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
Long Term Consequences of Estrogen Deficiency in the body: post menopausal
Bone Loss: Osteoporosis
- begins during the menopausal transition
- annual rates of BMD loss appear to be the highes during the one year before th FMP through two years after that
Cardiovascualr Disease
- risk of CVD increases after menopcuase
- slightly due to estrogen, but due to the change in lipid profile
Body Composition
- increased fat mass and decrease lean mass
Dementia
- limitied evidence
Osteoarthritis
- some but minamal evidence
Pelvic Organ Prolapse
define
4 types
Define
- decent of one or more pelvic organs into or beyond the vagina
Uterin Prolapse
- the apical compartment prolaspes
Cystocele: herniation of the anterior vaginal wall: bladder
Rectocele: herniation of the posterio vaginal wall: rectum
Enterocele: hernia of intestines through the vaginal wall
Prevelence
- unknown due to poor classification, underreported or undiagnosed
Pelvic Organ Prolapse
Risk Factors
Risk Factors
Parity/Vaginal Births
- risk of POP increases highest from 1st to 2nd birth
Advanced Age
- every 10 years increases risk 40%
Obestiy
- increased pressure on muscles
Hysterectomy or peliv surgery
- insturmentation
Race and ethniticthy : in minorities = more common
Pelvic Organ Prolapse: Symptoms
severit of symptoms does not = stage of prolapse
- postional = worse with standing, better with laying
- symptoms begin when things hit the hymen
Symptoms
- bulge/pressure: falling out of vagina
- urinary symptoms: lost anterior wall support or urethral function
- early on: stress incontinence
- later: difficult to void at all
- defication issues: constipation or incomplete emptying
Uterine Prolapse
weakness of pelvic floor muscles
- apical prolapse
1st degree: urterus within vagina
2nd degree: uterus within the introitus
3rd degree: uterus and vagina are outside intortius
Symptoms
- buldge
- chronic discharge
- bleeding from ulcerations
- stress incontinence
- urinary retetion in severe cases due to kinked urethra
Cystocele
Rectocele
Cystocele
prolapse of the anterior vaginal wall - bladder drops into anterior vaginal chamber
symtpoms
- vaginal buldge/pressure
- urianry: frequency, urgency, retentions, incontinence
- sexual dysfunction
Rectocele
- prolaspe of the posterior vaginal wall - rectum drops into vaginal canal
symptoms
- constipation = MC
- fecay urgency, incontinence
- pain/bleeding or sexual dysfunction
- can require digital “splinting” during defication (finger in vagina to hold
Enterocele
small intestine into the vagain chamber
Symptoms
- low back pain and pulling sensation
- improves with laying down
- peliv fullness or pain
- vaginal pressure/buldge/pain with sex
- constipation
Treatment of Pelvic Organ Prolapse
POP Treatment (decided by symptoms and assocaited conditions
- expectant (do nothing)
Conservative
- vaginal pessary (ring)
- pelvic floor muscle therapy (kegels)
- estrogen therapy no data supports the use of estrogen thearpy
Pessary
- mainstay of nonsurgical treatment: provides support to hernated defet: supportive ring is mC used
- help with symptoms but issue with erosin and bad smell
Surgical treatment for thsoe with symptoms or fialed conservative
oblitrative (no more vagina) no sex
Apical Prolapse repair
Vagingal surgical repair: help with muscles: but high recurrance
Mesh Utalization: higher anatomical success but recurracne
