selective estrogen receptor modulators (SERMs)
• Antidepressants- side effects common and few benefits
• Natural methods- high placebo effect and can be costly to woman
• Non-hormonal vaginal lubricants

Question 14

What are the benefits of HRT?

Answer 14

Reduced vasomotor symptoms
Reduced risk of osteoporosis
Improvement in local genital symptoms

Question 15

What are the risks of HRT?

Answer 15

Increased risk of breast cancer if combined HRT
Increased risk of ovarian cancer
Venous thrombosis if oral route
Increased risk of cerebrovascular event

Question 16

When does the risk of breast cancer associated with HRT dissipate?

Answer 16

Excess breast cancer risk is back to the same as never users 10 years following removal of HRT

Question 17

What extra step should be taken when prescribing HRT for severe vasomotor symptoms?

Answer 17

Annual review

Question 18

How should HRT be given if only vaginal symptoms are present?

Answer 18

Vaginal oestrogen

Question 19

How is primary amenorrhoea defined?

Answer 19

Primary amenorrhoea refers to women who have never had a period, affecting 5% of girls. It is defined as no period >14yo if no secondary sexual characteristics or >16yo if secondary sexual characteristics are present

Question 20

How is secondary amenorrhoea defined?

Answer 20

Secondary amenorrhoea is when a woman has had periods in the past but none for 6 consecutive months

Question 21

What are the causes of secondary amenorrhoea?

Answer 21

• 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

Question 22

What examinations and investigations can be useful in secondary amenorrhoea?

Answer 22

• BMI, Cushingoid
• Androgenic signs eg hirsutism, acne, enlarged clitoris, deep voice
• Abdominal/bimanual examination
• Urine pregnancy test + dipstick for glucose
• Bloods (FSH, oestradiol, prolactin, thyroid function, testosterone)
• Pelvic ultrasound- check for polycystic ovary morphology

Question 23

How is secondary amenorrhoea managed?

Answer 23

Management of secondary amenorrhoea involves treatment of the specific cause, aiming for a BMI of 20-25. Patients should be assumed fertile and offered contraception unless it has been >2 years since confirmed menopause. If premature ovarian insufficiency is the cause then offer HRT until 50, emotional support and check for a fragile X chromosome as this could affect other family members

Question 24

How is polycystic ovary syndrome diagnosed?

Answer 24

Presence of two of the following:
•PCO morphology on scan ( x 10 small peripheral follicles or ov volume >12ml), multicystic ovaries common in adolescence no implications
•Clinical or biochemical hyperandrogenism- hirsute/acne
•Oligo or anovulation – amenorrhoea or infertility

Question 25

What percentage of women will have polycystic ovaries on an ultrasound scan?

Answer 25

25%

Majority asymptomatic

Question 26

How is PCOS managed?

Answer 26

• Weight loss/exercise (can help alleviate all symptoms)
• Antiandrogens
• Endometrial protection (Combined hormonal contraception, progesterones, Miruna)
• Fertility treatment