Nov 03, · Many women approach menopause with the desire to take only “natural” hormones to help alleviate their symptoms. This causes quite a bit of confusion and miscommunication between doctors and their patients. That’s because all hormones can be marketed as “natural” or “plant-based,” and many pharmaceutical companies are capitalizing Dec 15, · As with most surgeries, after a hysterectomy, women will have to deal with pain. How much pain you will feel after the operation depends on what type of hysterectomy they performed and your individual susceptibility to pain. The degree of pain will vary depending upon the type of incision made. Some studies and research suggest that women have less pain Nov 18, · Menses: Many women do not get their next period for four to six weeks after surgery. When the period returns, you may notice heavy bleeding and more discomfort than before. Wait two to three periods; if it does not relieve, then you must seek medical advice. Having sex: Do not resume sexual intercourse until your doctor says. Full recovery with
Missed Periods (Amenorrhoea) | Absent or Irregular Periods | Patient
Articles in the December issue discuss various health issues affecting school-aged children, including acne, eczema and growth disorders. Volume 46, No. Premature ovarian insufficiency POIdefined as amenorrhoea due to the loss of ovarian function before 40 years of age, can occur spontaneously or be secondary do periods resume after hrt medical therapies.
POI is associated with cardiovascular morbidity, osteoporosis and premature mortality. Women with POI present in primary care with menstrual disturbance, menopausal symptoms, infertility and, often, significant psychosocial issues. General practitioners play an important role in the evaluation and long-term management of women with POI.
This article examines the diagnostic and management issues when providing care for women with POI in the primary care setting. Diagnosis of POI requires follicle-stimulating hormone FSH levels in the menopausal range on two occasions, at least four to six weeks apart in a woman aged Case A university student, 21 years of age, presents with concerns regarding a month history of amenorrhoea. She is otherwise well and has no significant medical or surgical history or recent weight loss.
The patient recalls menarche at 16 years of age, but her menses have been erratic, with only one day of light menstrual bleeding every three to four months. She has never been sexually active. She denies a history of hirsutism, vasomotor symptoms and family history of early menopause. She is normotensive. Thyroid function is normal. Presentations of menstrual abnormalities are common in primary care, and POI is often an under-recognised cause, do periods resume after hrt.
POI can be associated with a fluctuating and unpredictable course, with a small possibility that ovarian function may spontaneously resume. Depletion of ovarian follicles with POI leads to a decline in oestradiol, anti-Müllerian hormone and inhibin B levels, and a rise in pituitary gonadotrophins. Early diagnosis is important as women are at risk of morbidity, such as infertility, osteoporosis, accelerated cardiovascular disease CVD and neurocognitive disorders, and increased mortality.
General practitioners GPs play a vital role in the evaluation and initial management of women with POI, and also in monitoring for long-term consequences. The aetiology of POI is diverse, and it can occur spontaneously or be secondary to medical therapies.
Spontaneous POI can be associated with chromosomal and genetic defects, environmental factors, autoimmune diseases most commonly adrenal and thyroid disease and various infections, do periods resume after hrt, but is idiopathic in the majority of cases. A family history of POI and cigarette smoking are well recognised risk factors for the development of POI, 3 as is bilateral ovarian surgery for endometriomas, with a reported 2. The clinical presentation of POI can be variable, but the most common presenting symptom is menstrual disturbance, particularly oligomenorrhoea or amenorrhoea.
POI can have a significant negative impact on physical and emotional wellbeing, including menopausal symptoms, infertility and increased risk of long-term consequences Figure 1. Menopausal symptoms eg hot flushes and urogynaecological and sexual changes may be more severe in women with premature menopause, compared with do periods resume after hrt menopause, whereas women with primary amenorrhoea are unlikely to experience menopausal symptoms. Infertility is a key feature of POI given the loss of ovarian reserve.
Women with POI may present with adverse psychosocial symptoms, and have been found to have higher levels of depression and anxiety, a more negative body image, decreased sexual function and reduced confidence, compared with premenopausal controls. POI may be diagnosed as a consequence of a comorbid condition, and the clinical presentation may be related to the underlying cause, such as thyroid or adrenal autoimmune conditions or cancer-related medical therapies Box 1.
At times, difficulty interpreting hormone results can hinder diagnosis. It is important that women are not taking hormonal contraceptives or HRT, to ensure accurate interpretation of the hormone levels. These agents must be withdrawn for at least six weeks prior to hormone measurements.
The routine use of anti-Müllerian hormone levels in the diagnosis of POI is not currently recommended as its accuracy is not validated in this setting.
Following diagnosis, the aetiology of POI Figure 2 and long-term consequences Figure 3 should be evaluated, and specialist referral may be necessary. In the absence of clear iatrogenic causes of POI, investigations should include: 1. Figure 2. Figure 3. A pelvic ultrasound demonstrates a normal uterus with small ovaries and an absence of follicles.
Dual energy X-ray absorptiometry DEXA shows low bone mineral density BMD at the lumbar spine with a Z-score of —2. Calcium, phosphate, magnesium and hydroxy-vitamin D levels are normal. She has no other known cardiovascular risk factors, and her fasting glucose level and lipid profile are normal.
Women with POI are at risk of complications relating to the underlying cause of POI, such as breast cancer recurrence or complications of Turner syndrome, but are also at risk of developing long-term consequences from POI itself. The key long-term consequences are shown in Figure 1 and summarised below. POI is an independent risk factor for CVD, 16 with increased premature coronary artery disease 17 and CVD mortality. Observational studies suggest that there is an increased risk of diabetes following surgical menopause.
Osteoporosis is considered one of the most feared consequences by patients with POI. Women with POI are at risk of premature mortality, 18 largely due to CVD, and may be worsened by the presence of other modifiable CVD risk factors. It is important to reassure women that POI is associated with a reduced risk of breast cancer. The diagnosis of POI can be extremely distressing for women. Several consultations may be required to provide emotional and psychological support regarding the diagnosis, and to address the multisystem approach needed for optimal care.
After a long discussion with the patient about the diagnosis of POI, its clinical implications and her plans for pregnancy, the importance of oestrogen therapy until the average age of menopause approximately 51 years of age is explained. Our patient commences transdermal combined continuous HRT containing 50 µg oestradiol and µg norethisterone.
The consequences of POI on future fertility are particularly distressing for her, do periods resume after hrt she is counselled on the possibility of spontaneous ovulation in POI.
Importantly, she is advised that her current HRT is not contraceptive and, therefore, contraception is required should she not wish to become pregnant. The patient is also referred to a psychologist for counselling. Our patient continues to see her psychologist, and is managed by a multidisciplinary outpatient team and her GP. Comprehensive guidelines on the management of women with POI were recently published, 1 and key points from this review do periods resume after hrt highlighted below.
Referral for psychological support should be considered, and women should be made aware of available support groups and educational resources. A list of educational resources is provided at the end of the article.
Menopausal symptoms and reduction of CVD or osteoporosis risk can be addressed by dietary and lifestyle modification. Refer to AMS and Jean Hailes websites listed below. The IMS and ESHRE guidelines recommend that HRT be initiated early in all women diagnosed with POI unless contraindicated and continued until the natural age of menopause approximately 51 years of age. Currently, there is no conclusive evidence regarding the optimal HRT regimen.
The usual considerations regarding the choice of HRT or COCP applies to women with POI. For example, oestrogen-only therapy in women is recommended for women who have had a hysterectomy, do periods resume after hrt, cyclical progestin combined with oestrogen for women who prefer monthly withdrawal bleeds or continuous combined therapy in those who do not and transdermal oestrogen for women at increased risk of venous thromboembolism, migraines or liver disease.
HRT may be preferable to COCP for optimisation of bone health, but must be weighed against the need for contraception. Women with primary amenorrhoea requiring pubertal induction, contraindications to HRT hormone-sensitive tumoursor a history of thrombophilia or endometriosis require specialist referral. Initial doses may be low and up-titrated to achieve symptom control, although higher oestrogen doses may be required in POI for symptomatic management and maintenance of bone health.
As HRT is not contraceptive, counselling regarding contraceptive options is important for women not desiring pregnancy.
COCP can provide both hormone replacement and contraception and, if prescribed, women should be advised to take it continuously or long cycle, without the inactive pills, do periods resume after hrt, to avoid intermittent periods of symptomatic oestrogen deprivation. An option would be to use transdermal oestrogen with the levonorgestrel IUD, thereby providing contraception, symptom management and prevention of long-term sequelae.
Women should be reviewed frequently while the dose of HRT is titrated. Once a maintenance dose is established, consultations should occur at least annually to monitor for symptom control and to complete an annual complication screen. A sexual health history is important, as women are often reluctant to disclose sexual dysfunction. Key treatment issues to consider include optimisation of HRT, treatment of urogenital symptoms eg vaginal oestrogen or lubricant to treat dyspareuniado periods resume after hrt, review of medications that can have an impact on sexual function eg antidepressants, aromatase inhibitorscounselling, and referral to sexual health clinics.
Some women may benefit from consideration of testosterone therapy in this setting, but there is insufficient evidence regarding the efficacy do periods resume after hrt long-term safety in women with POI to support the routine use of testosterone.
Principles for managing the potential long-term sequelae of POI are listed in Figure 3, and include the issues of infertility, CVD and osteoporosis risk assessment; consideration of specialist referral; autoimmune screening; and management of the underlying cause of POI eg Turner syndrome, autoimmune conditions.
The diagnosis of POI is often challenging for health practitioners, and traumatic for affected women. In the primary care setting, evaluation should include confirmation of the diagnosis of POI, the underlying cause, and associated symptoms and consequences. First-line therapy includes oestrogen replacement eg HRT, COCPand multidisciplinary team involvement is often required.
Women require long-term follow-up by GPs to monitor therapies, and also to address complication screening. Hanh H Nguyen MBBS, BMedSci, FRACP, Endocrinology Research Fellow, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Vic; and Endocrinologist, do periods resume after hrt, Department of Endocrinology, Monash Health, Clayton, Vic. nguyen monash. Frances Milat MBBS HonsMD, FRACP, Endocrinologist, Head of Metabolic Bone Services, Department of Endocrinology, Monash Health, Clayton, Vic; Head, Metabolic Bone Research Group, Hudson Institute of Medical Research, Clayton, Vic; and Adjunct Clinical Associate Professor, School of Clinical Sciences, Monash University, Clayton, Vic.
Amanda Vincent MBBS, BMedSci Honsdo periods resume after hrt, PhD, FRACP, Endocrinologist, Department of Endocrinology, Monash Health, Do periods resume after hrt, Vic; Research Fellow, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, do periods resume after hrt, Vic; and Adjunct Clinical Associate Professor, School of Public Health and Preventive Medicine, Monash University, do periods resume after hrt, Clayton Vic.
Funding and competing interests: Amanda Vincent has received personal fees from Novo Nordisk, and research grants and personal fees from Amgen, outside the submitted work. Hanh Nguyen and Frances Milat have no disclosures. To open click on the link, your computer or device will try and open the file using compatible software.
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Premature ovarian insufficiency in general practice: Meeting the needs of women. Travelling do periods resume after hrt to places at high altitude — Understanding and preventing altitude illness.
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The diagnosis is often distressing and women are likely to require psychological support. Hormone replacement therapy, unless contraindicated, is required and should be continued until the age of natural menopause. Contraception is required if pregnancy is not wanted, and multidisciplinary management is necessary Jun 14, · People do not reach menopause itself until a year after their last menstruation. They may get the typical symptoms of menopause at this time, including hot flashes, irregular periods, and sleep • The randomised placebo-controlled trial the Women's Health Initiative study (WHI), and a meta-analysis of prospective epidemiological studies are consistent in finding an increased risk of breast cancer in women taking combined oestrogen-progestogen for HRT that becomes apparent after about 3 () years (see Section )
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