4/24 The Menopause Transition

Question 1

Define postmenopausal

Answer 1

has been one year since final menst period.

Question 2

define perimenopause

Answer 2

vague term: generally means the period before menopause to just after menopause

Question 3

define “menopausal transition”

Answer 3

Best term for this – all inclusive of entire transition

Question 4

define premature menopause

Answer 4

Pathologically early menopause (prior to age 40)

Question 5

define “early” menopause

Answer 5

not as early as premature, but starts around 40-45.

only 5% of women have menopause starting this early.

Question 6

mean age of menopause?

a few things that will hasten menopause?

Answer 6

Mean age 51

Hastened by: smoking, undernourishment, pelvic radiation, chemo, ovarian surgery

Question 7

do genetics play a role in the timing of menopause?

what about race, parity, age of menarche?

Answer 7

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.

Question 8

Symptoms associated with the menopausal transition?

Answer 8

-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)

Question 9

Change in length of cycle over mid 20s-30s?

Answer 9

Menstrual cycle length determined by rate and quality of follicular growth; note shorter cycle lengths of women in mid to late 30s

Question 10

Transition to menopause: length of cycles and overall pattern?

why does the cycle length change?

Answer 10

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)

Question 11

At what point in the cycle do VMS occur (ie hot flashes etc)?

Answer 11

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

Question 12

Describe what is meant by Luteal Insufficiency. at what age does it happen?

Answer 12

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.

Question 13

How does anovulation eventually occur?

Answer 13

• 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.

Question 14

What are the levels of hormones in post-menopause?

estrogen?

GnRH?

FSH?

testosterone?

Answer 14

Estrogen decr: due to decr ovarian synthesis.

• GnRH release increases greatly
• FSH therefore also increases
• Testosterone increases due to continued ovarian synthesis

Question 15

why do post-menopausal women have signs of androgenization?

Answer 15

ovary continues to make androgens in the hilar cells: continues for several years after menopause.

–> facial hair, hair loss

Question 16

Consequences of post-menopausal estrogen loss?

Answer 16

Early: hot flashes, insomnia, irritability

Intermediate: Vaginal atrophy, skin atrophy

Later: possible osteoporosis, heart disease

Question 17

describe a typical hot flash (the somatic experience)

Answer 17

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

Question 18

physiologically, why does a hot flash occur?

Answer 18

starts with peripheral vasodilation -> skin temp rises

associated drop in core temp

(sounds like when Jen takes a shot and becomes bright pink)

Question 19

why is there bone loss after menopause?

Answer 19

• Estrogen has a regulatory effect on bone resorption
• after menopause, bone is more responsive to PTH -> causes bone loss

Question 20

what are the CV effects of estrogen?

Answer 20

• 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.

Question 21

A few treatments we can offer for menopausal symptoms?

• for menorrhagia
• for sex
• for VMS/hot flashes

Answer 21

• Menorrhagia may need treatment with hormones
• sex: vaginal lubricants
• VMS: estrogen, or SSRIs/SNRIs (less helpful)

Question 22

We know that estrogen is harmful; when can we justify using it as medication for these symptoms?

Answer 22

• 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)

Question 23

Vaginal estrogen: how is it delivered?

what is the effect?

Answer 23

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

Question 24

The Women’s Health Initiative study on HRT: why was it stopped early?

Answer 24

stopped both arms prematuraly due to increased cardio problems and increased breast cancer

(arms were est only; est + progest)

Question 25

The WHI study: what occurred in the women given Premarin + Provera? (both est and progest)

(incidences of what went up, and what went down)

Answer 25

Estrogen and Progesterone arm:

INCREASED clotting/PE/stroke

INCREASED breast cancer

INCREASED cardio dz

PROTECTIVE for osteoporosis and colon cancer

Question 26

The WHI study: what occurred in the women given only Premarin (estrogen)

(incidences of what went up, and what went down)

Answer 26

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