Menopause and secondary ammenhorrea

Question 1

when is the average age for the last ever period?

Answer 1

51

Question 2

define premature menopause

Answer 2

<40yo

Question 3

outline ovarian failure

Answer 3

Oestradiol falls, FSH rises, Still some oestradiol from peripheral conversion of adrenal androgens in fat (Can be natural or follow oophorectomy/chemotherapy/radiotherapy)

Question 4

sy/sx of menopause

Answer 4

Vasomotor symptoms = ‘hot flushes’, Vaginal dryness/soreness (due to low levels of oestrogen), Low libido, loss of energy, Muscle and joint aches, Mood swings, hair loss, Weight gain, Poor memory, Osteoporosis (Reduced bone mass – low T score on DEXA scan, Fractured hip/vertebra, Risk factors = thin/Caucasian/smoker/amenorrhoea/ malabsorption/steroids/hyperthyroid, Prevention and treatment: weight bearing exercise, Adequate calcium and vit D, HRT, Bisphosphonates).
More irregular and heavier periods.

Question 5

DDX for menopause

Answer 5

depression, thyroid dysfunction.

Question 6

Ix of menopause

Answer 6

Thyroid function tests, FBC (to check Hb), LH:FSH ratio. THERE WILL BE HIGH LEVELS OF LH, FSH AND GONADOTROPHINS DUE TO LOSS OF NEGATIVE FEEDBACK BECAUSE THE OOCYTES BECOME DESENSITISED.

Question 7

symptomatic tx of menopause

Answer 7

HRT - Hormonal Therapy - Local vaginal oestrogen = pessary/ring/cream, Systemic = transdermal/oral, Transdermal avoids first pass – reduced VTE risk.
Oestrogen only if no uterus present.
Oestrogen + progesterone if uterus is present (progesterone needed so she has a withdrawl bleed to shed the endometrium each month - otherwise risk of endometrial cancer is increased).

Question 8

HRT Contraindications

Answer 8

History of: thromboembolism, breast cancer or migraines.

Question 9

NICE guidelines on HRT

Answer 9

Treatment of severe vasomotor symptoms, For women with premature menopause = premature ovarian insufficiency, Not as first line for osteoporosis prevention/treatment, Vaginal oestrogen for vaginal symptoms

Question 10

other tx for menopause

Answer 10

Selective oestrogen receptor modulator (SERMs) - Oestrogen effect on selected organs, SSRI/SNRI, Non hormonal lubricants

Question 11

define amenorrhoea

Answer 11

primary = never had a period, secondary = nno periods for the last 6 months.

Question 12

2ndary Amenorrhoea causes…

Answer 12

Pregnancy/breastfeeding, Contraception related = current use or 6-9 months after depoprovera, Polycystic ovaries, Early menopause, Thyroid disease/cushings, Raised prolactin – prolactinoma/medication related, Androgen secreting tumour, Sheehans syndrome = pituitary failure , Ashermans syndrome = intrauterine adhesions

Question 13

ix fo 2ndary amenorrhoea

Answer 13

BP, BMI, Cushingoid, Enlarged clitoris/deep voice = virilised, Abdominal + bimanual pelvic exams, Urine pregnancy dipstick + glucose dipstick, FSH, LH, Oestradiol, Prolactin, Thyroid, Testosterone, Pelvic ultrasound

Question 14

Mx for 2ndary amenorrhoea

Answer 14

Treat specific cause, aim for BMI 20-25, Assume fertile and need contraception unless 2 years after confirmed menopause, If premature – offer HRT until 50

Question 15

PCOS presentation

Answer 15

Oligo/amenorrhoea, Androgenic symptoms = hair/acne, Infertility, First trimester miscarriage, Diabetes, Cardiovascular disease

Question 16

what are polycyctic ovaries?

Answer 16

Small peripheral ovarian cysts 10/ovary, 20% women have this on scan but have no other features therefore not PCO syndrome

Question 17

PCOS- irregular ovulation

Answer 17

Irregular ovulation so irregular cycle, Plenty oestrogen but also high androgens, Underlying insulin resistance, Not a cause of pelvic pain, Not a cause of weight gain

Question 18

Mx of PCOS

Answer 18

Weight loss/exercise – can help with all symptoms, Antiandrogen = combined hormonal contraception, spironolactone, eflornithin cream for facial hair, Endometrial protection.

Question 19

HRT BENEFITS

Answer 19

Vasomotor
Local genital symptoms
Osteoporosis
Colon Ca

Question 20

HRT risks

Answer 20

Breast Ca
Ovarian Ca
VTE
CVA
Myocardial infarction