7. Menopause Flashcards
Name Risk factors for early menopause (6)
- Smoking (2 yr earlier on avgerge)
- Certain chemotherapy agents
- Radiation
- Hysterectomy and ovarian surgery
- Epilepsy
- Nulliparity
Define menopause (1)
Defined retrospectively as 12 consecutive months of amenorrhea due to loss of ovarian function
Describe: Premenopause (1)
the entire reproductive period before menopause
Describe: Perimenopause (1)
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
Describe: Postmenopausal (1)
the period of time following the final menstrual period (regardless of whether menopause was induced or natural)
Describe: Ovulation ceases (2)
- ovaries stop producing estradiol and progesterone but continue to produce testosterone
- small amount of E from peripheral conversion (in adipose tissue) of adrenal steroids
Name Risk factors or Delayed Menopause (3)
- Obesity
- Multiparity
- EtOH use
Name Types of menopause (3)
- Natural
- Induced
- Premature
Describe: Natural menopause (3)
- Biological process that occurs as part of female aging
- Average age 51 yr
- Average woman spends one-third of life post-menopausal
Describe: Induced menopause (2)
- Surgical removal of ovaries or medical ablation of ovarian function
- Iatrogenic, Chemotherapy, Radiation, Oophorectomy
Describe: Premature menopause (2)
- Occurs at age <2 SDs below mean age of menopause (before age 40 yr)
- Primary Ovarian Insufficiency = amenorrhea and persistently high FSH
Describe patient HX: Menopausa /postmenopausal woman (7)
- 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
Describe patient pelvic exam findings: Menopausa /postmenopausal woman (3)
- 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)
Describe investigations: Menopausa /postmenopausal woman (8)
- ↑ 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)
Name VASOMOTOR features of menopause (6)
- 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.
Name UROGENITAL ATROPHY features of menopause (4)
- 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
Name SKELETAL CHANGES features of menopause (3)
- 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)
Name SKIN AND SOFT TISSUE features of menopause (2)
- Thinning of skin/loss of elasticity, regression in breast size
- Change in adipose tissue distribution: increased central obesity
Name SLEEP DIFFICULTIES features of menopause (1)
Insomnia (sleep onset and sleep maintenance)
Name PSYCHOLOGICAL features of menopause (3)
- Mood disturbance
- anxiety
- cognitive difficulties (possibly 2° to hot flush/trouble sleeping)
Name HORMONAL features of menopause (1)
↑ FSH and LH
Name: Health Hazards of Menopause (3)
- 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.
Name: Factors not affecting menopause (5)
- OCP use
- Age of menarche
- Ethnicity
- Marital status
- Improved nutrition
Describe bone loss in menopause (2)
- 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)
Name Indication for Spine XR in Postmenopausal women (3)
- Historic height loss > 6 cm
- Prospective height loss > 2 cm (↑ kyphosis)
- Acute, incapacitating back pain: to R/O vertebral #
Name: Risk factors or Osteoporosis (9)
- 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
Describe Management of vasomotor Sx of menopause (5)
- 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)
Describe Management of urogenital Sx of menopause (4)
- 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
Describe Management of osteoporosis Sx of menopause (9)
- 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
Describe: Management Triad of Menopause (3)
- 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
Name: Duration of HRT in Rx of menopause (2)
- Short-Term Use (< 5 yr)
- Long-Term Use (>5 yr)
Describe: Short-Term use HRT in Rx of menopause (2)
- 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
Describe: Long-Term use HRT in Rx of menopause (3)
- 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
Name Valid indications of HRT in RX of menopause (2)
- Moderate to severe menopausal Sx
- Prevention of osteoporosis, #
Name risks and benefits: HRT in RX of menopause (1)
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
Name probable risks: HRT in RX of menopause (2)
- Gallbladder disease
- Observational studies and RCTs reveal 1.5- to 2.0-fold ↑ in gallbladder disease associated with HRT
Name benefits of HRT (7)
- 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
Name risks of HRT (4)
- 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
- Stroke and VTE: ↑ risk in healthy postmenopausal women CAD:
- 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
Describe: Modes of hormone delivery (4)
- 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
Name CIs to HRT: ET (4)
CULT
- Cancer (breast or uterine)
- Undiagnosed vaginal bleeding
- Liver disease (acute)
- Thromboembolic disease (active)
Name CIs to HRT: PT (4)
PUB
- Pregnancy
- Undiagnosed vaginal bleeding
- Breast
- CA
Name Relative CI to Combined HT (5)
- Strong FHx breast CA
- Atypical hyperplasia of the breast, fibroids
- Migraines
- ↑ TGs
- Active gallbladder disease
