W05: Secondary Amenorrhoea & Menopause

Question 1

Outline the menopause process, effects and management

Answer 1

• fall of oestradiol and FSH rises (pituitary)
• background level of oestriol from adrenal androgens (adipose tissue)
• precipitated by oophorectomy, chemo, RadioT
• vasomotor = flushes, sweat
• vaginal dryness/soreness
• low libido
• muscle / joint aches
• mood changes/poor memory

HRT
(1)
> local vaginal HRT (oestrogen pessary)
minimal systemic abs., longterm use for benefit

(2)
> systemic oestrogen patch
less risk of VTE
- oestrogen only if nil uterus
- oestorgen + progestogen if uterus present: progestogen prevents end. hyperplasia
- cyclical: alternate between E and P
- continuous combined: bleed-free

> MIRENA + E ccontraceptive cover too

Question 2

Describe the causes and investigation of secondary amenorrhoea

Answer 2

• prego

• TSH

• prolactin => MRI

• androgens
- PCOS
- insensitivity

• sex hormones => wt. loss, excercise, chronic illness
menopause
pituitary tumour

• anatomical defect

Question 3

Describe the causes and investigation and management of
PCOS

Answer 3

> Lifestyle

> CHContraceptive

> Clomifene + Metformin

?DM = >metformin

Question 4

Osteoporosis in Menopause

Answer 4

> DEXA SCAN

> wt bearing exercise

> calcium
vitamin d
bisphosphonates (first line before HRT)
denosumab-MonoAb to osteoclasts
calcitonin

Question 5

CI / considerations to systemic HRT

Answer 5

• current hormone dependent cancer breast/endometrium
• current active liver disease
• uninvestigated abn vag. bleeding
• hx of prev VTE, thrombophilia
• hx of breast ca or BRCA

Question 6

CI / considerations to vaginal HRT

Answer 6

• avoid for women taking aromatase inhibitor tx for breast ca.
• nil other CI dt minimal systemic abs.

Question 7

Symptom tx for menopause

Answer 7

• Selective Estrogen R Mod. (SERMS)
• osteoporosis, infertility and hormone responsive cancers
• Phytooestrogen herbs
• hypnotherapy; exercise; CBTx
• non hormonal lubricants for dryness

Question 8

Risks of HRT

Answer 8

breast ca if combined HRT

ovarian ca

VT (oral)

CVA (oral)

Question 9

Andropause

Answer 9

fall of testosterone by 1% a year after 30yo
- DHEAS falls

• fertility remains
• no sudden change

Question 10

Primary Amenorrhoea vs Secondary

Answer 10

Never had a period

Secondary = has periods in past but none for 6mos

Question 11

Secondary Amenorrhoea

Answer 11

dt
* preg. / breastfeeding
* contraception related
* PCOS

• premature ovarian insufficiency
• hypothalamic stress
• thyroid / prolactin / androgen disruption

meds: ?contraception; opiates; antipsychotics; metoclopramide
? galactorrhoea
? acne/hirsutism
?wt change

• BMI. cushingoid, PV exam, urine, preg test, FSH oestradiol prolactin TFT androgen markers
• pelvic USS

> BMI
solve underlying

Question 12

PCOS Dx

Answer 12

2 out of 3
1. OLIGO/AMENORRHOEA

2. ANDROGENIC SYMPTOMS
3. POLYVYSTIC OVARIAN MORPHOLOGY ON SCAN

” Small peripheral ovarian cysts x 10/0vary or
ovarian volume>12cm3”

• normal/high oestrogen
• increased androgens
  ? insulin resistance
• different to multicystic ovaries (var size)

Question 13

PCOS complications

Answer 13

• endometrial hyperplasia risk <4 periods a year
• reduced fertility
• higher risk of DM and CVD even with low BMI
• Wt gain can worsen PCOS symptoms dt as ↓SHBG
  levels so ↑ free androgen levels

Question 14

PCOS mgmt

Answer 14

> laparoscopy for fertility problems