CH 59 Menopause & Postmenopause

Question 1

Perimenopause/menopausal transition what does it mean

Answer 1

part of climacteric before the menopause occurs. menstrual cycle will be irregular

Question 2

What happens during the perimenopausal state

Answer 2

cycle length decreases due to shortening of follicular phase. ovary functioning is altered. FSH is extremely elevated at the beginning of the follicular phase (caused by inhibin) then falls as estradiol increases. LH levels remain unchanged from younger women’s levels. Cycles are shorter and further apart

Question 3

Physiologic menopause

Answer 3

oocytes responsive to gonadotropins disappear from the ovary, and the few remaining oocytes don’t respond to gonadotropins. Avergae age, 50-51

Question 4

premature menopause

Answer 4

menopause before age 40. causes are unknown. Damage to the ovarian follicular structures due to severe infections and tumors can cause this. Also can happen due to exposure to ionizing radiation, chemo, alkylating agents and surgical procedures that impair ovarian supply

Question 5

Artificial menopause

Answer 5

permanent cessation of ovarian function brought on by surgical removal of the ovaries or by radiation therapy.. Used as treatment for endometriosis. Can be caused by oophrectomy (used to prevent ovarian cancer)

Question 6

Androstenedione

Answer 6

primary ovarian androgen, reduction in postmenopausal women by 50%: reflects absence of follicular activity.

Question 7

testosterone levels in postmenopausal women

Answer 7

not much change in levels. production rate is only 1/3 less than in younger women, UNLESS they get oophrectomy (causing 60% decrease). No change in clearance rate. 15% of androstenedione is converted to testosterone. Postmenopausal ovary produces more testosterone than premenopausal ovary

Question 8

What causes defeminization, hirsutism, and virilism in some older women

Answer 8

increased ovarian testosterone secretion, coupled with reduction in estrogen production and decrease in sex hormone binding globulin (SHBG)

Question 9

DHEA and DHEAS levels in postmenopausal women

Answer 9

Secreted by adrenal glands. levels are decreased by 60% and 80% with age.

Question 10

Estradiol in postmenopausal women

Answer 10

greatest decrease up to 1 year after last menstrual period. greatest decrease comes from adrenal glands.

Question 11

Progesterone in postmenopausal women

Answer 11

major source is ovarian corpus luteum after ovulation, levels decrease by 70%.

Question 12

Gonadotropins in postmenopausal women

Answer 12

both LH and FSH rise substantially. Ovarian steroids and inhibin on gonadotropins is absent. Also occurs in women with hysterectomy without oophrectomy

Question 13

reproductive tract changes with menopause

Answer 13

atrophy of vaginal epithelium related to estrogen changes. vaginal rugae flatten and epithelium thins (leads to atrophic vaginitis). Cervix becomes atrophic, smaller, stenotic, and dry (causing dyspareunia). Uterus shows atrophy of endometrium and myometrium. Endometriosis and fibroid symptoms decrease or disappear. May have spontaneous bleeding. Ovaries get smaller (palpable ovary after menopause is suspicious for neoplasm)

Question 14

Urinary tract changes with menopause

Answer 14

estrogen deficiency produces atrophic changes in bladder and urethra. may see atrophic cystitis, recurrent UTIs, loss of urethral tone, occasional hematuria, dysuria. Treat with vaginal estrogen.

Question 15

Mammary gland changes with menopause

Answer 15

regression of breast size. Breast pain, cyst formation that comes with menses disappears

Question 16

prevention of menopause

Answer 16

It cannot be prevented, postponed, or slowed. Artificial menopause can be prevented with avoidance of ionizing radiation. Elective removal of ovaries will cause artificial menopause

Question 17

atropic vaginitis what is it and diagnosis

Answer 17

thinned epithelium, red and patchy vagina, brown discharge, disappearance of lactobacilli, vaginal burning and soreness, trauma associated with coitus or exam, urinary complaints. Diagnosis based on symptoms.

Question 18

Hot flashes what is it

Answer 18

sudden flushing and perspiration, sensation of pressure in head, palpitations, weakness, fatigue. Can last up to 10 minutes. severe flushes can take up to an hour and happen 1-2 times per hour or week. Caused by alterations in cutaneous vasodilation, perspiration, reduction of core temp and elevations in pulse rate.

Question 19

atropic vaginitis treatment

Answer 19

treat with water soluble and/or topical vaginal estrogen, and systemic estrogens

Question 20

hot flashes treatment

Answer 20

Treated with estrogen, progestin, clonidine. SSRIs (like paxil and fluoxetine), Tibolone, and black cohosh have more risk than benefit (related to breast CA). Gabapentin works well but has level of sedation.

Question 21

Osteoporosis

Answer 21

systemic skeletal disorder characterized by low bone mass and deterioration of bone tissue. Caused by cessation of ovarian function (estrogen). occurs more frequently in white women, and those with early oophrectomy or premature ovarian failure. increases risk for fractures. Diagnose with bone density test

Question 22

Osteoporosis prevention and treatment

Answer 22

calcium consumption, vitamin D, biphosphates (alendronate, Risedronate), calcitonin (100IU), estrogen, parathyroid hormone, raloxifene, denosumab, progestins

Question 23

Sexual dysfunction

Answer 23

hypoestrogenemic state leads to atrophy of the internal genitalia. Most obvious sign is vaginal atrophy, suboptimal sexual function can occur without frank dyspareunia. Diminished genital sensation, lessened glandular secretions, less vasocongestion and decreased vaginal expansion

Question 24

Abnormal vaginal bleeding after menopause

Answer 24

endometrial biopsy or D&C needed to rule out hyperplasia or CA if bleeding is more frequent or heavier bleeding persists after menopause. but some irregular vaginal bleeding is expected.

Question 25

back pain in menopausal pt

Answer 25

vertebral compression from osteoporosis may mimic that of gastic ulcer, renal colic, pyelonephritis, pancreatitis, spondylolisthesis, acute back strain, or herniated intervertebral disk

Question 26

Increased risk with hormone replacement therapy

Answer 26

increased risk for coronary heart disease, mood disorders, risk for cognitive decline over the age of 65, skin problems (less collagen, some people have balding)

Question 27

Decreased risk with hormone replacement therapy

Answer 27

decreased risk for diabetes

Question 28

When to use estrogen therapy

Answer 28

for prevention of osteoporosis, treatment of vasomotor symptoms, treatment of vulvovaginal atrophy

Question 29

Complications of estrogen replacement

Answer 29

endometrial CA, Breast CA, Thromboembolic dz, stroke, uterine bleeding, gallbladder dz, lipid metabolism (leading to heart dz), generalized edema, mastodynia, breast enlargement, abdominal bloating, headaches, excessive cervical mucous

Question 30

Contraindications to estrogen replacement therapy

Answer 30

undiagnosed vaginal bleeding, known/suspected/history of breast CA, known/suspected estrogen dependent neoplasia, active DVT, PE, or history of these conditions, arterial thromboembolic disease (myocardial infarction, stroke), liver dysfunction or dz. History of treated carcinoma of ovary and cervix is not a contraindication