18 - Menopause Flashcards
Menopause difinitions and terms:
Menopause: Time following 1 yr of complete cessation of menstruation
Post menopause: time after
Average age: 51
Premature ovarian failure: menopause <40
Menopausal transition?
- Premenopausal or climacteric changes
- 42-58 y/o
- begins w menstrual irregularity UTC
- average = 4-7 yrs
Stages of menopause?
Stage 5 - early reproductive period Stage 4 - reproductive peak Stage 3 - late reproductive period Stage 2 - early menopausal transition Stage 1 - late menopausal transition Stage + 1a - 1st yr after FMP (final menses) Stage + 1b - yrs 2-5 post menopause Stage + 2 - later menopausal yrs
Chart on 380 (review) with a big old pink star on it maybe important (honestly who knows w her)
Factors that hasten menopause?
Smoking hastens by 2 yrs
Chemo
Radiation
Ovarian surgery
Menopausal transition sx?>
Menstrual pattern - shorter/longer, irregular Vasomotor - hot flashes etc Psychological/cognitive - PMS, depression, mood swings Sexual dysfunction - dry vag, L libido, dyspareunia Somatic - HA, dizziness, palpitations Other - list of shit to bitch about
Early vs late menopausal transition?
Early
- cycle irregular (7+ days off) (usually shorter)
- FSH and estridiol levels increase
- anovulation mixed w regular cycle (surprise babies happen here)
Late menopausal transition
- > /= 2 skipped menses
- 1+ interval = 60+ days (longer periods of anovulation)
Menopausal physiologic changes?
FSH/LH increase Estrogen/progesterone decrease Central thermoregulation Cardiovascular changes Wt gain/fat distribution Derm changes Dental changes CNS changes Psychosocial changes Breast changes Lower reproductive tract changes GU changes Lipido changes Bone and metabolism
When can women stop contraception?
Should be safe after 55
- no spontaneous pregnancies above age of 55 reported
- menses may continue past 55 but rarely include ovulation
MCC of erratic bleeding during menopause?
Anovulation
Typical Hot flashes
Typicall last 1-5 min - skin tepm 10-15C change - sweating - increase BP 30 min to return to normal
Approx 2 years before FMP
Thermoregulation changes are associated with?
Race
AA>Caucasian>asian
Low exercise Smoking H FSH L estradiol BMI Lower socioeconomic status Premenstrual dysphoric d/o PMDD Depression
Cardio changes w menopause/?
Estrogen is cardioprotective
- it goes away, so does its protection
CVD = leading cause of death > 50
Derm changes of menopause?
Age spots - hyperpigmentation
Decreased elasticity
Lower collagen content
Decreased blood supply
Dental changes of menopause?
Buccal epithelium atrophies (w reduced estrogen)
Increased cavity risk
Bad taste in mouth
Osteoporosis -> tooth loss
CNS changes?
Sleep quality decrease
Lighter sleeper
- esp to pain
Cognitive function decrease
Psychosocial changes?
Women have more depression than men
She says it may have to do with their perceived role of bearing children or their lack of children during life
Now their chances are gone and all is lost or some such shit.
- her words not mine (slide 390)
Breast changes
Hormonal withdraw leads to breast tissue swapping for adipose tissue
Lower reproductive changes?>
Muscle decrease
- susceptible to estrogen deprivation
GU symptoms of menopause?
Dryness/lubrication Dyspareunia Postcoital bleeding Poor arousal Vulvovaginal itching, burining Dysuria Urinary frequency/urgency J
GU signs?
Labia minor resorption Narrowed introitus Absent hymenal tags Tissue pallor/erythema Urethral eversion/prolapse Prominent urethral meatus Recurrent UTI Absent rugae Fragile/fissured tissue Petechial hemorrhages Scant vaginal secretions Poor elasticity
Libido changes
Yeah it happens
More or less
Bone changes?
Bone mass declines at 2-5% per year
- high risk of fracture and osteoporosis
Hormone therapy for cardioprotection?
No longer recommended
Benefits of hormone therapy?
Can be cardioprotective
Reduced mortality <60 (not so for >60)
Colon cancer reduction
Hip fracture reduction
Hormone therapy increases risk of?
Breast ca Stroke VTE Cholecystitis Ovarian ca (w long term use) Blood clots (CV risk for older)
Indications for hormone therapy?
Vasomotor symptoms
Vaginal atrophy
Osteoporosis prevention or tx
Reevaluate q 6-12 mo intervals
Hormone therapy if pt has uterus?
Must add progestin
- endometrial cancer risk
Contraindications for estrogen?
Absolute
- looks like cancer
- VTE
- Cardiac prob
- liver
- pregnant
Relative
- dementia
- gallbladder
- hx of cholestatic jaundice
- hypothyroidism
- hypercalcemia
- hx of endometrosis
- hepatic hemangiomas
Hormone therapy options?
Estrogen (no uterus)
Estrogen + progesterone
Estrogen + bazedoxifen
- SERM
vasomotor sx drugs?
Serotonin or norepi SSRI SNRI Clonidine Gabapentin
Non pharm/alternative meds?
Phytoestrogens Don quai Black cohosh Phytoprogesterones Bellergal-S
More info on 402
Osteoporosis screening?
Age 65+
Have 1+ risk factors
Sustain fx
Major osteoporosis risk factors?
Age >65 Compression fx Fragility fx >40 Fam hx Systemic glucocorticoid x 3 mo Malabsorption syndrome Hyperparathyroidism Propensity to fall Osteopenia Hypogonadism Early menopause (<45)
Minor risk factors for osteoporosis?
RA Clinical hyperthyroidism Anticonfulsant therapy Low Ca intake Smoker Drinker Caffeine use (excessive) Weight <57kg >10% wt loss at age 25 Chronic heparin therapy
WHO criteria for osteopenia/osteoporosis?
Normal BMD - T score +2.5 : 1.0 Osteopenia - T score -1.0 : -2.5 Osteoporosis - T score at or below -2.5 Severe/established T score at or below -2.5 + fractures
What is osteoporosis Z score?
Standard deviation between pt’s measuriment and average bone mass for pt with same age and wt
- <2.0 eval for secondary cause
Secondary cause of osteoporosis?
- Primary/secondary hyperparathyroidism
- Hyperthyroidism or excess thyroid hormone tx
- increase calcium excretion
- hypercortisolism
- etoh abuse
- metastatic ca
- osteomalacia
Fall risk factors?
Psysiologic changes
- hx of falls
- bad balance
- reduced muscle
Environmental
- light,
- shoes,
- clutter
Meds - narcs - anticonvulsants - antiarrhythmic - psych Antihypertensive
Comorbid conditions
- arthritis
- ETOH
- arrhythmia
- gait d/o
- blind
- Cognitive
- orthostatic HOTN
Prevention guidelines of osteoprosisis in postmenopausal?
A bunch of bs - dont smoke - get screened - eat food Bla bla bla
Slide 409 if you want to read it
Osteoporosis tx?
Prevention is key
- exercise
- get vitamin D
- get calcium
- dont smoke
- dont drink
- dont fall
Who needs osteoporosis tx?
- Big fx
- T score = -2.5
- Postmenopause total hip or spine t scores from -1.0 : -2.5 + 1 risk factor
Med goal for osteoporosis tx?
Restore balance by:
- Reduce bone resorption
- antiresorptive agents - Stimulate bone formation
- anabolic agents
Action of bisphosphonates?
Bind to calcium in bone
Decrease bone resorption
- block function of osteoclasts
Use 3-5 yrs
Contraindications for bisphosphonates?
Esophageal dysmobility
Inability to be upright x 30 min
Hypersensitivity
Hypocalcemia
If you take bisphosphonates > 5yr
Osteonecrosis of Jaw (ONJ)
Atypical femur fx (AFF)
Hormones for osteoprosis tx?
Estrogen and progesterone
- reduced rate of bone resorption and increase BMD
Raolxifen is a ?
SERM
- agonist at bone level
- prevents vertebral fx
Meds for osteoprosis
Bisphosphonates Hormones Monoclonial antibodies (denosumab) - inhibit osteoclast development/activity Salmon calcium - decrease bone absorption Recombinant PTH - osteoclast numbers and activity - only 18-24 mo of therapy
Monitoring for osteoporosis tx?
DEXA scan q 2 yrs Bone metabolism markers q 6 mo T-score guides DEXA freq -2 :-2.5 q 1 yr -1.5 : -2 q 3-5 yr -1.01 : -1.5 q 10-15 yr -1.0 + q 15 yrs
The cat in the hat on aging
I cannot see I cannot pee I cannot chew I cannot screw Oh my god what can i do? My memory shrinks My hearing stinks No sense of smell I look like hell My mood is bad —- can you tell? My body’s drooping Having trouble pooping The golden years have come at last The golden years can kiss my ass
