Secondary Amenorrhoea and Menopause

Question 1

Definition of menopause

Answer 1

When a women aged 45 or over has amenorrhoea for 12 months

Question 2

Average age of menopause

Answer 2

51

Question 3

Perimenopause lasts for how long before menopause?

Answer 3

5 years before

Question 4

What age is classified as premature menopause?

Answer 4

40 years or less

Question 5

What physiological change occurs during menopause?

Answer 5

Ovarian insuffiency

Question 6

Ovarian insufficiency of menopause involves….

Answer 6

Oestradiol falls
FSH rises - telling brain to produce more oestrogen
Still some oestradiol from peripheral
Conversion of adrenal androgens in fat (women with more body fat will have fewer hot flushes/sweats)

Question 7

Causes of menopause

Answer 7

Natural
Follow oophorectomy
Follow chemotherapy
Follow radiotherapy

Question 8

Symptoms of menopause

Answer 8

Itchy 
Irritable 
Sweaty
Sleepy
Bloated
Mood changes
Possibly forgetful 
Vasomotor symptoms - "hot flushes"
Vaginal dryness/soreness
Low libido 
Muscle and joint aches
Silent change of osteoporosis

Question 9

Risks of osteoporosis in menopause

Answer 9

Thin
Caucasian 
Smokers
EtOH
Positive FH of amenorrhoea 
Malabsorption 
Oral steroids
Hyperthyroid

Question 10

Prevention/treatment of osteoporosis

Answer 10

exercise 
adequate calcium + vit D
HRT
Bisphosphonates
Denosumab 
Teriparatide

Question 11

What does denosumab do?

Answer 11

It is a monoclonal antibody to osteoclasts

Question 12

Symptom treatment of menopause

Answer 12

Hormone replacement therapy (HRT)
Selective oestrogen receptor modulators (SERMS)
SSRI SNRI antidepressants
Natural methods e.g. herbs, exercise
Non-hormonal lubricants e.g. Reptes, Sylk

Question 13

Types of HRT

Answer 13

Local vaginal oestrogen pessary/ring/cream

Systemic transdermal/oral transdermal

Question 14

Systemic transdermal/oral transdermal HRT - which hormones are indicated?

Answer 14

Oestrogen ONLY if no uterus

Oestrogen AND progesterone if uterus present

Question 15

Contraindications to HRT

Answer 15

Current hormone dependent cancer of breast/endometrium
Current active liver disease
Uninvestigated abnormal bleeding

Question 16

Seek advise before giving HRT if….

Answer 16

Previous VTE
Thrombophilia
FH VTE
Previous breast cancer 
BRCA carrier

Question 17

Benefits of HRT

Answer 17

Vasomotor
Local genital symptoms
Osteoporosis

Question 18

Risks of HRT

Answer 18

Breast cancer if combined HRT 
Ovarian cancer
VTE if oral route
CVA if oral route
after 60 y/o can affect CVS

Question 19

Natural methods for the treatment of menopause

Answer 19

Phytooestrogen 
Herbs e.g. red clover
Hypnotherapy 
Exercise
CBT - high placebo effect

Question 20

Testosterone falls by 1% a year after what age in males?

Answer 20

30 y/o

Question 21

Definition of primary amenorrhoea

Answer 21

Never had a period

Question 22

Definition of secondary amenorrhoea

Answer 22

Has had periods in the past but none for 6 months

Question 23

Causes of secondary amenorrhoea

Answer 23

Pregnancy/breast feeding
Contraception related (current use or 6 months after DP)
Polycystic ovaries
Early menopause
Thyroid disease/cushings
Any significant illness
Raised prolactin (prolactinoma, medication related)
Hypothalamic
Androgen screening tumour (testosterone >5mg/l)
Sheehan’s syndrome (pituitary failure)
Asherman’s syndrome (intrauterine adhersions)

Question 24

Investigations for secondary amenorrhoea

Answer 24

BP
BMI
Acne
Hirsituism 
Cushingoid 
Enlarged clitoris/deep voice = virulised
Abdominal/bimanual 
Urine pregnancy test + urine glucose dipstick 
Bloods (FSH, LH, oestrogen, prolactin, TFTs, testosterone)
Pelvic USS for PCO

Question 25

Treatment for secondary amenorrhoea

Answer 25

treat specific cause Aim BMI 20-25 Assume fertile and need contraception unless 2 years after confirmed menopause if premature ovarian insuffiency offer HRT until 50 Emotional support - daisy network Check for fragile X

Question 26

Presentation spectrum for polycystic ovarian syndrome (PCOS)

Answer 26

Oligo/Amenorrhoea Androgenic symptoms; excess hair/acne Anovulatory fertility

Question 27

What do polycystic ovaries NOT cause

Answer 27

weight gain | pain

Question 28

Treatment of polycystic ovarian syndrome (PCOS)

Answer 28

``` Weight loss/exercise Antiandrogen - combined hormonal contraception (CHC) - Spironolactone - Eflornithine cream facial hair Endometrial protection - CHC - Progesterones - Mirena IUS Fertility treatment - clomiphene/metformin ```

Question 29

Definition of polycystic ovaries

Answer 29

Small peripheral ovarian cysts x10/ovary or ovarian volume >12cm3

Question 30

Perimenopause definition

Answer 30

The time leading up to menopause. Many women experience menopausal symptoms during this

Question 31

Blood values indicative of menopause

Answer 31

Low oestrogen | High FSH and LH

Question 32

In order to find the correct HRT regime, what 3 things must be addressed?

Answer 32

1. Is there a uterus? 2. Is the patient perimenopausal or menopausal? 3. Is a systemic or a local effect required?

Question 33

Is continuous or cyclical HRT recommended in perimenopausal HRT?

Answer 33

Cyclical

Question 34

Why is systemic oestrogen only HRT not appropriate for women with a uterus?

Answer 34

Increased risk of endometrial cancer

Question 35

What % of women of reproductive age are affected by PCOS?

Answer 35

5 - 20%

Question 36

Investigations of PCOS

Answer 36

Pelvic USS (multiple cysts on ovaries) FSH, LH, prolactin, TSH, testosterone Glucose tolerance

Question 37

Diagnostic criteria for PCOS

Answer 37

2/3 out of; - Infrequent or no ovulation - Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone - polycystic ovaries on ultrasonography or increased ovarian volume

Question 38

What test is done to confirm menopause?

Answer 38

FSH

Question 39

Describe sheehans syndrome

Answer 39

Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic shock

Question 40

Features of sheehans syndrome

Answer 40

``` Agalactorrhoea Amenorrhoea Symptoms of - hypothyroidism - hypoadrenalism ```

Question 41

What is ashermans syndrome?

Answer 41

Intrauterine adhesions

Question 42

What can ashermans syndrome occur after?

Answer 42

Dilatation and curettage

Question 43

How can ashermans syndrome cause secondary amenorrhea?

Answer 43

Prevent the endometrium responding to oestrogen as it normally would