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Essentials - Gynecology > 7. Menopause > Flashcards

7. Menopause Flashcards

1
Q

Name Risk factors for early menopause (6)

A
  • Smoking (2 yr earlier on avgerge)
  • Certain chemotherapy agents
  • Radiation
  • Hysterectomy and ovarian surgery
  • Epilepsy
  • Nulliparity
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2
Q

Define menopause (1)

A

Defined retrospectively as 12 consecutive months of amenorrhea due to loss of ovarian function

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3
Q

Describe: Premenopause (1)

A

the entire reproductive period before menopause

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4
Q

Describe: Perimenopause (1)

A

encompasses the period of time (~2–8 yr) characterized by Ds in menstrual regularity and amount of menstrual flow immediately preceding menopause during and the first year after the final menstrual period

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5
Q

Describe: Postmenopausal (1)

A

the period of time following the final menstrual period (regardless of whether menopause was induced or natural)

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6
Q

Describe: Ovulation ceases (2)

A
  • ovaries stop producing estradiol and progesterone but continue to produce testosterone
  • small amount of E from peripheral conversion (in adipose tissue) of adrenal steroids
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7
Q

Name Risk factors or Delayed Menopause (3)

A
  • Obesity
  • Multiparity
  • EtOH use
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8
Q

Name Types of menopause (3)

A
  • Natural
  • Induced
  • Premature
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9
Q

Describe: Natural menopause (3)

A
  • Biological process that occurs as part of female aging
  • Average age 51 yr
  • Average woman spends one-third of life post-menopausal
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10
Q

Describe: Induced menopause (2)

A
  • Surgical removal of ovaries or medical ablation of ovarian function
  • Iatrogenic, Chemotherapy, Radiation, Oophorectomy
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11
Q

Describe: Premature menopause (2)

A
  • Occurs at age <2 SDs below mean age of menopause (before age 40 yr)
  • Primary Ovarian Insufficiency = amenorrhea and persistently high FSH
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12
Q

Describe patient HX: Menopausa /postmenopausal woman (7)

A
  • Menstrual Hx (Ds in volume or duration of flow, date of LMP, abnormal bleeding)
  • Vaginal Sx (dryness, pruritus, discharge, postcoital bleeding, dyspareunia)
  • Urinary Sx (dysuria, urgency, ↑ frequency, nocturia)
  • Vasomotor instability (hot ushes)
  • Skin/soft tissue Ds
  • Dx of osteoporosis/osteopenia
  • Mood and sleep Ds
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13
Q

Describe patient pelvic exam findings: Menopausa /postmenopausal woman (3)

A
  • Pale, thin, friable vulvovaginal epithelium
  • Vaginal shortening, smooth, narrow walls, loss of rugae
  • Vaginal wall or uterine prolapse (secondary to hypoestrogen state and other patient risk factors)
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14
Q

Describe investigations: Menopausa /postmenopausal woman (8)

A
  • ↑ Serum FSH
  • ↑ Serum LH
  • ↓ Serum estradiol
  • ↑ Vaginal pH > 6
  • Vaginal wall maturation index with ↑ parabasal cells (> 20% )
  • Endometrial biopsy (if abnormal vaginal bleeding)
  • Osteoporosis RF assessment (bone densitometry as indicated)
  • Urine R&M, C&S (if urinary symptoms)
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15
Q

Name VASOMOTOR features of menopause (6)

A
  • Hot flushes are sudden onset of warmth that begin in the chest and progress to face and neck lasting ~4 min. May be associated with chills/sweats.
  • Maximal prevalence within the rst 2 yr of menopause, after which prevalence ↓
  • Affects up to 85% of women
  • Possibly hypothalamic origin
  • Can have major impact on quality of life
  • Management depends on severity.
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16
Q

Name UROGENITAL ATROPHY features of menopause (4)

A
  • The hypoestrogen state of menopause results in urogenital aging.
  • Vulvovaginal Sx: dryness, dyspareunia, thin discharge, pruritus, postcoital bleeding
  • Urinary Sx: dysuria, urgency, frequency/nocturia
  • Prolapse Sx: pelvic pressure, introital bulge, constipation, incomplete bladder emptying, low back pain
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17
Q

Name SKELETAL CHANGES features of menopause (3)

A
  • Progressive reduction in trabecular > cortical bone mass (osteoporosis)
  • Prevalence of osteoporosis: 6% at age 50, 50% at age 80
  • At 50 y.o. Caucasian female has 40% risk of fragility # (hip, spine, wrist)
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18
Q

Name SKIN AND SOFT TISSUE features of menopause (2)

A
  • Thinning of skin/loss of elasticity, regression in breast size
  • Change in adipose tissue distribution: increased central obesity
19
Q

Name SLEEP DIFFICULTIES features of menopause (1)

A

Insomnia (sleep onset and sleep maintenance)

20
Q

Name PSYCHOLOGICAL features of menopause (3)

A
  • Mood disturbance
  • anxiety
  • cognitive difficulties (possibly 2° to hot flush/trouble sleeping)
21
Q

Name HORMONAL features of menopause (1)

A

↑ FSH and LH

22
Q

Name: Health Hazards of Menopause (3)

A
  • Osteoporosis is a major consequence of menopause.
  • Heart disease is the main cause of death in postmenopausal women.
  • All vaginal bleeding that occurs 12 mo after amenorrhea is considered postmenopausal bleeding and requires investigation.
23
Q

Name: Factors not affecting menopause (5)

A
  • OCP use
  • Age of menarche
  • Ethnicity
  • Marital status
  • Improved nutrition
24
Q

Describe bone loss in menopause (2)

A
  • Osteoporosis: BMD> 2.5 SD below young adult mean (T-score at or below −2.5)
  • Osteopenia: BMD between 1 and 2.5 SD below young adult mean (T-score between −1 and −2.5)
25
Q

Name Indication for Spine XR in Postmenopausal women (3)

A
  • Historic height loss > 6 cm
  • Prospective height loss > 2 cm (↑ kyphosis)
  • Acute, incapacitating back pain: to R/O vertebral #
26
Q

Name: Risk factors or Osteoporosis (9)

A
  • Age > 65yr
  • Vertebral compression #
  • > 40 yr with fragility #
  • Low BMD
  • FHx osteoporotic # (especially maternal hip #)
  • Primary Ovarian Insufficiency
  • Primary hyperparathyroidism
  • Systemic steroid use > 3 mo
  • Malabsorption, falls, hyperparathyroidism
27
Q

Describe Management of vasomotor Sx of menopause (5)

A
  • Reassurance and lifestyle Ds: Use fans to keep cool, dress in layers, quit smoking, exercise, weight loss if overweight, avoid hot food, caffeine, and EtOH
  • Alternative medicine: Evidence lacking for long-term safety/efficacy for black cohosh, dietary soy, phytoestrogens clover, Vit E, kava, evening primrose oil, Chinese herbs
  • Nonhormonal Rx: venlafaxine/SSRIs, gabapentin, clonidine, bellergal
  • Nonestrogenic hormonal Rx: Ps
  • Systemic HRT: Estrogen therapy (ET), estrogen/progesterone therapy (EPT)
28
Q

Describe Management of urogenital Sx of menopause (4)

A
  • Generally Worsen with Age
  • Reassurance, patient education, and smoking cessation
  • Vaginal moisturizer (polycarbophil gel/Replens)
  • Local ET: intravaginal E is the Rx of choice for isolated vaginal Sx (e.g., Vagifem).
    • At recommended dose/frequency do not need to add P
29
Q

Describe Management of osteoporosis Sx of menopause (9)

A
  • Generally Worsens with Age
  • Patient education: exercise, healthy diet, and smoking cessation
  • Osteoporosis RF assessment
  • Vit D (800 IU/d) and Ca2+ supplementation (1.5 g/d): recommended as mandatory adjunct to other pharmacologic Rx to maintain bone density and prevent accelerated bone loss
  • Bisphosphonates (alendronate, risedronate): efficacious in ↓ #. First-line Rx in women with osteoporosis, with evidence that they reduce fracture risk
  • SERMs: efficacious in prevention and Rx of osteoporosis
  • Calcitonin: approved for Rx, not prevention of osteoporosis
  • E: ↓ bone resorption, ↑ intestinal Ca2+ absorption, ↓ renal Ca2+ excretion
  • Estrogen has been shown to improve BMD, but evidence is not conclusive in reducing fracture risk
30
Q

Describe: Management Triad of Menopause (3)

A
  • Behavioral modifications
  • Nonhormonal medications
  • HRT
    • Oral most effective Rx for severe hot ushes, first-line Rx for women with POI; considered for women with osteopenia and early menopause (< 45 yr)
    • Benefits must outweigh the risks of HRT
    • Reasonable choice in the absence of CI
    • Intravaginal E
    • first-line Rx for isolated urogenital Sx (does not require progesterone)
    • Nonhormonal Rx is a reasonable choice for women with CI or concerns about HRT
31
Q

Name: Duration of HRT in Rx of menopause (2)

A
  • Short-Term Use (< 5 yr)
  • Long-Term Use (>5 yr)
32
Q

Describe: Short-Term use HRT in Rx of menopause (2)

A
  • Appropriate for relieving moderate to severe Sx of menopause if no CI
  • Avoided or considered second line in those with known CHD, with no other indication for HRT
33
Q

Describe: Long-Term use HRT in Rx of menopause (3)

A
  • Consider risk of breast CA with extended use
  • Good candidates: individuals with documented or high risk for osteoporosis/osteopenia and no CI
  • Poor candidates: personal Hx of CHD/CVD, breast biopsy with atypia or CA, first-degree relative with breast CA, BRCA1, BRCA2
34
Q

Name Valid indications of HRT in RX of menopause (2)

A
  • Moderate to severe menopausal Sx
  • Prevention of osteoporosis, #
35
Q

Name risks and benefits: HRT in RX of menopause (1)

A

Initial support for the use of HRT to prevent CVD, osteoporotic #, colon CA, and dementia was based on observational studies and is now being contradicted by randomized controlled trials

36
Q

Name probable risks: HRT in RX of menopause (2)

A
  • Gallbladder disease
  • Observational studies and RCTs reveal 1.5- to 2.0-fold ↑ in gallbladder disease associated with HRT
37
Q

Name benefits of HRT (7)

A
  • ET and EPT:
    • vasomotor Sx: > 70%–80% improvement
    • Osteoporosis:
      • Prevention of bone loss, #
      • First-line preventative Rx in postmenopausal women with: a.Low BMD and b. Early onset menopause (< 45 yr)
      • Note: risks may outweigh the benfits if used only for prevention of postmenopausal osteoporosis.
      • Second-line Rx for postmenopausal women with osteoporosis
  • ET only:
    • Same as above
    • Local ET (intravaginal): decreases recurrent urinary tract infections
  • EPT only:
    • Same as above
    • Colon CA: ↓ risk
    • Decreased incidence of new diagnosis of diabetes requiring treatment
38
Q

Name risks of HRT (4)

A
  • ET and EPT:
    • Stroke and VTE: ↑ risk in healthy postmenopausal women CAD:
      • No bene t for prevention of CAD
      • ↑ Risk of second CV event in the first year of Rx only
      • ↑ The risk of CAD in healthy postmenopausal women
  • ET only:
    • Endometrial CA: ↑ Risk of endometrial CA (unopposed ET). (Note: risk ↓ with addition of progesterone)
  • EPT only: breast CA:
    • ↑ Risk of incident breast CA after 5 yr of use
    • This ↑ risk is felt to return to normal 5 yr after stopping HRT
39
Q

Describe: Modes of hormone delivery (4)

A
  • cyclic or continuous
  • E (ET): oral/TD/vaginal (TD preferred if ↑ TG, ↓ sex drive)
  • Progesterone (PT): oral/TD/IM/intrauterine (recommend lowest dose for shortest possible time required to treat Sx)
  • Low-dose OC may be prescribed for relief of hot flashes and contraceptive benefit in perimenopause
40
Q
A
41
Q

Name CIs to HRT: ET (4)

A

CULT

  • Cancer (breast or uterine)
  • Undiagnosed vaginal bleeding
  • Liver disease (acute)
  • Thromboembolic disease (active)
42
Q

Name CIs to HRT: PT (4)

A

PUB

  • Pregnancy
  • Undiagnosed vaginal bleeding
  • Breast
  • CA
43
Q

Name Relative CI to Combined HT (5)

A
  • Strong FHx breast CA
  • Atypical hyperplasia of the breast, fibroids
  • Migraines
  • ↑ TGs
  • Active gallbladder disease

Essentials - Gynecology (14 decks)

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