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Menopausa e 6 dec de vida Flashcards

1
Q

Menopausa

A
  • Conjunto sintomas fisicos e e emocionais com impacto na vida da mulher e de quem a rodeia
  • Idd média: 51 anos (white Caucasians with ethnic and regional variations after a significant decrease of ovarian estrogen production)
  • Data da ultima menstruação: estadio 0
  • Altura perimenopausa: estadio -2 e -1
  • menopausa: estadio 1 e 2
  • permanent cessation of menses, (devido a dim de estrogénio) is a retrospective clinical diagnosis, as the final menstrual period can only be defined if followed by 12 months of amenorrhea
  • Dx retrospetivo
  • Menopausa tardia apos 55 anos
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2
Q

Falência ovarica prematura

A

menopause before the age of 40 years; whether occurring naturally or as a result of surgery or some other intervention (e.g. chemotherapy).
- 1% casos

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3
Q

Perimenopausa

A

-The time in which a woman has irregular cycles of ovulation and menstruation leading up to menopause and continuing until 12 months after her final period.

  • Alt ciclo menstrual
  • Encurtamento ciclos inicialmente (fase folicular + rapida pelo aum FSH)
  • Alongamento ciclos no final
  • Ausência de mentruação - amenorreia
  • Ciclos + longo que 2 meses (passar um progestativo enquanto a mulher menstruar para evitar hiperplasia do endométrio)
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4
Q

Posmenopausa

A

-The time after menopause has occurred, starting when a woman has not had a period for 12 consecutive months

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5
Q

Menopausa induzida

A
  • Cessation of ovarian function induced by chemotherapy, radiotherapy, or bilateral oophorectomy
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6
Q

Climaterio

A

The phase in the aging of women marking the transition from the reproductive phase to the nonreproductive state. This phase incorporates the perimenopause by extending for a longer variable period before and after the perimenopause.

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7
Q

Sindrome climaterico

A

When the climacteric is associated with symptomatology

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8
Q

Idd Menopausa

A
  • Genetica
  • Estilo vida (mal nutrida, tabagismo) - + precoce
  • idd menarca
  • Numero de ovulações
  • numero de gravidezes
  • Lactação
  • Contraceção oral
  • Raça
  • Estatuto socioeconomico
  • Educação
  • Altura
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9
Q

Oocitos

A
  • nascença: 1000000 a 2000000
  • Puberdade: 400 000
  • 30-35 anos: 100 000
  • Mulher ovula cerca de 400 oocitos durante a vida reprodutiva
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10
Q

Caracteristicas hormonais pre menopausa

A
  • Depleção foliculos ovaricos + alt de mecanismos intrafolicular -> freq ciclos anovulatórios + Dim inibina B e estrogénios N -> Aum FSH e LH normal
  • Maior resistência folicular a FSH
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11
Q

Menstruação e menopausa

A
  • Ovaries of postmenopausal women are not quiescente
  • Under the stimulation of LH theca cell Island in the ovarian stroma produce hormones, primarily the androgens, testosterone and androstenedione.
  • Testosterona appears to be the major product of the postmenopausal ovary
  • Testosterone concentrations decline after menopause. Remains 2x higher in menopausal with intact ovaries than in those with ooforectomy
  • Estrona E1- predominant endogenous estrogen in postmenopausal. Is termed extragonadal estrogen because the concentration is directly related to body weigt
  • Androstenedione is converted to E1 proprotionate to the amount of fatty tissue
  • Estrogénio promove prolif endometrio, mulheres obesas na menopausa -> maioe risco de hiperplasia endometrio e carcinoma; mulheres magras tem maior risco de sintomas menopausicos
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12
Q

Caracteristicas hormonais pos menopausa

A
  • Menos foliculos -» FSH aum pela resistência folicular (10-20x, max 1-3 anos); estrogénios baixam (única fonte conversão periferica de androgénios); prod de androstenediona e T (Suprarrenal + ovarios (ação Gn)
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13
Q

Hormonas pre menopausa vs posmenopausa

A
  • Pre: FSH+ e LH N- anovulação freq -> atividade estrogenica desequilibrada vs progesterona
  • Pos: FSH ++, LH+, sem atividade folicular -> deprivação de estrogénios
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14
Q

Manif clinicas

A
  • precocemente: ciclos irregulares, afrontamentos, sint psicogénicos
  • Medio: sintomas Genitourinarios e cutâneos
  • Tarde: dim qualidade vida, disfunção sexual, osteoporose, doença CV anormalidad ecognitiva
  • Sintomas: dispareunia, muc com sangue, prurido vulvar, urgência, freq, incontinência stress, relaxamento pav pelvico ou prolapso, secura pele, aum rugas, hirsutismo leve, boca seca, alopecia/ cabelo seco, doença coronária, osteoporose, dor articular, mastalgia, alt energia e equilibrio, sono alterado, afrontamentos, diaforese
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15
Q

Afrontamentos

A
  • geralmente a primeira manif e mais comum na perimenopausa/posmenopausa imediata
  • Instabilidade vasomotora
  • Recorrente, transitorios
  • Suores noturnos: ocorrem no sono associado a diaforese
  • rpd instalação e solução
  • vasodil cutaneao na parte sup tronco pescoço e face
  • 90 seg
  • fenómeno inteiro é 3 min
  • calor, ansiedade, tremor
  • Dim 17 beta estradiol -> aum norepinefrina e serotonina?
  • Resolução espontânea em 2-3 anos (pode durar >10 anos em 10% mulheres)
  • Com terapia hormonal - resolve em 3-6 sem as x’s + rpd
  • Prev: 75% US, 10% hong kong, 62% Australia
  • More prevalent African American women
  • BMI is a more reliable factor of the incidence of hot flushes (more prevalent in higher body mass indices)
  • Surgical or induced menopause is associated with a greater prevalence and severity of vasomotor symptoms
  • less education
  • lower income
  • mood disorders,
  • women who are cigarette smokers
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16
Q

Doenças que imitam eventos vasomotores

A
  • doença tiroideia, epilepsia, infeção, drogas (alccol, opioides, IRSS, Block canais Ca, Block de estrogenios), alguns cancros (tiroide, pancreas, rim, linfoma), ansiedade
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17
Q

Alt Sono

A
  • Dim niveis E2
  • Latent phase of sleep ( the time required to fall asleep) is lengthened, with alterations in rapid eye movement patterns
  • The actual period of sleep is shortened
  • The women complain of having difficulty falling asleep and of waking up soon after going to sleep
  • The women are often tense, irritable and have difficulty with concentration and interpersonal relationships
  • Tx hormonal melhora
  • Insonia, fadiga, irritabilidade, depressão
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18
Q

Sindrome genitourinario

A
  • Defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder
  • The vaginal epitheliun, cérvix, endocervix, endometrium, miometrium and uroepithelium are estrogen-dependente tissues
  • Tecidos atroficos
  • Vaginal epithelium becomes thin and cervical secretions diminish
  • > dim prazer sexual e dispareunia
  • Atrophic vaginites also may presente with itching and burning. The thinned epithelium is more susceptible to becoming irritated by skin irritants or infected by local flora
  • Symptoms can be relieved with systemic HT or topical estrogen
  • GSM is now replacing vulvovaginal atrophy (alt termo)
  • endometrium becomes atrophic, sometimes resulting in postmenopausal spotting
  • paravaginal tissues that support the bladder and rectum becomes atrophic. This with the chilbearing can result in loss of support for blader or and rectum
  • Uterine prolapse is more common in hipoestrogenic patient
  • Uretrite atrofica: disuria e freq, devido a alt epiteio do trato -> terapia subs melhora os sintomas de urgência, freq e disuria
  • Incontinência urinária ->Kegel
  • Atrofia endometrio -> maior causa de hemorragia pos menopausa
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19
Q

Alt memória e humor

A
  • Perimenopausal and postmenopausal women often complains of mood swings
  • Some experience memory loss, depression, apathy and crying spells
  • The cause could be menopause, sleep disturbance or both
  • If they have a comorbid sleep disorder, such as obstrutive sleep apnea and rest legs syndrome -> sleep expert com sleep study se apropriado
  • Sex steroid hormone receptores are presente in the central nervouse system (CNS). There is insuficiente evidence about the role of estrogens in the CNS function to implicate a direct mechanism
  • TX: Counseling and emotional support; medical therapy
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20
Q

Alt pele, cabelo e unhas

A
  • Estrogens influences skin thickness (fibroblastos, colagenio e queratinocitos)
  • Declining estrogen prodution the skin becomes more thin, less elastic,and eventually more susceptible to abrasion and trauma
  • Estrogens stimulates the production of SHBG which binds androgens and estrogens
  • Menos estrogenios -> menos SHBG disponivel -> mais testo livre -> mais bigode na tia Alice
  • Estrogen production affect the rate of hair shedding. Hair from the scalp is lost and replaced in a asynchronous way. The process is self-limiting and requires no therapy
  • Nails becomes thin and brittle with estrogen deprivation, but are restored to normal over time or with estrogen therapy
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21
Q

Osteoporose

A
  • Bone desmineralization ia a natural consequence of aging, and occurs in men and women.
  • In women occurs 15 to 20 Y earlier because of acceleration after ovarian funtion ceases.
  • Decreased estrogen production occurs in natural menopause, eating disorders or elite athletes with exercice associated lower BMI (ou corticoterapia de longa duração)
  • Bone density diminishes at the rate of 0,5% Y in perimenopausal women and 1%-2% Y in postmenopausal women
  • Estrogen receptors (Ers) are presente in osteoblast, which suggests a role for estrogen in bone formation
  • Estrogen afeccts the developement of cortical (+ tardio) , but the effect is more pronunced in trabecular bone (+ precoce)
  • Dim massa ossea com (mineral/matriz) N, alt microarquitetura
  • Aum risco fraturas
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22
Q

Testes anteriores à tx

A
  • Anamnese
  • EO
  • Exame gineco e mama
  • Análises rotina
  • Mamografia
  • Eco e Densitometria em situações especificas
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23
Q

Anamnese

A
  • Sintomas
  • Fatores de risco para doenças
  • FR para doença + prevalente na menopausa (CV, cancro e osteoporose)
  • Hx obstetrica relevante
  • Hx de doenças (TVP, cancros, CV, etc)
  • Hx familiar
  • Alcool tabaco
  • Medicação
  • Hx social, psicologica e sexual
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24
Q

FR CV

A
  • Idd, Sexo, Hx familiar, Raça, Menopausa
  • Dislipidemias, HTA, DM, tabagismo, obesidade, sedentarismo
  • Novos fatores: PE ou HTA na gravidez, D Gestacional
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25
Q

EO

A

IMC, Cintura, PA, Exame gineco, Exame mama, Palpação tiroide

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26
Q

Testes laboratoriais

A
  • Glicemia, Hemoglobin A1C
  • Função hepatica, renal
  • Colesterol, HDL, LDL, trigliceridos
  • Tiroide -TSH
  • Urina 2
  • Screening for thrombophilia is not indicated prior to MHT use
  • Selective screening may be indicated on the basis of personal and familial history
27
Q

Estudos hormonais

A
  • Quando administrar7realizar estudo?
    o Early Menopause / Early Ovarian Failure
    o Women in oral contraceptives?
  • 2 doseamentos FSH >30 em 2 determinações de 4 semanas
  • Histerectomizada não tem menstruação
  • Sem necessidade em sintomatica (já está na menopausa)
    o Carriers of Mirena
    o Implanon Carriers
    o Hysterectomize
28
Q

Eco transvaginal

A
  • Asymptomatic women should be informed of their risk of developing endometrial carcinoma, educated about their symptoms (especially abnormal uterine bleeding) and encouraged to seek medical advice
  • Eco transvaginal in the woman to do continuous combined MHT can be performed at any time; In women to do combined sequential MHT should be done shortly after deprivation bleeding
  • EcoTV should not be used as screening for endometrial cancer
  • EcoTV is indicated in all postmenopausal women with vaginal bleeding
29
Q

Avaliação mama

A
  • Mamografia: 50-69- 2 em 2 anos, >69 - a cada 2-3 anos

- se tiver mamo recente não precisamos de outra para fazer tx

30
Q

Quando fazer screen para densidade ossea <65 anos

A
  • Todas >65 anos
  • Bone density shoud be screened in postmenopausal women younger than 65Y if any of following risk factos are noted
    o Medical history of a fragility fracture
    o Body weight less than 57,6 Kg
    o Medical causes of bone loss ( medications or diseases)
    o Parental medical history of hip fracture
    o Current smoker
    o Alcoholism
    o Rheumatoid arthritis
31
Q

Frax

A
  • designed by the WHO to assess fracture risk using a mathematical model
  • Takes in account factors like BMI, personal medical history, parenteral history of fracture, alcool use, current smoking, and others
  • Screening <65 para osteoporose se:
    o Risco Major osteoporotic fracture >9,3%
    o They have one of several risk factors
  • Evita densitometria sem necessidade
32
Q

Tx osteoporose

A
  • Risco de fratura osteoporotica - 20%
  • Risco de fratura anca - 3% (em 10 anos)
  • TX hormonal + suplementos calcio + ecercicio fisico -> diminui osteoporose
  • Não é indicação primária para inicio de Tx hormonal
33
Q

Gestão da menopausa

A
  • 17 Beta estradiol e metabolitos usados para diminuir sintomas menopausa -> Oral, transdermica e topica

o Orally 17B estradiol is oxidized in the enterohepatic circulation to E1

o Trandermally, transbuccaly, transvaginally, intravenously or intramuscularly 17B estradiol remains inaltered
o Transdermal E2 results in steady, sustained estrogen blood levels and may be alternative to oral dosing for many patients

o IM E2 results in unpredictable fluctuations in plasma concentration

o E2 across the vaginal epitheliun, absortion is poorly controlled, but remains at very low levels when appropriated use

  • Transdermica/oral: eficacia semelhante mas prefere-se transdermica em + comoborbilidade(HTA, cefaleias)
  • Topica: atrofia local sem sintomas genitourinarios
34
Q

Tx combinada estrogenios e progestativos

A
  • Continuous unopposed estrogens can result in endometrial hyperplasia and an increased risk of endometrial adenocarcinoma
  • women with a uterus is essential to administer a progestin
  • Progestin may include any variety of synthetics , such as medroxyprogesterone acetate, norethindrone or micronized progesterone or dydrogesterone
  • Progestin may be given continously in low dosis or sequentially in higher doses
  • Sequential dosing is usualy administered for 10 or 12 days each month
  • Progestativos antagonizam os efeitos dos estrogenios no endometrio
  • Histerectomia: não e preciso progestativo a não ser endometriose
  • Progestins, particularly medroxiprogesterone acetate, may have unacceptable side effects such as depressive symptoms and weight gain
  • Estrogen administered alone is imperative and endometrial surveillance given the increased risk for neoplastic changes
35
Q

Regimes de terapeutica hormonal combinada

A
  • Sequential- Continous estrogen+ cyclic progestin ( resolution of symptoms and cyclic withdrawal bleeding ). The progestin converts the proliferative endometrium into a secretor, brings about endometrial sloughing, and prevents hiperplasia or celular atypia (estrogenio 21-28 dias, + progestativo ultimos 10-14 dias) -> perimenopausa, menopausa precoce, mulheres que querem menstruar porque vai dar hemorragia de privação
  • Continuous- Continous estrogen+ progestin - ( resolution of symptoms and no withdrawal bleeding ). Continuous oral progestin or a levonorgestrel intrauterine device produce endometrial decidualization and eventually atrophy
    (utilizado nas mulheres que nao querem menstruar e endometriose)
36
Q

Tx sistémica estrogenio

A

Oral, transdermica
- Indicações:
o Management of moderate-to-severe vasomotor symptoms
o Prevention of osteoporosis among women at high risk of osteoporotic fracture who are unable to tolerate standard preventive medications
o Premature ovarian failure, premature menopause, or early menopause (SEMPRE INDICAÇÃO)

37
Q

Objetivos tx

A
  • Alleviating the patient`s symtoms with the smallest dose
  • Treatment should be limited and patient expectations and continued symptomatology should be revisited periodically
  • A careful risk-benefit analysis shoud be performed taking into account patiente goals
  • The need for HT should be individualized based on women`s specific risk factors
  • Tx hormonal: The result suggested when compared with placebo, CEE+AMP continuous low dose increase risk of heart attack, stroke, thromboembolic disease, and breast cancer, Reduced risk of colorectal cancer and hip fractures
  • Women taking unopposed estrogen had no risk of cardiac events and a trend toward decrease in breast cancer
  • Mulheres que inicam tx hormonal entre 50-59: não havia aum risco cv e havia dim causas de mortalidade -> com aum da idade os riscos são superiores
38
Q

Alt CV e lipidicas

A
  • Colesterol total aum, HDL baixa, LDL aum -> perimenopausa
  • Tx hormonal melhora estes riscos
  • DOPS, KEEPS, ELITE -> estudos mais recentes mostram que não havia aum risco CV se TX precoce
  • TX hormonal não deve ser oferecida como prevenção primaria de doença CV
39
Q

Quando usar TX hormonal - NAMS 2017

A
  • evitar sintomas e evitar osteoporose em mulheres com maior risco de fraturas

o Systemic HT does not improve urinary incontinence and may increase the incidence of stress urinary incontinence

o For women with POI and early menopause HT is recomended until at least the median age of menopause (52Y)
o Once women discontinue HT, there is about a 50% chance that VasoMotorSymptoms will return, regardless of their age or how long they`ve been using it

40
Q

TX hormonal sistémica quanto tempo?

A
  • Considerations for long-term (or extended) use of HT include persistent VMS, QOL issues, or prevention of osteoporosis in women at elevated risk of fracture.
  • Annual reevaluation, including reviewing comorbidities and periodic trials of lowering or discontinuing HT or changing to potentially safer low-dose transdermal routes, should be considered. Vaginal estrogen (and systemic if required) or other non estrogen therapies may be used at any age for prevention or treatment of GSM.
  • The decision to continue or discontinue must be made jointly with the woman and her physician
  • Women with spontaneous or iatrogenic menopause before the age of 45 years, especially before the age of 40 years, have a high risk of CVD, osteoporosis and increased risk of affective disorders and dementia, so that the therapy should be performed until at least the middle age of menopause
41
Q

CI TX hormonal

A

o Undiagnosed abnormal genital bleeding
o Known or suspected estrogen-dependent neoplasia except in appropriately selected patients
o Active deep vein thrombosis, pulmonary embolism, or history of these conditions
o Active or recent arterial thromboembolic disease (for example, stroke, MI)
o Liver dysfunction or liver disease
o Known or suspected pregnancy
o Hypersensitivity to HT preparations

42
Q

Parar Tx hormonal

A
  • Offer women who are stopping HRT a choice of gradually reducing or immediately stopping treatment:

o gradually reducing HRT may limit recurrence of symptoms in the short term

o gradually reducing or immediately stopping HRT makes no difference to their symptoms in the longer term.

43
Q

Tibolona

A
  • S.T.E.A.R. Selective Tissue Estrogenic Activity Regulator
  • Synthetic steroid derived from 19-nortestosterone.
  • Estrogenic, progestational and androgenic action on target organs.
  • Indications and contraindications comparable to conventional MHT
  • Adverse effects
    o Less frequent; Light / more acceptable?
44
Q

Complexo estrogenico seletivo de tecido (TSEC)

A
  • Bazedoxifene, a selective ER modulator (SERM; estrogen agonist or antagonist), has been combined with CEE (conjugated equine estrogen- retirado de urina de eguas gravidas) to form a tissue-selective estrogen complex. The combination provides endometrial protection without the need for a progestogen.
  • An additional FDA-approved option for women with concerns about breast tenderness, breast density, or abnormal uterine bleeding with conventional therapy
  • Indications and contraindications comparable to conventional MHT
45
Q

Tx alternativa

A
  • mulheres não podem fazer ou não querem
  • Afrontamentos: bebidas frias, vestir por camadas, etc
  • The placebo effect on vasomotor symptoms is high
  • Alternative therapies for the short-term treatment of common symptoms of menopause with mixed results include: Fitoestrogénios, black cohosh, acumpuntura, exercicio
  • Therapies showing no convincing benefit include: Tecnicas de relaxamento, medicinas ervanaria chinesa, Evening primrose oil
  • Necessário mais estudos e não estão recomendadas
  • Muitas naturais
  • Um medicamento off-label é a progesterona (usualy in the form of depot medroxiprogesterone acetate in the treatment of hot flushes)
46
Q

Estilo de vida, dieta, exercicio

A
  • Weight loss of only 5–10% is sufficient to improve many of the abnormalities associated with the insulin resistance syndrome.
  • The basic components of a healthy diet are: several servings/day of fruits and vegetables, whole grain fibers, fish twice per week, and low total fat, less than 30% (but the use of olive oil is recommended).
  • Consumption of salt should be limited. Limiting caffeine and alcohol intake. The daily amount of alcohol should not exceed 30 g for men and 20 g for women
  • Smoking should be avoided.
  • Lifestyle modifications include socializing and being physically/mentally active
  • Getting regular health care NOT only help relieve symptoms, but prevents health problems
  • Regular exercise is advised to reduce cardiovascular and total mortality.
  • Optimal exercise prescription is at least 150 minutes of moderate-intensity exercise per week. Two additional weekly sessions of resistance exercise may provide further benefit.
  • The recommended intensity of aerobic activity should take into account the older adult’s aerobic fitness
47
Q

TX complementar não farmacologica

A
  • Complementary therapies have limited evidence for efficacy and safety and are not regulated by the medicines agencies
  • Paced respiration, cognitive behavioral therapy, mindfulness training, acupuncture, hipnosis and stellate ganglion blockade may be useful procedures to consider when treating vasomotor symptoms
48
Q

Isoflavonas

A
  • There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms.
  • Multiple preparations are available but their safety is uncertain.
  • Different preparations may vary, interactions with other medicines have been reported.
    o Many soy products interact with thyroid medications
    o Dong quai and red clover potentiate warfarin and other anticoagulants
  • Not recommended in women with breast cancer
49
Q

Tx farmaco sintomas vasomotores

A
  • SSRI e SSNRI also has been used with some success.
  • Venlafaxine, desvenlafaxine, paroxetine, citalopram, and escitalopram are effective in reducing hot flushes in postmenopausal women.
  • A low dose formulation of paroxetine mesylate currently represents the only nonhormonal medication that is FDA-approved to treat vasomotor symptoms
  • Paroxetine should be avoided in women receiving tamoxifen. (cancro da mama)
  • Gabapentin is as effective but has more side-effects compared to SSRIs/SNRIs.
  • Clonidine provide moderate relief of vasomotor symptoms, but more side -effects
50
Q

Tx osteoporose

A
  • Weight-bearing activity- walking as 30 minutes a day increases the mineral contente of older women
  • Calcium- Prevent bone loss.
    o Women>50Y- 1,200mg day
    o Calcium+HT is more effective than calcium alone
  • Vitamin D- should be considered for those with limited sun exposure and lacking others dietary sources
    o 51-70Y- 600UI/day
    o >70Y- 800UI/day
51
Q

Calcio

A
  • Postmenopausal women need a dietary reference intake (DRI) of 1000–1500mg of elemental calcium.
  • Calcium supplementation should be restricted to bridge the shortfall between dietary intake and the DRI and to patients being treated for high fracture risk
  • Routine dietary calcium supplementation cannot be justified in terms of efficacy, safety and health economics.
  • Excessive calcium supplementation may be associated with increased cardiovascular risk, renal calculi and constipation
52
Q

Vit D

A
  • The DRI for vitamin D is 800–1000 IU in the postmenopausal period. As the major source of vitamin D is dependent on sunlight exposure, the need for supplementation will vary
  • Measuring the blood 25- hydroxyvitamin D level may be helpful in selected individuals
  • Vitamin D supplementation has been shown independently to lower the risk of fracture and of falling in elderly patients
53
Q

Regimes não hormonais para osteoporose

A
  • Risedronato (bifosfonados) - inibe reabsorção
  • Ibandronato (bifosfonados) - inibe reabsorção
  • Alendronato (bifosfonados) - inibe reabsorção
  • Carbonato ca- natural
  • Raloxifeno (não leva estimulação endometrio- sem risco cancro)
54
Q

SERM- selective estrogen recetor modulators

A
  • SERMs are ER ligands that act like estrogens in some tissues but block estrogen action in others
  • Raloxifene – ER antagonist activity in the breast and endometrium but agonist activity in the bone.
  • Lacks the capabilities of mitigating other estrogens deprivation symptoms, and may even exacerbate symptoms like hot flushes and sleeplessness
  • Some SERMs like tamoxifen can increase the risk of hyperplasia and endometrial cancer
55
Q

Ospemifene

A
  • SERM
  • Indicações: Treatment of genitourinary symptoms of menopause, including vaginal dryness and dyspareunia, among women preferring an oral treatment
  • CI: Same as for lowdose vaginal estrogen
  • Should not be used in patients with past or current venous or arterial thromboembolic disease, severe liver disease, or those using estrogens or estrogen agonists–antagonists.
  • não existe em PT
56
Q

Prasterona

A
  • A once-daily vaginal insert, is the first FDA-approved product containing the active ingredient prasterone, also known as dehydroepiandrosterone (DHEA).
  • Pain during sexual intercourse is one of the most frequent symptoms of VVA reported by postmenopausal women. Prasterona provides an additional treatment option for women seeking relief of dyspareunia caused by VVA
  • According to the FDA, the efficacy of prasterona was demonstrated in two 12-week placebo-controlled clinical trials involving 406 healthy postmenopausal women reporting moderate to severe pain during sexual intercourse as their most bothersome symptom of VVA.
  • Is promising in the treatment of VVA and sexual associated symptoms, due to a favorable safety profile in women with contraindications to MHT.
  • Efficacy appears to be lost with twice-weekly maintenance administration
57
Q

Tx hormonal bioidentica

A
  • The term ‘bioidentical’ means having the same molecular structure as a substance produced in the body
  • Bioidentical hormones are not ‘natural’. They are synthesized in laboratories from plant-based precursors in the same way that regulated hormone products are prepared. Advertising and promotional claims made for the safety and efficacy of compounded BHT are not validated by medical evidence.
  • Endometrial cancer has been associated with estrogen-containing BHT. The progesterone used in these preparations may be insufficient to inhibit estrogen induced endometrial stimulation
  • The hormones available in these preparations are all available in safe regulated products.
  • Prescribing of compounded BHT is not recommended due to the lack of quality control and regulatory oversight associated with these products, together with lack of evidence of safety and efficacy.
  • The use of serum or salivary hormone levels is not recommended to assist in the management of MHT as these levels are of little value in selecting initial medication doses or in monitoring efficacy.
  • Women requesting compounded BHT should be encouraged to consider regulated products containing hormones which are structurally identical to those produced in the body. These are available in a wide range of doses and delivery methods
58
Q

Follow up

A
  • por volta dos 3 meses-> 6 meses seguintes -> anualmente
  • In a women with a uterus unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3-month review appointment, or promptly if it occurs after the first 3 months
  • Women taking MHT should have at least an annual consultation to include a physical examination, update of medical and family history, relevant laboratory and imaging investigations, a discussion on lifestyle, and strategies to prevent or reduce chronic disease. assess efficacy, dose, type, route of administration and need for continued treatment. Changes in the balance of benefits and risks need to be ascertained
  • There is currently no indication for increased mammographic or cervical smear screening
  • EO: 3, 6,12,24,36 meses
  • Exsudado cervical: antes e 36 meses
  • Testes LAB: antes, 12,24 e 36 meses
  • Mamo: antes e 12 meses
59
Q

Insuf ovarica prematura

A
  • The diagnosis aplies to aproximately 1% of women who experience menopause before the age of 40Y
  • Diagnosis shoul be suspected
    o Yong women with hot flushes and other symptoms of hipoestrogenism and secundary amenorreia
  • The diagnosis is confirmed
    o FSH levels >30-40 mUI/mL on two separate occasions
  • Hot flushes are not as common as might be expected.
  • The diagnosis has reprodutive and emotional implications, as well metabolic and constitutional.
  • There are many causes of premature loss of oocytes and premature menopause
  • Demands a careful working in order to identify the underlying cause and appropriated management
60
Q

Fatores genéticos Insuf ovarica prem

A
  • Causa idiopatica em 90% casos
  • Genetic information that determines the lengt of a woman`s reprodutive life is carried in the distal long arm of the X chromosome.
    o Partial deletion of this arm results in primary ovarian insufficiency
    o Total loss of this arm , as seen in Turner syndrome, results in ovarian failure at birth or in early childhood
  • When suspected diagnosis can be established by mapping of the X chromosome
  • Screening for premutations for the fragile X syndrome should be offered because of its association with primary ovarian insufficiency
  • These patients are at risk for having children with mental disabilities
  • Evaluation for any Y chromosome material should be performed, if identified, ooforectomy shoud be performed as a result of the risk of cancer
61
Q

DAI

A
  • Some women develop autoantibodies against thyroid, adrenal, and ovarian endocrine tissues. Theses autoantibodies may cause ovarian failure.
  • These women need HT for the indications described above
  • Some will spontaneously resume ovarian function
62
Q

Tabagismo

A
  • Women who smoke tobacco can undergo menopause 3 to 5 Y earlier than the expected time
  • This women metabolize E2 primarily to 2-hydroxiestradiol, a catecholestrogen ( strutural similarity to catecholamine)
  • The catecholestrogens acts and block estrogen action
  • Counseling women stop smoking
63
Q

Quimioterapia alquilante de cancro

A
  • This agents affect the membrane of ovarian follicles and hasten folicular atresia -> Loss of ovarian function
  • Young women being treated with this agentes should be advised that they may be candidates for cryopreservation and other fertility preservation methods
64
Q

Histerectomia

A
  • Hysterectomy in reproductive age is associated with menopausal 3-5Y earlier than the expected age
  • The mechanism for this occurrence is unknown. It is likely to be associated with alteration of colateral ovarian blood flow resulting from the surgery

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