Secondary Amenorrhoea and Menopause Flashcards
What is the dentition of menopause?
The Menopause is a woman’s last ever period
What is the average age of the menopause?
51
When does perimenopause start?
Approx. 5 years before
What is premature menopause and how common is it?
- Premature menopause = 40 years or less
* Affects 1% of women
What happens in menopause?
•Ovarian insufficiency (oestradiol falls)
->Follicle stimulating hormone (FSH) rises
- Still some oestriol from conversion of adrenal androgens in adipose tissue
- FSH levels fluctuate in perimenopause - a premenopausal level does not exclude perimenopause as a cause for symptoms
- Menopausal transition may be natural or sudden following oophorectomy/chemotherapy/radiotherapy
What are the symptoms of menopause?
- Vasomotor symptoms
- Vaginal dryness/soreness
- Low libido
- Muscle and joint aches
- Mood changes/poor memory - possibly related to vasomotor effect on sleep
What are the vasomotor symptoms in menopause?
- Hot flushes/night sweats - 80% women
- 45% find them a problem
- Usually last 2-5 yrs but may be 10 years+
What is a silent change in menopause?
Osteoporosis
What is osteoporosis?
- Reduced bone mass
* DEXA scan •Bone density described as T score
What are the problems that come with osteoporosis?
•Fractured hip/vertebrae
What are the risk factors for osteoporosis?
- Thin
- Caucasian
- Smoking
- High EtOH - alcoholic
- +ve FH
- Malabsorption Vit D or Calcium
- Prolonged low oestrogen amenorrhoea
- Oral corticosteroids
- Hyperthyroidism
How is osteoporosis prevented in menopausal women?
- Weight-bearing exercise
- Adequate calcium and vitamin D
- HRT
How is osteoporosis treated in menopausal women?
- Bisphosphonates
- Denosumab - monoclonal antibody to osteoclasts
- Calcitonin (hormone)
What are the 2 types of HRT?
- Local
* Systemic
What is local HRT?
- Oestrogen pessary/ring/cream
- Local effects and minimal systemic absorption
- Need to use longterm to maintain benefit
What is systemic HRT?
- Oestrogen given transdermally or orally
- Transdermal - avoids first pass, less risk of VTE
- No uterus - oestrogen only
- Uterus - oestrogen and progestogen
- Progestogen given orally, transdermally and LNG IUS
Why is progestogen treatment required if the patient has a uterus?
•Prevents endometrial hyperplasia from unopposed oestrogen
What is combined cyclical menopause treatment?
- 14 days E + 14 days E+P
- Expect withdrawal bleed after the P
- Used if there may still be some ovarian function to avoid irregular bleeding
What is combined continuous menopause treatment?
- 28 days E+P oral/patch
- Expect to be bleed-free (after 1st 3 months)
- Used if > 1yr after menopause or age 54+
What combined treatment can any age use?
Any age can use Mirena LNG IUS + daily E and expect
to be bleed free (and contraceptive cover under age 55)
What are the contraindications for systemic HRT?
•NOT the same as contraindications to combined
hormonal contraception- very few CI
- Current Hormone dependent cancer of breast/endometrium
- Current active liver disease
- Uninvestigated abnormal bleeding
- Seek advice if previous VTE, thrombophilia, FH VTE
- Seek advice if previous breast cancer or BRCA carrier
How are the symptoms of menopause treated?
•Selective Estrogen Receptor Modulators (SERMs)
E effect on selected organs (eg tibolone )
NOT clonidine or SSRI SNRI antidepressants eg venlafaxine common side effects &few benefit
phytooestrogen herbs eg red clover/soya
hypnotherapy/ exercise / Cognitive behavioural therapy
Non hormonal lubricants for vaginal dryness Regular eg Replens TM or Pre sex ‘Sylk’ TM
What are the benefits of HRT?
- Vasomotor symptoms
- Local genital symptoms
- Osteoprosis
What are the risks of HRT?
- Breast cancer if combined HRT
- Ovarian cancer
- VT if oral route
- CVA if oral route (stroke)
What does HRT not affect?
- No effect on Alzheimer’s
* No increase in CV risk if started before 60
How does HRT affect mortality?
- No overall increased mortality for HRT users recent studies
- Reduced mortality - not certain enough to recommend HRT for all
What are the indications for HRT?
- 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 is andropause?
- Testosterone falls by 1% a year after 30
- DHEAS falls
- Fertility remains
- No sudden change
- Different from hypogonadism
What is primary amenorrhoea?
- Never had a period
- Affects 5% of girls
- > 14yrs and no 2ndry sexual characteristics
- > 16 years if 2ndry sexual characteristics
What is secondary amenorrhoea?
Has had periods in past but none for 6 months
What are the causes of secondary amenorrhoea?
- Pregnancy / Breast feeding
- Contraception related - current use or for 6-9 months after depoprovera
- Polycystic ovary syndrome
- Premature ovarian insufficiency
- Thyroid disease/Cushings/Any significant illness
- Raised prolactin - prolactinoma/medication related
- Congenital adrenal hyperplasia (CAH)
- Hypothalamic - stress/10% wt change/excess exercise
- Androgen secreting tumour - testosterone >5mg/l
- Sheehans syndrome - pituitary failure
- Ashermans syndrome - intrauterine adhesions
What examinations are carried out in secondary amenorrhoea?
- BP
- BMI
- Hirsutism
- Acne
- Cushingoid
- Enlarged clitoris/deep voice =virilised
- Abdominal/bimanual
What investigations are carried out in secondary amenorrhoea?
•Urine pregnancy test + dipstick for glucose •Bloods -FSH -oestradiol (menopause) -prolactin -thyroid function testosterone -17 hydroxy progesterone - congenital adrenal hyperplasia -pelvic ultrasound - polycystic ovaries
How is secondary amenorrhoea treated?
•Treat specific cause
•Aim BMI 20-30 for ovulation
•Assume fertile and need contraception unless 2 yrs after confirmed menopause
•If premature ovarian insufficiency offer HRT till 50
-emotional support
-Daisy network (for POI)
-check for Fragile X - relatives may wish testing
How is polycystic ovary syndrome diagnosed?
Need 2/3:
•Oligo/amenorrhoea
•Androgenic symptoms: excess hair/acne
•Polycystic ovarian morphology on scan
How may hormone levels indicate PCOS?
- Normal/high oestrogen levels
* Increased androgens
What are the issues associated with PCOS?
- Risk of endometrial hyperplasia if < 4 periods a year (and not on hormones)
- Reduced fertility if not ovulating regularly BUT assume fertile and use contraception if not plan pregnancy
- ?Higher risk diabetes & cardiovascular disease even if lean
- Polycystic ovaries do NOT cause weight gain or pain
- Weight gain can worsen PCOS symptoms as ↓SHBG levels ↑ androgens
How may polycystic ovaries be seen?
US, laparoscopy
What does PCOS look like on an USS?
- Small peripheral ovarian cysts x 10/ovary or ovarian volume>12cm3
- N.B. 20% women have this on scan but no other features ie not PCO syndrome
- N.B. Multicystic ovaries common in adolescents – not associated with PCOS
How is PCOS managed?
•Weight loss/exercise to BMI 20-25
- can help all symptoms
- increases SHBG so less free androgens
- ?increased NIDDM (non-insulin dependent) risk even if slim - consider GTT
- Support & information– Verity patient support group
- Antiandrogen
- combined hormonal contraception if no CI
- spironolactone
- eflornithine cream reduces facial hair growth
•Endometrial protection
- CHC, Mirena IUS
- Oral provera 10/90 if no period
•Fertility Rx clomiphene/metformin
-ovulation induction
•Metformin - may encourage ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss
