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Women's health trigger > Lecture 8: Menopause > Flashcards

Lecture 8: Menopause Flashcards

1
Q

Define climacteric

A

Phase of the aging process during which a woman passes from reproductive to nonreproductive stage.

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2
Q

Define menopausal transition/perimenopause

A

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

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3
Q

What is the average age for menopause?

A

51 years old

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4
Q

What qualifies as premature menopause?

A

Prior to age 40

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5
Q

When do women have the most oocytes?

A

At birth

Nature’s clock

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6
Q

As levels of inhibin decrease due to loss of oocytes, what rises?

A

FSH

FSH rises as you have less oocytes

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7
Q

What happens to the oocytes responsiveness to gonadotropins over time? (4)

A
  • Less responsive to FSH and LH
  • Irregular response
  • Irregular length of follucular phase
  • Irregular menstrual cycles

Less responsive and irregular

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8
Q

Why do we see bursts of estradiol in physiologic menopause?

A

Recruitment of multiple oocytes

Primary estrogen prior to menopause

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9
Q

What is the MCC of premature ovarian failure/premature menopause?

A

Idiopathic

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10
Q

What is the primary predisposing factor to menopause?

A

Smoking

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11
Q

Why might we cause artificial menopause on purpose? (4)

A
  • Endometrial cancer
  • Endometriosis
  • ER+ breast cancer
  • Ovarian cancer predisposition

All estrogen related

Cancer, cancer, cancer, endometriosis

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12
Q

What is the primary androgen in women that is decreased in production in menopause?

A

Androstenedione

Has a DI, same like estraDIol which is low in menopause.

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13
Q

What happens to testosterone levels in menopause?

A

They appear decreased lab-wise, but the ovaries are making more after menopause.

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14
Q

Which estrogen decreases the greatest in menopause?

A

Estradiol

Often measured to also confirm menopause

It is the primary estrogen prior to menopause.

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15
Q

Should we check progesterone levels in postmenopausal women?

A

NO

No clinical use.

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16
Q

What hormone measurements can help confirm menopause? (3)

A
  • Estradiol
  • FSH
  • LH

FSH and LH go up, estradiol should be low in menopause.

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17
Q

What are the MC S/S seen in menopause? (8)

A
  1. Irregular bleeding
  2. Irritability and mood swings
  3. Vaginal dryness
  4. Decreased libido
  5. Hot flashes
  6. Hair loss
  7. Hirsutism
  8. Wt gain

Menopause causes HAVOCS

  • Hot flashes
  • Atrophy of the Vagina
  • Osteoporosis
  • CAD
  • Sleep Disturbances
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18
Q

What is the major growth factor of the female reproductive tract?

A

Estrogen

Estrogen Enhances

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19
Q

As estrogen decreases, what can happen to urinary and mammary epithelium as well? (4)

A
  • Atrophic cystitis: urgency, frequency, incontinence and dysuria
  • Uretheral curuncle as urethral tone is lost
  • GU syndrome of menopause
  • Mammary: regress in size and flatten
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20
Q

What is characteristic of atrophic vaginitis? (5)

A
  • Burning
  • Soreness
  • Dyspareunia
  • Dryness
  • Thin watery or serous discharge
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21
Q

What happens to vaginal pH in atrophic vaginitis?

A

Increases

Becoming basic

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22
Q

How is atrophic vaginitis diagnosed?

A

Clinically

Can do pap smears to help

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23
Q

Image of normal, early, and late atrophic vaginitis

A
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24
Q

How is atrophic vaginitis treated initially? (2)

A
  • Vaginal moisturizers: replens, vagisil, K-Y liquibeads
  • Lubricants with sexual activity

Moisturize daily, lubricants only with sex

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25
Q

What is the pharmacologic treatment for mod-severe atrophic vaginitis?

A

Vaginal estrogen therapy

26
Q

What are the 3 benefits of vaginal estrogen therapy?

A
  1. Restored vaginal pH and microflora
  2. Increased vaginal secretions and thickened vaginal epithelium
  3. Diminished overactive bladder symptoms and fewer UTIs
27
Q

In what situation might vaginal estrogen therapy be detrimental to health?

A

If someone is on aromatase inhibitors for breast cancer

Estrogen and aromatase inhibitors do not work well together

Think anastrazole

28
Q

What is the newer alternative treatment to atrophic vaginitis? (1)

A

Ospemifene (Osphena): selective estrogen receptor modulator (SERM)

Only mimics estrogen on vaginal receptors

29
Q

What is the MC SE of ospemifene?

A

Hot flashes

30
Q

What are the alternative therapies for atrophic vaginitis besides ospemifene? (3)

A
  • Prasterone (Vaginal DHEA) suppository (caution in ppl with ER+ women)
  • Testosterone cream
  • Pelvic PT
31
Q

What is the most common and characteristic symptom of menopause?

A

Hot flashes

75% of all women or bilateral oophorectomies

32
Q

How long do hot flashes last?

A

4 minutes on average

seconds to around 10 mins

Lasting hours would be SUS

33
Q

How frequent are hot flashes?

A

1-2 per hour every 1-2 weeks

34
Q

How are hot flashes typically described?

A
  1. HA-like pressure
  2. Physiologic flush with pressure increase
  3. Sweating that is prominently over the head, neck, upper chest, and back
35
Q

What changes are specifically not seen in hot flashes? (2 vitals)

A
  • No change in heart rhythm
  • No change in BP
36
Q

What 3 things do hot flashes tend to contribute to/lead to?

A
  1. Night sweats
  2. Insomnia
  3. Cognitive/psychiatric symptoms
37
Q

What ethnicity tends to report hot flashes more frequently?

A

AA women

38
Q

What is the mainstay of tx for hot flashes?

A

Estrogens

39
Q

If a woman cannot take estrogen, what is the other hormone can they take for their hot flashes?

A

Progestin

Depot or norethindrone acetate

40
Q

What are the hormonal alternatives to estrogen for hot flashes? (3)

A
  • Progestin
  • Tibolone: synthetic steroid to mimic estrogen, progesterone, and androgens
  • Bioidentical hormones: expensive af
  • SERMs + estrogen
41
Q

What are the non-hormonal alternatives for treating hot flashes? (6)

A
  • SSRIs: paxil, citalopram/escitalopram
  • SNRIs: venlafaxine/desvenlafaxine
  • Black cohosh/phytoestrogens
  • Gabapentin
  • Clonidine
  • CAM (alternative medicine)
42
Q

In what situation should paxil be avoided in hot flash treatment?

A

Pt is already on tamoxifen for breast cancer

Tam and pax do not get along.

43
Q

What are the 2 emerging therapies for hot flashes?

A
  • Oxybutynin
  • Neurokinin-3 receptor antagonist (hypothalamus binding)
44
Q

What are the 2 biggest known benefits of MHT/HRT?

A
  • Reduced menopausal symptoms
  • Reduced risk of osteoporosis (from estrogen!)

For GU symptoms only, vaginal estrogen is as good as other routes.

45
Q

What are the 5 primary known risks of MHT?

A
  1. Endometrial cancer
  2. Breast cancer (only if using combo MHT)
  3. Thromboembolic dz (combo and estrogen are highest risk)
  4. Stroke (combo and estrogen are highest risk)
  5. Gallbladder dz (estrogen)
46
Q

How is endometrial cancer risk mitigated in MHT tx?

A

Must add progesterone to estrogen therapy

47
Q

What are the 4 Fs of gallbladder dz?

A
  1. Female: Gallbladder disease, particularly gallstones, is more common in women than in men.
  2. Fat: A high-fat diet can contribute to the development of gallstones, which are a major cause of gallbladder disease.
  3. Forty: Gallbladder disease is more common in individuals over the age of 40, although it can occur at any age.
  4. 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

48
Q

How can MHT affect lipids? (2)

A
  • Can lower LDL and increase HDL
  • Can increase TGs
49
Q

What are the contraindications to MHT? (7)

A
  1. Breast cx
  2. Estrogen-dependent cx
  3. DVT/PE (known or hx)
  4. Arterial thromboembolic dz (active or within 1 yr)
  5. Liver dz
  6. HSR to components of MHT
  7. 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)

50
Q

In what conditions should we be cautionary in implementing MHT? (8)

A
  • Gallbladder dz (4 Fs)
  • Hypertriglyceridemia (increases TGs)
  • Prior cholestatic jaundice
  • Hypothyroidism
  • Fluid retention/cardiac/renal dysfunction
  • Severe hypocalcemia
  • Prior endometriosis
  • Hepatic hemangiomas
51
Q

For a patient with predominantly vasomotor S/S in menopause, what medication route is preferred?

A

Transdermal

52
Q

What is the “standard daily dose” of MHT?

A

0.625mg of PO conjugated estrogen

53
Q

How long do you wait to increase MHT?

A

1 month intervals

54
Q

When are we required to add progestin for MHT?

A

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

55
Q

What is the standard recommendation of MHT duration?

A

Do not use more than 5 years and taper down later.

56
Q

Describe regimen 1 of MHT (3)

A
  • 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.

57
Q

Describe regimen 2 of MHT (2)

A
  • Daily estrogen and progestin
  • Will eventually produce atrophic endometrium

Initial bleeding or spotting is common

Easier to do, but more symptomatic?

58
Q

Which MHT form is primarily aimed at minimizing the risk of breast cx and endometrial cx?

A

SERM + estrogen

Bazedoxifine + conjugated estrogen

59
Q

What foods are phytoestrogens/isoflavones?

A
  • Soy
  • Lentils
  • Chickpeas

Risky

60
Q

What two alternative therapies are barely better than placebo in MHT?

A
  • Black cohosh
  • Vit E
61
Q

What two MHT therapies have the highest efficacy in reducing hot flash severity? (besides estrogens)

A
  • MPA 400
  • Megestrol

After 4 weeks

62
Q

What are the 3 vaginal preparations for atrophic vaginitis?

A
  • Cream (CE or estradiol)
  • Rings (estradiol)
  • Tablet (estradiol)

Rings tend to have more reliable absorption than cream.

Women's health trigger (23 decks)

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