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Y3 repro > 2y amenorrhoea and menopause > Flashcards

2y amenorrhoea and menopause Flashcards

(43 cards)

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1
Q

what is menopause

A

a woman’s last ever period
~51y/o
1/3 of UK lifespan after menopause

perimenopause 3-5yrs before final period, can have menopausal symptoms during this

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2
Q

what is premature menopause

A

<40y/o

affects 1% women

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3
Q

what happens at menopause - hormones

A

ovarian insufficiency - oestradiol falls
FSH from pituitary rises
still some oestriol from conversion of adrenal androgens in adipose tissue

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4
Q

FSH levels in perimenopause

A

levels fluctuate

one off level doesn’t exclude perimenopause as a cause for symptoms

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5
Q

how does menopausal transition occur

A

may be natural or sudden following oophorectomy/chemotherapy/radiotherapy

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6
Q

menopause symptoms

A

vasomotor - hot flushes/night sweats, 80% women affected, 45% significant problem, usually last 2-5yrs, may be >10yrs

vaginal dryness/soreness
low libido
muscle and joint aches
mood changes/poor memory - possibly related to vasomotor symptoms affecting sleep

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7
Q

osteoporosis in menopause

A

reduced oestrogen - lowered BMD

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8
Q

what is osteoporosis

A

reduced bone mineral density

tested for w/ DEXA scan - T score

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9
Q

problems with osteoporosis following menopause

A

fractured hip/vertebrae
1% women 50-69
significant morbidity and mortality

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10
Q

osteoporosis risk factors

A 
thin 
caucasian 
smoker
high alcohol intake (EtOH)
\+ve FHx esp male or younger age
malabsorption vit D and Ca
prolonged low oestrogen before menopause and amenorrhoea
oral corticosteroids
hyperthyroid
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11
Q

prevention and treatment of osteoporosis

A 
wight bearing exercise
adequate Ca and vit D
HRT 
bisphosphonates
denosumab - monoclonal ab to osteoclasts 
calcitonin
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12
Q

HRT for menopausal symptoms

A
  1. local vaginal HRT - oestrogen pessary/ring/cream - minimal systemic absorption, need to use longterm to maintain benefit
  2. systemic oestrogen transdermal patch/gel or oral - transdermal avoids 1st pass + less risk VTE

oestrogen only if no uterus
oestrogen and progesterone is uterus present - progestogen oral, patch or LNG IUS

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13
Q

why can oestrogen alone not be used if the woman still has a uterus

A

risk of endometrial hyperplasia and endometrial cancer

progesterone has to also be used for protection against this

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14
Q

combined oestrogen and progestogen HRT - women with ovarian function

A

for women who still have some ovarian function to avoid inconvenience of irregular bleeding

cyclical combined HRT - 14 days E, 14 days E+P

expect withdrawal bleed after P

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15
Q

combined oestrogen and progestogen HRT - women w/o any likely natural ovarian function

A

continuous combined 28 days E+P oral/patch
expect to be bleed free after 1st 3mths
use if >1yr after LMP or age >54

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16
Q

what combined oestrogen and progestogen HRT can be used for women of any age

A

Mirena LNG IUS 5yrs + daily E

expect to be bleed free

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17
Q

what HRT regime gives contraceptive cover

A

mirena + E

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18
Q

CI to systemic HRT

Study These Flashcards
A

not the same as CI to combined hormonal contraception

  1. current hormone dependent breast/endometrium cancer
  2. current active liver disease
  3. uninvestigated abnormal vaginal bleeding
  4. seek advice if prev VTE, thrombophilia, FH VTE
  5. seek advice if prev breast cancer or BRCA carrier
19
Q

CI to vaginal HRT

Study These Flashcards
A

avoid for women taking aromatase inhibitor treatment for breast cancer - but may choose to use if symptoms affecting QOL
no other CI as minimal systemic absorption

20
Q

treatment for symptoms of menopause

Study These Flashcards
A

HRT
SERMs
clonidine/SSRI/SNRI antidepressants
phytooestrogen herbs e.g. red clover, soya
hypnotherapy/exercise/CBT
non-hormonal lubricants for vaginal dryness

21
Q

SERMs

Study These Flashcards
A

selective oestrogen receptor modulators
E effect on selected organs

e.g. tibolone has E effect on flushes, bones but not endometrium

22
Q

clonidine or SSRI SNRI antidepressants

Study These Flashcards
A

e.g. venlafaxine
NOT recommended for vasomotor symptoms

frequent side effects and few women benefit

23
Q

HRT benefits

Study These Flashcards
A

vasomotor
local genital symptoms
osteoporosis

no effect on alzheimers
no increase in CV risks if start before 60y/o (before significant atherosclerosis develops)

24
Q

risks of HRT

Study These Flashcards
A

breast Ca if combined HRT
ovarian Ca
VTE if oral route
CVA if oral route

25
HRT risks vs benefits
no overall increased mortality for HRT users - suggests reduced mortality but not certain enough to recommend for all women XS breast Ca risk returns to baseline as for never users after 5yrs off HRT
26
NICE guidance for HRT
- treatment of severe vasomotor symptoms, review annually - premature ovarian insufficiency, HRT benefits > risks until 50y/o - not as 1st line for osteoporosis prevention/treatment (bisphosphonates instead) - use vaginal oestrogen if vaginal symptoms - no absolute upper age limit of max duration of HRT use
27
andropause - male menopause
testosterone falls by 1% a year after 30y/o DHEAS falls no sudden change and fertility remains
28
what is 1y amenorrhoea
``` never had a period 5% delayed pubery if: >14 and no 2y sexual characteristics >16 if 2y sexual characteristics ```
29
what is 2y amenorrhoea
has had periods in past but none for 6mths
30
causes of 2y amenorrhoea
pregnancy/BF contraception related PCOS ``` premature ovarian insufficiency hypothalamic thyroid disease, cushings raised prolactin congenital adrenal hyperplasia androgen secreting tumour Sheehan's syndrome - pituitary failure Asherman's syndrome - IU lesions ```
31
contraception related 2y amenorrhoea
current use of 6-9mths after depoprovera
32
hypothalamic 2y amenorrhoea
stress 10% weight change XS exercise any severe illness
33
causes for raised prolactin
prolactinoma | medication
34
androgen secreting tumour and 2y amenorrhoea
testosterone >5mg/l
35
hx for 2y amenorrhoea
possibility of pregnancy BF medications - contraception, opiates, antipsychotics, metoclopramide galactorrhoea/visual change (increased prolactin) acne, hirsutism, voice change (increased androgen) weight change exercise/stress significant illness
36
2y amenorrhoea examination and investigation
BMI Cushing's features acne, hirsutism, virilised - enlarged clitoris, deep voice abdo and bimanual exam - pelvic mass, pregnant uterus, ovarian cyst urine pregnancy test bloods - raised FSH, low oestadiol (menopause); prolactin, TFTs, testosterone and SHBG (free androgen index), 17 hydroxy progesterone (CAH) pelvic US - PCOS
37
2y amenorrhoea treatment
treat specific cause BMI >20 <30 ideal for ovulation assume fertile and need contraception unless 2yrs after confirmed menopause if premature ovarian insufficiency - offer HRT until 50, emotional support (incl Daisy network), check for fragile X (also relatives)
38
diagnosis of PCOS
need 2/3 of: oligo/amenorrhoea androgenic symptoms - XS hair/acne (or increased levels on testing) PCO morphology on scan - can have PCOS with normal looking ovaries normal/high oestrogen levels increased androgens - acne/hirsutism ? underlying cause is insulin resistance
39
risks with PCOS
risk of endometrial hyperplasia if <4 periods a year (and not on hormonal contraception) reduced fertility if not ovulating regularly - assume fertile and use contraception if not planning pregnancy higher risk DM and CVD even w/ BMI <25
40
weight gain and PCOS
PCOS DOES NOT cause pain or weight gain weight gain can worsen PCOS symptoms as reduced SHBG levels so increased free androgen levels
41
US definition of polycystic ovaries
small peripheral ovarian cysts x10/ovary or ovarian volume >12ml 20% women have this on scan but not other features e.g. not PCOS multicystic ovaries common in adolescents and not associated w/ PCOS - don't diagnose PCOS until late teens
42
management of PCOS - symptoms
weight loss/exercise to BMI 20-25 can help with all symptoms - increases SHBG so less free androgens increased NIDDM risk even if slim - consider GTT support and info - Verity support group antiandrogen - combined hormonal contraception if no CI, spironolactone, eflornithine cream to reduce facial hair growth
43
management of PCOS complications
endometrial protection - CHC, mirena IUS, oral provera 10 days every 90 days if no period to cause withdrawal bleed fertility Rx clomiphene/metformin usually effective for ovulation induction underlying cause - insulin resistance, metformin may encourage ovulation but no consistent evidence of benefit for androgenic symptoms or helping weight loss

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