4/24 The Menopause Transition Flashcards
Define postmenopausal
has been one year since final menst period.
define perimenopause
vague term: generally means the period before menopause to just after menopause
define “menopausal transition”
Best term for this – all inclusive of entire transition
define premature menopause
Pathologically early menopause (prior to age 40)
define “early” menopause
not as early as premature, but starts around 40-45.
only 5% of women have menopause starting this early.
mean age of menopause?
a few things that will hasten menopause?
Mean age 51
Hastened by: smoking, undernourishment, pelvic radiation, chemo, ovarian surgery
do genetics play a role in the timing of menopause?
what about race, parity, age of menarche?
Genetics: yes. age of mom at menopause predicts age of daughter. also some genetic variation in estrogen receptors
Race, parity, age of menarche: no effect.
Symptoms associated with the menopausal transition?
-Changed menstrual patterns
-Vasomotor Symptoms (VMS): Hot flashes, night sweats, sleep disturbances
- Psychological probs (possibly due to lack of sleep)
- Sexual dysfunction (vag dryness, decr libido)
Change in length of cycle over mid 20s-30s?
Menstrual cycle length determined by rate and quality of follicular growth; note shorter cycle lengths of women in mid to late 30s
Transition to menopause: length of cycles and overall pattern?
why does the cycle length change?
Shortened cycles with interspersed “normal” cycles then long cycles then amenorrhea.
-Fewer oocytes recruited per cycle
–>↓ Estradiol (bc fewer oocytes)
—> ↑FSH
- Higher FSH causes the follicles to mature faster and produce enough Estradiol to trigger an LH surge
- Ovulation occurs early
- Luteal phase remains the same (14d)
At what point in the cycle do VMS occur (ie hot flashes etc)?
points in cycle when estradiol levels are lowest
May notice in the middle of the cycle, and also at the end of the cycle when estrogen drops
Describe what is meant by Luteal Insufficiency. at what age does it happen?
After age 40, ovarian follicles become less responsive to FSH.
- There are fewer oocytes available in the early follicular phase (leads to less inhibin, less estrodiol –> FSH levels increase further)
- Corpus luteum doesn’t function as well -> progesterone secretion diminisned -> heavier menses.
How does anovulation eventually occur?
- accelerated decline in follicles
- eventually, cycle length and variablility increases (cycles may be 21-60d)
- bleeding due to estrogen withdrawal (rather than an organized bleed)
- bleeding episides eventually spread out, stop.
What are the levels of hormones in post-menopause?
estrogen?
GnRH?
FSH?
testosterone?
Estrogen decr: due to decr ovarian synthesis.
- GnRH release increases greatly
- FSH therefore also increases
- Testosterone increases due to continued ovarian synthesis
why do post-menopausal women have signs of androgenization?
ovary continues to make androgens in the hilar cells: continues for several years after menopause.
–> facial hair, hair loss
Consequences of post-menopausal estrogen loss?
Early: hot flashes, insomnia, irritability
Intermediate: Vaginal atrophy, skin atrophy
Later: possible osteoporosis, heart disease
describe a typical hot flash (the somatic experience)
sudden sensation of heat centered in face/chest
rapidly becomes generalized
lasts 2-4 min
may have one or a lot per day
may wake from sleep, –> insomnia
physiologically, why does a hot flash occur?
starts with peripheral vasodilation -> skin temp rises
associated drop in core temp
(sounds like when Jen takes a shot and becomes bright pink)
why is there bone loss after menopause?
- Estrogen has a regulatory effect on bone resorption
- after menopause, bone is more responsive to PTH -> causes bone loss
what are the CV effects of estrogen?
- Decreases vascular resistance
- Incr blood flow
- decr production of endothelin (vasoconstrictor)
- increases HDL; decreases LDL
—> so it is understandable that we thought that estrogen replacement would be a good thing! turns out it is not.
A few treatments we can offer for menopausal symptoms?
- for menorrhagia
- for sex
- for VMS/hot flashes
- Menorrhagia may need treatment with hormones
- sex: vaginal lubricants
- VMS: estrogen, or SSRIs/SNRIs (less helpful)
We know that estrogen is harmful; when can we justify using it as medication for these symptoms?
- Estrogen replacement is reasonable in symptomatic patients
- use smallest dose possible for shortest duration of time
- remember if the woman has a uterus, give progesterone as well! (to prevent endometrial carcinoma)
Vaginal estrogen: how is it delivered?
what is the effect?
can be given as a cream, intra-vag tablet, or a vag ring
local effect: doesn’t cause endometrial problems, but also doesn’t help with hot flashes. only helpful for vaginal atrophy/dryness
The Women’s Health Initiative study on HRT: why was it stopped early?
stopped both arms prematuraly due to increased cardio problems and increased breast cancer
(arms were est only; est + progest)
The WHI study: what occurred in the women given Premarin + Provera? (both est and progest)
(incidences of what went up, and what went down)
Estrogen and Progesterone arm:
INCREASED clotting/PE/stroke
INCREASED breast cancer
INCREASED cardio dz
PROTECTIVE for osteoporosis and colon cancer
The WHI study: what occurred in the women given only Premarin (estrogen)
(incidences of what went up, and what went down)
Estrogen only arm (these subjects had no uterus):
INCREASED clotting/PE/stroke
NO CHANGE in breast cancer
NO CHANGE in cardio dz
PROTECTIVE for osteoporosis
