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
2
Q
Define menopause (1)
A
Defined retrospectively as 12 consecutive months of amenorrhea due to loss of ovarian function
3
Q
Describe: Premenopause (1)
A
the entire reproductive period before menopause
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
5
Q
Describe: Postmenopausal (1)
A
the period of time following the final menstrual period (regardless of whether menopause was induced or natural)
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
7
Q
Name Risk factors or Delayed Menopause (3)
A
- Obesity
- Multiparity
- EtOH use
8
Q
Name Types of menopause (3)
A
- Natural
- Induced
- Premature
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
10
Q
Describe: Induced menopause (2)
A
- Surgical removal of ovaries or medical ablation of ovarian function
- Iatrogenic, Chemotherapy, Radiation, Oophorectomy
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
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
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)
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)
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.
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
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)
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
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 #
26
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
27
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)
28
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
29
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
30
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
31
Name: Duration of HRT in Rx of menopause (2)
* Short-Term Use (\< 5 yr)
* Long-Term Use (\>5 yr)
32
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
33
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
34
Name Valid indications of HRT in RX of menopause (2)
* Moderate to severe menopausal Sx
* Prevention of osteoporosis, #
35
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
36
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
37
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
38
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
* 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
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
40
41
Name CIs to HRT: ET (4)
CULT
* Cancer (breast or uterine)
* Undiagnosed vaginal bleeding
* Liver disease (acute)
* Thromboembolic disease (active)
42
Name CIs to HRT: PT (4)
PUB
* Pregnancy
* Undiagnosed vaginal bleeding
* Breast
* CA
43
Name Relative CI to Combined HT (5)
* Strong FHx breast CA
* Atypical hyperplasia of the breast, fibroids
* Migraines
* ↑ TGs
* Active gallbladder disease
