Menopause Flashcards
Menopause
Definintion
descirbed perimenopause, menopause transtion and post-menopause
Menopause
- inevitable transition defined by 12 months concecuatively of amenorrhea in the abscences of pathologic causes
- due to a depletion of the ovarina follicles: resulting in low estrogen levels and high FSH
- median age = 50-52 years
Perimenopause (transition time before and technically after)
- the changes occur in the menstural cycle, abnormal length, bleeding etc. up to 4 years before menopuase begins
- defined as: chagnes in menstration & irregualar mensturation
- ending at the final period: FMP
Menopause Transtion: takes 12 months to make dx. as there needs to be no period for this amoutn of time
Post-menopause
- menopause has been established at this point: in that there have been 12 months without period
- the symptoms do continue through this period
premature menopause: a menopuase occuring PRIOR TO THE AGE OF 40
Menopause: changes in physiology and hormones
estrogen changes
progesterone
Gonadotropins
Hormones at Play
- estrogen: decreased
- progesterone: decreased
- Gonadotropins: LH and FSH (increasing)
Estrogen Changes
- the endogenous production of estrogen decreases: largerly due to the decrease in estradiol from the lack of estrogen produced by the follicles: no granusola cells to produce estrogen
- decreased by 30%: but still some estrogen around!
- because estrogen is secreted from the adrenal glands too: there is some peripheral conversion from testosterone
Progesterone Changes
- premenopause: noramlly progesterone release from teh corpus lutem: after ovulation
- since there is no active follicles: there is nocorpus lutem and therefore not creating progesteron low levels
- a 70% reduction in progesterone!!!!
- a small proportion of progesterone is released from the adrenal glands
FSH/LH Leels
- since they are trying to respond to the lowe levesl of estrogen and progesterone:there is an INCREASE in FSH/LH in menopausal women
- more LH thant FSH, but both realtively high in comparison
In sum
- progesteron drops fast and firat
- then enstrogen falls
- FSH and LH increase as negative feedback loop
- result: disrupted hormone influence and decreased follicular develop: failure of endometrium to thicken: lack of menses
Labwork during perimenopause
is it helpful? what would you see
Labwork: not really that helpful as you cannot fully rely on the FSH/LH levels to diagnosis menopause
BUT: the labs will be…..
Perimenopause
- high FSH, low estradiol
- in reality: irregulat cycles in perimenopuase will create dramatic flux in these levels and can vary from women to women and time to time
Menopause
- early on: high FSH
- later on: decling FSH
- slowly a decline as it soverstimualted eventaully “gets tired”
in sum: estimating the FMP is a good predicotr to measure and estiamate menopause
Physical Changs of Menopause: Reproductive Tract
Reproductive Tract
atrophy of the vaginal tissue: loss of ruggae in vagina
can lead to atropic vaginitis
atrophy of the cervical tissue: cervical size decreases, os can become stenotic painful/uncomfortable ; decrease transitional zone too
Reduced cervical mucous production: vaginal dryness and painful sex
Atrophy of uterus: thinning of endometrium and myometrium
ovaries and oviducts decrease size: can be unable to palpate on exam
Physical Changs of Menopause: Urinary Tract
Physical Changs of Menopause: Mammary Glands
Urinary Tract
- loss of estrogen: decreased ability to maintain the epithelium of the bladder and the urters
results in
- UTI
- hematuria: skin is fragile
- urethral caruncle formation: a thickening, friability/red peri–ureteral meatus formation
Mammary Glands
- reduced breast size = because decreased estrogen
- reduction in glabdualr tissue
- increased fatty tissue
- postive: less estregoen and no cycle means those with fibrocystic breast disease wont have the cyclial pain that usually occurs
Menopause: Symptoms
seen in perimenopause
Symptosm
- menstural irregularities
- Hot flashes: the MOST COMMON symptoms and gives the most issues: lasts a while and shows up early too
- sexual dysfunction: due to decreased lubercation & concurrent mood disorders
- sleep disturbances: due to hot flashes and mood disorders
- mood disorders: anxiet,depression and highest increase in women with pre-exisitng depression
- GU changes: atrophy and dryness This usually presents later, after the hot flashes first
- cognitive changes: women present with “foggy” but no clinical sigsn of decresed cognition: they actaully have good mental function early on with estrogen decline
Hot Flashes: when they occur
why they occur
symptos and specifics
Hot Flashes in Menopause & peri-menopause
a common and early sign: beginning in perimenopause
- considered the Hallmark syptoms of menopausal transition
Symptoms
- sudden sensation of heat: centered in teh chest and face = then RAPIDLY becomes a generalized feeling acorss the body
- happening frequently: several times a day
- increased and most bothersome at night impacting sleep!!
Duration
- textbook: diminisheds within a few years
- reality: can persist for as long as 20 years past FMP
Differntial between hot flashes and other dx.
- hot flasesh will be short in duration and body disturbution of symptoms AND the presence of fluctuation menses
Hot Flashes: Treatment
Treatment
First line : Estrogen
- most often used and first line
Clonidine
- central alpha agonist (decrease sympathetic action)
- works well but watch anti-cholenergic symptoms
SSRI and SNRI
- effective for hot flashes and sleep/mood disturbances in combo.
- sleep = best is mertazapine
- avoid paroxetine and fluoxetine in those women whoa re taking tamoxifen
Black Cohosh: a supplement, unregualted and can stimulate breast and uterine tissue watch out
Gabapentin
- good at decreasing hot flashes
- but fatigue limitis dose: give at bedtime becuase thats whent eh flashes are the most botehrsome and will help with the fatigue SE
Tibolone
- not in US; avoid
Hormone Thearpy
indications
what preparations for what symptoms
menopausal hormone therapy (MHT) is indicated for the management of menopasual symptoms (hot flashes and Gu symptoms) ONLY – NOT for the prevention of CVD, OP or dementia
Treatment of the Vasomotor Symptoms: hot flashes
- oral and transdermal formualtion
- high does cane be used
Treatment of the Vulvovaginal atrophy
- topical/vaginal preparations are preferred
- creasm, tablets nad rings
Menopausal Hormne therapy (MPT)
side effects & complications
breast and endometrial CA
VTE and Stroke
Uterine Bleeding
Endometrial Cancer
- unapposed estrogen use can cause endometrial hyperplasia = 2-8x risk
- recommendation: used COMBINATION treatment (with progestin) to avoid this
Breast Cancer
- long term use (4-10 years) assocaited with a mild increased risk
- adding progestine does not decrease, may increase this risk
Thromboemolic Disease
- seen in estrogen alone and in combination
- increased risk fo VTE: because estrogen works directly on liver to increase coag factors = hypercoaguable state
Stroke
- increase risk of stroke in estrogen alone and combo meds
Uterine Bleeding
- estrogen alone can lead to endometrial hyperplasia
- combined HT may lead to scheudles or unscheudled bleeding but does lower risk of hyperplaisa
Menopausal Hormne therapy (MPT)
side effects & complications
Gallbladde and Lipids
Lipids
- estrogen increases HDL and TG, lowers LDL
- thus, thsoe with increased TG or familial hypertriglycerides can have increased risk of pancreatits
Gallbladder
- increased lipids can accumulated in bile and created gallstones
Contraindications to Hormone Thearpy
undiagnosed abnormal vaginal bleeding
Known, suspected or history of breast cancer
known, suspected estrogen-deended neoplasia (endometrial CA) : treated ovarian or cervical CA is not a contraind.
active or pmhx. of DVT or PE
arterial thromboemoblic disease (MI or stroke)
liver dysfunction/disease
How to Evaulate menopause
general approach
General evaulation
- if < 40 = think other causes or priamry ovarian sufficiency
- 40-45 or 45+ = think menopuase
Evaulate mentraul hx. and complete list of symptoms (sleep, mood, hot flashes, etc.)
**ALL WOMEN WITH symptoms of vaginal dryness, dyspareunia or sexual dysfunction need a pelvic exam: looking for vaginal atrophy
How to Evaulate menopause
in women 45+
For women 45+
- women presenting with menopasual symptoms are more likely to be going through menopoause than have a new underlying endocrined disorder
those 45+ with typical symptoms + irregular menses do no need a diagnostic evaluation
Labs
- changes in menstruation are better predictors than the labs
- MUST GET hcg pregnancy test in all sexually active women we are not using reliable contraception
- can get FSH: but not necessary to make dx and can be misleading
- addition endocrin testing can be done if there are symptoms suggestive of other disorders
How to Evaluate menopause
in women 40-45
women 40-45 with irregular menstrual cycle (with or without menopausal symptoms) it is reasnable to consider them to be perimenoupausal
BUT
you must still rule out other diagnosis: because this is a littler early
LAbs
- HCG : preg test
- prolactin: for hyperprolactinemia
- TSH: thyriod
- FSH: measures but not typically helpful or needed
