Lecture 14 - Menopause Flashcards
Menopause definition
normal physiologic event
defined as final menstrual period and reflecting loss of ovarian follicular involvement
spontaneous menopause: 12 months of amenorrhea, average age is 52
if you are between the age 45 - 55 and have gone a year without your period ==menopause
Induced menopause
cessation of menstruation caused by bilateral oophorecomy or interference of ovarian function (chemotherapy or pelvic radiation)
Perimenopause
Menopause transition reflects the natural decline of ovarian follicular estrogen production
Characterized by a number of menstrual cycle changes
Increasing episodes of amenorrhea
Vasomotor sxs may occur 2 years immediately before and after final menstrual period, but may continue for many years to come in some women
What pathophysiology changes are occurring during perimenopause?
HPO axis
- decreased ovarian feedback of inhibin and estradiol
- elevations of follicle stimulating hormone (FSH)
- oocytes in the ovaries decline in quantity and quality of follicles
How do you dx menopause?
Although hormone measurements are not routinely indicated they are best predictor for stage of menopause
FSH will be elevated (elevated since we aren’t using it anymore. Inhibin typically recruited it to the follicles, but there are no more follicles)
Estradiol will be low
Pelvic US to note endometrial thickness which should be little or none (<5mm), diminished ovarian volume (small atrophic ovaries), small uterus
What are the effects of low estrogen?
HA and hot flashes Teeth loosen and gums recede Breasts droop and flatten Nipples become smaller and flatten Abdomen loses muscle tone Vaginal dryness, itching, and shrinking Bones lose mass and become more fragile Hair becomes thinner and loses luster Skin becomes drier Backaches Risk of CV Stress or urge incontinence
What are typical menopausal sxs?
Hot flashes Sweating Irregular menstrual cycles Palpitations Vaginal dryness Superficial dyspareunia Urinary frequency and urgency Mood changes Insomnia Depression Anxiety Weight gain and bloating HA Skin less elastic Brittle nails
What is the most common presenting symptom of menopause?
Vasomotor instability
Estrogen plays a role in thermoregulation by modulating the levels on neurotransmitter in the CNS
Diminished levels may lead to instability in the normal concentration of these transmitters which manifests as hot flashes, night sweats, excessive perspiration
What does the decrease of estrogen do to the nervous system?
May contribute to a decline in certain cognitive capabilities
Studies have shown that postmenopausal women receiving estrogen therapy perform better on memory testing
What are the urogenital changes in menopause?
decreased estrogen causes a thinning in the microenvironement of the lining of the urethra, urinary bladder, vagina and vulvua
alterations in pH (more acidic)
What are the bone metabolism effects of menopause?
low levels of estrogen accelerate the progressive bone loss
changes occur particularly in the 5 years after menopause
predisposition to osteoporosis and osteoporosis related to fx in femoral neck, vertebra, or distal forearm
How does menopause effect the nervous system?
lack of estrogen may contribute to a decline in certain cognitive capabilities
studies have shown that postemenopausal women receiving estrogen therapy reduced the relative risk of alzheimer disease or delayed it’s onset
the menopause transition is commonly a time of depression
A 52 y/o women G4P2 presents with menopause sxs over the past 2 years, she has hx of DVT, what medications can we give her to help with her sxs?
SSRI or SNRI
Perimenopause treatment and benefits
OCPs combined or progesterone only, implant, IUD
provides contraception for women who have not gone one year without menstrual cycle
helps decrease vasomotor sxs
treats irregular mentsrual bleeding
decreases risk for ovarian and endometrial cancers
maintains bone mineral density
we try not to let women >52 stay on OCPs d/t risk of blood clots
estrogen can increase HTN – CV risk
What are contraindications of perimenopause treatment?
women who smoke should not use combined OCPs
any medical condition that increases risk of certain methods, ex. thromboembolism
What lifestyle modifications should a women going through menopause change?
calcium and vitamin D
engage in regular exercise
stop smoking
limit EtOH intake (no more than 1 drink a day)
Why don’t women who have had a hysterectomy need to take progesterone?
progesterone protects the lining of the uterus from overgrowing
they don’t have a uterus
What drugs can be used to treat vulvovaginal atrophy?
SERMs
(since its not estrogen you can give it to women with clotting disorders, even though the packaging says not to)
benefits:
- compounds that act as estrogen agonists in some tissues and estrogen antagonists in others
- Raloxifiene is approved for prevention and treatment of osteoporosis
- Ospemifene improves vaginal pH, vaginal maturation index, and dsypareunia due to vulvovaginal atrophy
What therapies are there for hot flashes?
SSRI
SNRI
How do you council your postmenopasual pt in regards to osteoporosis?
take calcium and vitamin D
weight bearing exercises
bisphosphonates (alendronate, ibandronate, xoledronic acid) prevent fractures
What did the women’s initiative study show?
breast cancer risk increases in estrogen + progestin group after used for 4 years – only use in short duration if needed
5 years at the most for estrogen only
HRT in older women is inadvisable because of increased risk of illness due to age alone - HRT magnifies risk
A 72 YEAR OLD G3 P3 PRESENTS COMPLAINING OF RECURRENT AND PERSISTENT VAGINAL ITCHING AND IRRITATION FOR 6 MONTHS. SHE HAS EXTREME PAIN WHEN SHE TRIES TO HAVE SEX WITH HER HUSBAND OF 45 YEARS. SHE DENIES ANY VAGINAL DISCHARGE. HER PCP HAS CALLED IN DIFLUCAN FOR HER NUMEROUS TIMES AND PATIENT HAS USED OTC YEAST INFECTION CREAM WITHOUT ANY RELIEF IN HER SYMPTOMS. PATIENT HAS H/O DIABETES AND HYPERTENSION FOR WHICH SHE USES INSULIN AND TAKES DIOVAN. ON EXAM, YOU FIND PALE, DRY VAGINAL EPITHELIUM WITHOUT ANY NOTED VAGINAL DISCHARGE. WHAT IS THIS PATIENT’S DIAGNOSIS?
atrophic vaginitis
Signs and sxs of vulvovaginal atrophy?
irritation burning itching vaginal discharge postcoital bleeding dyspareunia
vaginal epithelium is red at first
later, vaginal epithelium becomes path
rugation diminishes; vaginal wall becomes smooth
What is the treatment for vulvovaginal atrophy?
local estrogen therapy
non estrogen meds: osphena –acts like estrogen to reverse changes in vaginal tissue
Stages of prolapse
Stage 0 - no prolapse
Stage 1 - descent of the most distal portion of prolapse is more than 1 cm above the hymen
Stage 2 - maximal descent of prolapse is between 1 cm above and 1 cm below the hymen
Stage 3 - prolapse extends more than 1 cm beyond the hymen, but no more than within 2cm of the total vaginal length
Stage 4 - total or complete vaginal eversion
Uterine prolapse is a defect where?
of the apical segment of the vagina and it is characterized by eversion of the vagina with attendant decent of the uterus
How do you examine a pt with suspected uterine prolapse?
in both lithotomy and standing position
What is the treatment for uterine prolapse?
conservative:
Pessary use –remove and clean every 3 months –you canNOT have sex with this in —(pts much be on estrogen vaginal tx to keep it elastic)
surgery:
depends on if they want to preserve the cervix or not
hysterectomy for postmenopausal women
When prescribing a pessary, what else must you prescribe?
estrogen vaginal treatment to keep the vagina elastic –this can be painful to remove
Rectocele
prolapse of the back wall of the vagina - rectovaginal fascia
How do pts with rectocele present?
a bulge in the vagina
feeling of pelvic pressure, a sensation of “bearing down” or a perception that something is “falling out”
this bulge may become especially noticeable during bowel movements
What is the best position to observe a rectocele in?
dorsal lithotomy position with the head elevated 45 degrees (maximal valsalva)
What is the treatment of rectocele?
conservation:
pessary
surgery:
posterior colporrhaphy - lifting the prolapsed rectum back into place
Cystocele
prolapsed bladder
sxs:
feeling of pressure in the pelvis and vagina, increased discomfort when straining, coughing, bearing down, lifting
feeling of incomplete emptying of bladder after urinating, repeated bladder infections, pain or urinary leakage during sexual intercourse
What is the treatment for cystocele?
typically mild cases dont need to be treated
kegel exercises
pessary
estrogen therapy
surgery:
anterior colporrhaphy
SUI
stress urinary incontinence
involuntary leakage on exertion on exertion or sneezing or coughing
estrogen improves blood flow and increases transudation and gland secretion which are responsible for lubrication
What urodynamic studies are done for a SUI?
focus on the bladders ability to hold urine and to empty steadily and completely
non-invasive uroflow studies: standing cough stress test
obtaining postvoid residual (PVR)
cytoscopy/cystometography
What is the treatment for SUI?
topical estrogen can improve incontinence, it is unclear whether systemic estrogen is helpful or harmful
behavioral therapy with bladder training and biofeedback
surgery:
retropubic urethropexies
