Lecture 8: Menopause Flashcards
Define climacteric
Phase of the aging process during which a woman passes from reproductive to nonreproductive stage.
Define menopausal transition/perimenopause
Part of climacteric before menopause occurs when menstrual cycle is irregular and when other climacteric symptoms/complaints may be experienced.
Usually lasts 1-3 yrs
What is the average age for menopause?
51 years old
What qualifies as premature menopause?
Prior to age 40
When do women have the most oocytes?
At birth
Nature’s clock
As levels of inhibin decrease due to loss of oocytes, what rises?
FSH
FSH rises as you have less oocytes
What happens to the oocytes responsiveness to gonadotropins over time? (4)
- Less responsive to FSH and LH
- Irregular response
- Irregular length of follucular phase
- Irregular menstrual cycles
Less responsive and irregular
Why do we see bursts of estradiol in physiologic menopause?
Recruitment of multiple oocytes
Primary estrogen prior to menopause
What is the MCC of premature ovarian failure/premature menopause?
Idiopathic
What is the primary predisposing factor to menopause?
Smoking
Why might we cause artificial menopause on purpose? (4)
- Endometrial cancer
- Endometriosis
- ER+ breast cancer
- Ovarian cancer predisposition
All estrogen related
Cancer, cancer, cancer, endometriosis
What is the primary androgen in women that is decreased in production in menopause?
Androstenedione
Has a DI, same like estraDIol which is low in menopause.
What happens to testosterone levels in menopause?
They appear decreased lab-wise, but the ovaries are making more after menopause.
Which estrogen decreases the greatest in menopause?
Estradiol
Often measured to also confirm menopause
It is the primary estrogen prior to menopause.
Should we check progesterone levels in postmenopausal women?
NO
No clinical use.
What hormone measurements can help confirm menopause? (3)
- Estradiol
- FSH
- LH
FSH and LH go up, estradiol should be low in menopause.
What are the MC S/S seen in menopause? (8)
- Irregular bleeding
- Irritability and mood swings
- Vaginal dryness
- Decreased libido
- Hot flashes
- Hair loss
- Hirsutism
- Wt gain
Menopause causes HAVOCS
- Hot flashes
- Atrophy of the Vagina
- Osteoporosis
- CAD
- Sleep Disturbances
What is the major growth factor of the female reproductive tract?
Estrogen
Estrogen Enhances
As estrogen decreases, what can happen to urinary and mammary epithelium as well? (4)
- Atrophic cystitis: urgency, frequency, incontinence and dysuria
- Uretheral curuncle as urethral tone is lost
- GU syndrome of menopause
- Mammary: regress in size and flatten
What is characteristic of atrophic vaginitis? (5)
- Burning
- Soreness
- Dyspareunia
- Dryness
- Thin watery or serous discharge
What happens to vaginal pH in atrophic vaginitis?
Increases
Becoming basic
How is atrophic vaginitis diagnosed?
Clinically
Can do pap smears to help
Image of normal, early, and late atrophic vaginitis
How is atrophic vaginitis treated initially? (2)
- Vaginal moisturizers: replens, vagisil, K-Y liquibeads
- Lubricants with sexual activity
Moisturize daily, lubricants only with sex
What is the pharmacologic treatment for mod-severe atrophic vaginitis?
Vaginal estrogen therapy
What are the 3 benefits of vaginal estrogen therapy?
- Restored vaginal pH and microflora
- Increased vaginal secretions and thickened vaginal epithelium
- Diminished overactive bladder symptoms and fewer UTIs
In what situation might vaginal estrogen therapy be detrimental to health?
If someone is on aromatase inhibitors for breast cancer
Estrogen and aromatase inhibitors do not work well together
Think anastrazole
What is the newer alternative treatment to atrophic vaginitis? (1)
Ospemifene (Osphena): selective estrogen receptor modulator (SERM)
Only mimics estrogen on vaginal receptors
What is the MC SE of ospemifene?
Hot flashes
What are the alternative therapies for atrophic vaginitis besides ospemifene? (3)
- Prasterone (Vaginal DHEA) suppository (caution in ppl with ER+ women)
- Testosterone cream
- Pelvic PT
What is the most common and characteristic symptom of menopause?
Hot flashes
75% of all women or bilateral oophorectomies
How long do hot flashes last?
4 minutes on average
seconds to around 10 mins
Lasting hours would be SUS
How frequent are hot flashes?
Anywhere from 1-2 per hour to 1-2 per week
How are hot flashes typically described?
- HA-like pressure
- Physiologic flush with pressure increase
- Sweating that is prominently over the head, neck, upper chest, and back
heat or burning in the Face neck and chest
What changes are specifically not seen in hot flashes? (2 vitals)
- No change in heart rhythm
- No change in BP
What 3 things do hot flashes tend to contribute to/lead to?
- Night sweats
- Insomnia
- Cognitive/psychiatric symptoms
What ethnicity tends to report hot flashes more frequently?
AA women
What is the mainstay of tx for hot flashes?
Estrogens
If a woman cannot take estrogen, what is the other hormone can they take for their hot flashes?
Progestin
Depot or norethindrone acetate
What are the hormonal alternatives to estrogen for hot flashes? (3)
- Progestin
- Tibolone: synthetic steroid to mimic estrogen, progesterone, and androgens
- Bioidentical hormones: expensive af
- SERMs + estrogen
What are the non-hormonal alternatives for treating hot flashes? (6)
- SSRIs: paxil, citalopram/escitalopram
- SNRIs: venlafaxine/desvenlafaxine
- Black cohosh/phytoestrogens
- Gabapentin
- Clonidine
- CAM (alternative medicine)
In what situation should paxil be avoided in hot flash treatment?
Pt is already on tamoxifen for breast cancer
Tam and pax do not get along.
What are the 2 emerging therapies for hot flashes?
- Oxybutynin
- Neurokinin-3 receptor antagonist (hypothalamus binding)
What are the 2 biggest known benefits of MHT/HRT?
- Reduced menopausal symptoms
- Reduced risk of osteoporosis (from estrogen!)
For GU symptoms only, vaginal estrogen is as good as other routes.
What are the 5 primary known risks of MHT?
- Endometrial cancer
- Breast cancer (only if using combo MHT)
- Thromboembolic dz (combo and estrogen are highest risk)
- Stroke (combo and estrogen are highest risk)
- Gallbladder dz (estrogen)
How is endometrial cancer risk mitigated in MHT tx?
Must add progesterone to estrogen therapy
What are the 4 Fs of gallbladder dz?
- Female: Gallbladder disease, particularly gallstones, is more common in women than in men.
- Fat: A high-fat diet can contribute to the development of gallstones, which are a major cause of gallbladder disease.
- Forty: Gallbladder disease is more common in individuals over the age of 40, although it can occur at any age.
- Fertile: Pregnancy and estrogen use (such as in hormone replacement therapy or birth control pills) are factors that can increase the risk of gallbladder disease.
A Fat, Fertile, Forty year old Female
How can MHT affect lipids? (2)
- Can lower LDL and increase HDL
- Can increase TGs
What are the contraindications to MHT? (7)
- Breast cx
- Estrogen-dependent cx
- DVT/PE (known or hx)
- Arterial thromboembolic dz (active or within 1 yr)
- Liver dz
- HSR to components of MHT
- Pregnancy (known or suspected)
CIA PRISM
C: Current or history of Certain types of cancer (e.g., breast cancer, endometrial cancer)
I: Irregular vaginal bleeding (without known cause)
A: Active or history of Arterial disease (e.g., stroke, heart attack, blood clots)
P: Pregnancy (MHT is not for use during pregnancy)
R: Recent liver disease (or severe liver dysfunction)
I: Individual history of blood clots (deep vein thrombosis, pulmonary embolism)
S: Severe migraines with aura
M: Migraine headaches (generally with aura)
In what conditions should we be cautionary in implementing MHT? (8)
- Gallbladder dz (4 Fs)
- Hypertriglyceridemia (increases TGs)
- Prior cholestatic jaundice
- Hypothyroidism
- Fluid retention/cardiac/renal dysfunction
- Severe hypocalcemia
- Prior endometriosis
- Hepatic hemangiomas
For a patient with predominantly vasomotor S/S in menopause, what medication route is preferred?
Transdermal
What is the “standard daily dose” of MHT?
0.625mg of PO conjugated estrogen
How long do you wait to increase MHT?
1 month intervals
When are we required to add progestin for MHT?
If the patient still has a uterus
MPA (most studied), micronized (might be better)
MPA = medoxyprogesterone acetate
Look for any Q with hx of hysterectomy
What is the standard recommendation of MHT duration?
Do not use more than 5 years and taper down later.
Describe regimen 1 of MHT (3)
- Estrogen days 1-25
- Progesterone 5-10 mg days 14-25
- No hormones from day 26 to end of month
Lighter, more painless monthly period.
Describe regimen 2 of MHT (2)
- Daily estrogen and progestin
- Will eventually produce atrophic endometrium
Initial bleeding or spotting is common
Easier to do, but more symptomatic?
Which MHT form is primarily aimed at minimizing the risk of breast cx and endometrial cx?
SERM + estrogen
Bazedoxifine + conjugated estrogen
What foods are phytoestrogens/isoflavones?
- Soy
- Lentils
- Chickpeas
Risky
What two alternative therapies are barely better than placebo in MHT?
- Black cohosh
- Vit E
What two MHT therapies have the highest efficacy in reducing hot flash severity? (besides estrogens)
- MPA 400
- Megestrol
After 4 weeks
What are the 3 vaginal preparations for atrophic vaginitis?
- Cream (CE or estradiol)
- Rings (estradiol)
- Tablet (estradiol)
Rings tend to have more reliable absorption than cream.
