Menopause/secondary amenorrhoea

Question 1

What does menopause mean?

Answer 1

Last ever period

Question 2

What is the average age of menopause?

Answer 2

51

Question 3

When is perimenopause?

Answer 3

Approx 5 years before menopause

Question 4

What counts as premature menopause?

Answer 4

40yrs or less

Question 5

What is the physiology of menopause?

Answer 5

Ovarian insufficiency
- Oestradiol falls
- FSH rises
Still some oestriol from peripheral conversion of adrenal androgens in fat

Question 6

Apart from naturally, when else might menopause occur?

Answer 6

Following oophroectomy, chemotherapy or radiotherapy

Question 7

What are the symptoms of menopause?

Answer 7

Vasomotor: hot fluses
Vaginal dryness/dyspareunia
Low libido
Muscle and joint aches
?Mood changes/poor memory
Osteoporosis

Question 8

How long can vasomotor symptoms like hot flushes be a problem in menopause?

Answer 8

Usually last 2-5yrs

Some cases 10yrs+

Question 9

What is osteoporosis?

Answer 9

Reduced bone mineral density

Question 10

What are the tests for osteoporosis?

Answer 10

DEXA scan w/ T score

Question 11

What scoring system can determines risk of fracture?

Answer 11

FRAX score

Question 12

What is the prevention/treatment for osteoporosis?

Answer 12

Exercise
Adequate calcium and vit D
Bisphosphonaes
Denosumab
Teriparatide

Question 13

What are symptom treatments for menopause?

Answer 13

Hormone replacement therapy (HRT)
Selective estrogen receptor modulators (SERMs)
SSRI SNRI antidepressants
Natural methods phytoestrogens
Non-hormonal vaginal lubricants

Question 14

How can HRT be delivered?

Answer 14

Systemic transdermal patch or gel/oral

Locally, vaginal oestrogen only, pessary/ring/cream

Question 15

What does transdermal HRT avoid and what risk factor does it reduce?

Answer 15

First pass metabolism

Less risk VTE

Question 16

When would the HRT be oestrogen only?

Answer 16

If no uterus

Question 17

When would the HRT be oestrogen and progesterone?

Answer 17

If uterus present to prevent endometrial hyperplasia

Question 18

How is progesterone given in HRT?

Answer 18

Oral, transdermal patch or LNG IUS

Question 19

What are the benefits of vaginal eostrogen?

Answer 19

Minimal absorpton so no increased VTE/Breast Ca risk

No need progesterone for endometrial protection

Question 20

What are the contraindications to systemic HRT?

Answer 20

Current hormone dependent cancer breast/endometrium
Current active liver disease
Uninvestigated abnormal PV bleeding
?Prev VTE/thrombophilia, FHx VTE
?Prev Ca breast or BRCA carrier

Question 21

What cancer risk reduces on combined estrogen and progesterone HRT?

Answer 21

Endometrial cancer

Question 22

If on combined HRT when are women typically bleed free?

Answer 22

After 3mo

Question 23

What is likely is still some ovarian function (perimenopause) and on continuous combined HRT?

Answer 23

Breakthrough bleeding

Question 24

What is a way to have HRT without bleeding problems?

Answer 24

Cyclical combined:
14days E
14days E+P
Withdrawal bleed after stop P
(Mirena LNG IUS + daily E)

Question 25

What are natural methods of HRT?

Answer 25

Phytooestrogen e.g. red clover & soy, black cohosh Hynotherapy Exercise CBT

Question 26

What are the benefits of HRT?

Answer 26

Vasomotor Local genital symptoms Osteoporosis

Question 27

What are the risk of HRT?

Answer 27

Breast Ca (combined) Ovarian Ca VT (oral) CVA (oral)

Question 28

Does HRT increase CVS risks?

Answer 28

Not if start before 60yrs

Question 29

When is there excess risk of breast cancer on HRT?

Answer 29

5-10yrs after HRT

Question 30

When does HRT benefits outweigh risks with premature ovarian insufficiency ?

Answer 30

Till age 50

Question 31

What is first line for osteoporosis prevention/treatment?

Answer 31

Biphosphonates

Question 32

What is first line for vaginal symptoms?

Answer 32

Vaginal oestrogen

Question 33

Case I: Woman, 48yo, hot flushes, night sweats. Periods 5/3- cycle but missed 2 periods in last years. What are differentials?

Answer 33

TB/thyroid/lymphoma Likely perimenopause Lifestyle - red clover HRT

Question 34

Case I: Woman, 48yo, hot flushes, night sweats. Periods 5/3- cycle but missed 2 periods in last years. Which HRT should be recommended and why?

Answer 34

Vasomotor symptoms = oestogen Has uterus = progesterone Some ovarian function = cyclical combined OR Mirena + oestrogen oral/transfermal

Question 35

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. Could she be menopausal?

Answer 35

Yes, ovaries can stop sooner if hysterectomy

Question 36

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. What are the investigations to see if she is menopausal?

Answer 36

FSH

Question 37

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. What HRT treatment could she be started on?

Answer 37

If symptomatic = oestrogen | No uterus = no progesterone

Question 38

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. Why is there more benefit than risk to be on HRT due to her age?

Answer 38

<50 so HRT only replacing 'what should be there'

Question 39

Case II: Women had hysterectomy for menorrhagia when 36, 18/40 size fibroids. Ovaries conserved. Now 39, has hot flushes. What is she does not want to be started on oestrogen?

Answer 39

Check FRAX score DEXA scan Bisphosphonates if necessary May accept vaginal HRT if symptomatic

Question 40

Case III: Woman, 55yo. Periods stopped when 51, attends for route cervical cytology, more uncomfortable than before, mentions she has vaginal dryness and dyspareunia. Tried non hormonal vaginal moisturisers and lubricants but still has symptoms. Which HRT and why?

Answer 40

Uterus and >2yrs postmenopausal Significant atrophy = oestrogen Vaginal oestrogen - pessary/cream/ring

Question 41

What is andropause?

Answer 41

'Male menopause' Testosterone falls by 1% a year after 30 DHEAS (hormone) also falls Fertility remains No sudden change

Question 42

What is primary amenorrhoea?

Answer 42

Never had a period

Question 43

When is it primary amenorrhoea?

Answer 43

>14yes and no 2ndry sexual characteristics | >16yrs with 2ndry sexual characteristics

Question 44

What is secondary amenorrhoea?

Answer 44

Had periods in past but none for 6mo

Question 45

What are some causes of secondary amenorrhoea?

Answer 45

Pregnancy/breast feeding Contraception related -current or after Depo-provera Polycystic ovaries Early menopause Thyroid/Cushing's/sign illness Raised prolactin - prolactinoma/medication-related Hypothalamic - stress/wt change/exercise Androgen secreting tumour - testosterone Sheehans syndrome - pituitary failure Ashermans syndrome - intrauterine adhesions

Question 46

What are the exams/investigations for secondary amenorrhoea?

Answer 46

``` BMI Cushingoid signs Androgenic signs Abdominal/bimanual exam Urine pregnancy test Dipstick glucose Bloods: FSH, oestradiol, prolactin, thyroid, testosterone Pelvis US ?PCOS ```

Question 47

What are androgenic signs?

Answer 47

Hirsutism Acne Enlarged clitoris Deep voice

Question 48

What is the management of secondary amenorrhoea?

Answer 48

Treat specific cause

Question 49

What is the treatment for premature ovarian insufficiency?

Answer 49

HRT till 50 Emotional support Check if Fragile X carrier

Question 50

When can you diagnosis polycystic ovary syndrome?

Answer 50

2 out of 3 of: - PCO morphology on scan (x10 small peripheral follicles or ov volume >12ml) - clinical or biochemical hyperandrogenism - hirsutism/acne - oligo or an ovulation - amenorrhoea or infertility

Question 51

What are the risks of PCOS?

Answer 51

Higher risk diabetes/CVS disease | Risk endometrial hyperplasia if <4 periods a year

Question 52

What is the management for PCOS?

Answer 52

Weight loss/exercise can help symptoms Increase SHBG so less free androgens - AntiandrogensL CHC, spironolactone, eflornithine cream facial hair - Endometrial protection: CHC, progestogens, Mirena IUS

Question 53

What are the fertility treatments that can help PCOS?

Answer 53

Clomiphene | Metformin

Question 54

What does metformin do for fertility?

Answer 54

Helps ovulation