Menopause Flashcards
(71 cards)
1
Q
phase of the aging process during which a woman passes from reproductive to nonreproductive stage
A
Climacteric
Symptoms - “climacteric symptoms” or “climacteric complaints”
2
Q
Part of climacteric before menopause occurs when menstrual cycle is irregular and when other climacteric symptoms or complaints may be experienced
AKA “perimenopause”; usually lasts ____
A
- Menopausal Transition
- 1-3 years
3
Q
Term for final menstrual cycle
avg age?
A
menopause
51
4
Q
Premature menopause happens at what age?
A
40 or younger
5
Q
the phase of life occurring after menopause
Most live at least ⅓ of lives in state
A
Postmenopause
6
Q
As ovaries age, they lose oocytes to ___ and ___
A
ovulation
atresia
7
Q
When do we have the most oocytes?
A
during gestation
8
Q
As ovaries lose oocytes, levels of
____ slowly decrease = higher levels of ____
A
inhibin
FSH
9
Q
Oocytes responsive to ____ disappear from the ovary over time
how does this affect the length of the menstrual cycle?
A
gonadotropins
- Remaining oocytes - less responsive to FSH and LH
- Irregular follicle response to gonadotropins→
- Irregular length of follicular phase→
- Irregular menstrual cycles
10
Q
there may be possible bursts in ____ during menopause
why?
A
estradiol
- 2-3x above normal
- Recruitment of multiple follicles from high FSH
11
Q
- Permanent cessation of ovarian function due to surgical removal of ovaries or by radiation therapy - May be intentionally induced to improve endometriosis or estrogen-sensitive breast CA or endometrial CA
- Usually a SE of tx of intra-abdominal disease
- May be electively removed
term?
A
Artificial Menopause
12
Q
6 predisposing factors
A
- Smoking - advances age by 2 years
- Reproductive tract disease
- Severe GU infections or tumors
- radiation or chemo
- Surgery that impair ovarian
- blood supply
- endocrine or chromosomal abnormality
13
Q
Primary androgen in women
A
androstenedione
14
Q
what happens to androgens during postmenopausal
A
- Decreased production of androstenedione
- Mildly decreased levels of testosterone
- Adrenal glands produce less DHEA and DHEAS
15
Q
what is believed to contribute to virilization sx
postmeopausal hormones - androgens
A
Mildly decreased levels of testosterone
- Androstenedione converted to testosterone
- Decreased sex hormone-binding globulin levels
- Ovary secretes more testosterone after menopause
16
Q
Which form of estrogen do you think would be decreased the most?
A
estradiol
- no circadian variation of estradiol after menopause
- after menopause - primarily secreted by arenal glands
17
Q
Major source of progesterone in young women is ?
A
corpus luteum after ovulation
18
Q
what happens to progesterone uring postmenopausal time
A
- no functional follicles and low progesterone levels overall
- Most remaining progesterone - adrenal glands
- No clinical use found for the measurement of progesterone in postmenopausal women
19
Q
what happens to gonadotropins during postmenopause
A
- FSH and LH rise substantially - FSH usually higher than LH
- Measurement of FSH and LH, along with estradiol, can help diagnose menopause
20
Q
6 common s/s of menopause
A
- menstrual changes
- somatic
- psych and cog
- sexual dys
- vasomotor sx
- other sx - Urinary incontinence; Dysuria; Dry, itchy skin; Hair loss; Hirsutism; Weight gain
21
Q
menstrual changes during menopause
A
- Shorter or longer cycles
- Irregular bleeding
22
Q
somatic changes during menopause
A
- Headache and dizziness
- Palpitations
- Breast pain and enlargement
- Joint aches and back pain
23
Q
Psych and Cognitive changes of menopause
A
- Worsening of PMS
- Depression
- Irritability and mood swings
- Loss of concentration
- Poor memory
24
Q
sexual dysf of menopause
A
- Vaginal dryness
- Decreased libido
- Dyspareunia
25
vasomotor sx of menopause
1. **Hot flashes**
1. Night sweats
1. Sleep disturbances
26
What is the major growth factor of the reproductive tract?
what physical changes of the reproductive tract can happen from menopause if this growth factor is removed?
Estrogen is the major growth factor of the female reproductive tract
* **Vaginal epithelium** - thinning and atrophy with flattening of vaginal rugae and dryness
* **Cervix** - atrophy with decreased size, less cervical mucous, possible canal stenosis
* **Uterus** - atrophy with shrinkage of endometrium and myometrium
* **Oviducts** - decrease in size; usually not palpable on PE
* **Ovaries** - atrophy and decrease in size; less production of hormones; no ovulation; often not palpable on PE
* **Supporting structures** - loss of tone; pelvic relaxation
27
What hormone helps maintain epithelium of bladder and urethra?
what physical changes of the urinary and mammary system from menopause?
estrogen
* atrophy of lower urinary tract epithelium
* **Atrophic cystitis** - urinary urgency, frequency, incontinence, dysuria
* Loss of urethral tone - may see **urethral caruncle** with dysuria, meatal tenderness, and hematuria
* **“Genitourinary syndrome of menopause”**
* **Mammary glands** - regress in size and flatten
28
Atrophic epithelium with flattened rugae
Vaginal burning, soreness, dyspareunia, dryness or thin watery or serous discharge may occur
**Early** - Diffuse or patchy reddening, +/- scattered petechiae, flattened rugae
**Late** - smooth, shiny, pale surface
**Friable mucosa** - may see mild bleeding after minimal trauma (exam, coitus)
**Urinary sx** - urgency, frequency, dysuria, urge incontinence
**pH** - Increased to 5.0-7.0
dx?
how to diagnose?
Atrophic Vaginitis
clinical; May do vaginal cytology to assist - varied findings
29
initial tx for atrophic vaginitis
**1st line - conservative, symptomatic management**
1. **Vaginal moisturizers** - routinely used, not just during sexual activity
- Typically OTC - Replens, Vagisil Moisturiser, K-Y Liquibeads
1. **Lubricants** - with sexual activity
- Water-based (Astroglide, K-Y Jelly), Silicone-based (Pjur), Oil-based (Elegance)
30
mgmt mod-severe atrophic vaginitis
**vaginal estrogen therapy**
* Restored vaginal pH and microflora
* Increased vaginal secretions and thickened vaginal epithelium
* Diminished overactive bladder sx, fewer UTIs
* Is systemically absorbed, but less than oral or transdermal therapy
* Conjugated estrogen (cream) or estradiol (cream, tablet, capsule, ring)
systemic or systemic+vaginal if vasomotor sx present
31
vaginal estrogen therapy may be harmful if pt is on what medication?
aromatase inhibitors for breast cancer
32
alt mgmt for atrophic vaginitis if not responsive to conservative therapy and unable or unwilling to use topical estrogens?
MC SE?
* Ospemifene (Osphena)
* Prasterone (Vaginal DHEA)
* Testosterone
* Pelvic PT
* vitamin supplements, and probiotics - mixed data; laser not effective
33
* alt mgmt for atropgic vaginitis
* SERM that mimics estrogen only in the vaginal tissue
* **Limited data** - no head-to-head studies with vaginal estrogen, no demonstrated safety in women with high risk of breast cancer or VTE
what med?
MC SE?
**Ospemifene** (Osphena)
* **MC SE - hot flashes**; mild endometrial thickening, but no reports of atypical endometrial hyperplasia or endometrial cancer; may reduce bone turnover
34
* Converts androstenedione and testosterone locally to estrone and estradiol
* Still could be problematic for estrogen-sensitive women!
* suppository
which alt tx for atrophic vaginitis?
Prasterone (Vaginal DHEA)
35
**MC and characteristic sx**
Feeling of **heat or burning in face, neck, and chest**
begins with HA-like sense of pressure in head
Pressure increases until physiologic flush
Followed by sweating that affects the entire body but is especially prominent over the head, neck, upper chest, and back
Palpitations, weakness, fatigue, faintness, and vertigo may occur
**75%** of women going through menopause or who have bilateral oophorectomy
dx?
duration/freq?
up to what % will eventually experience this?
hot flashes
* Duration - from seconds up to 10 min (average - 4 min)
* Frequency - 1-2 per hour to 1-2 per week
* **80%** - Most describe sx as “severe;” Only about 20-30% seek help!
36
hot flashes causes true alterations in what signs?
what does it NOT change?
* cutaneous vasodilation, perspiration, reductions of core temperature, and elevations of HR
* _No changes in HR or BP observed_
37
hot flashes can contribute to what other s/s? (3)
1. Night sweats
1. Insomnia
1. Cognitive/psychiatric changes
38
Risk factors for hot flashes?
1. Obesity
1. Lower physical activity
1. Smoking
1. Genetic predisposition
1. Socioeconomic status
1. Ethnicity/Race: AA report more frequently; Japanese and Chinese report less frequently
39
mainstay hormonal tx for hot flashes?
**estrogens**
* Block perceived symptom and physiologic changes; helps improve sleep
* Estrogen/Progestin combo - if pt cannot take estrogen
* Addition of progestins to MHT associated with increased risk of breast cancer
40
what hot flash hormonal tx can be given for women who cannot take estrogens
**Progestin alone**
* Depot medroxyprogesterone acetate 500 mg IM x 1 dose and PRN
* Norethindrone acetate 10 mg PO daily
41
which hot flash hormonal tx is synthetic steroid with estrogenic, progestogenic and androgenic properties
Tibolone
42
* Custom-made hormone formulations with different doses and routes of hormones based on patient serum levels
* Expensive - little research
Bioidentical Hormones - hot flashes
43
possible hormonal tx for hot flashes?
1. estrogen
2. progestin alone
3. Tibolone
4. Bioidentical Hormones
5. Selective Estrogen Receptor Modulator (SERM) + Estrogen
44
non-hormonal tx for hot flashes
1. **SSRI/SNRI**
2. **black cohosh or phytoestrogens:** modest effects; Can stimulate breast and uterine tissue
3. **gabapentin** - Limited by SE of sedation
4. **clonidine**
- more effective than placebo
- anticholinergic SE
- Recommended to use 0.1 mg transdermal patch
5. **CAM** - wt loss, acupuncture, mind-body relaxation, vitamin E
6. **oxybutinin** - anticholinergic SE
7. **neurokinin-3 receptor antagonist**
- experimental new therapy
- Binds to receptors in the hypothalamus to reduce stimulation
- _AST/ALT elevations noted_ in early trials
45
first line in pts who can’t take or don’t want MHT for hot flashes?
use caution with what?
* **SSRIs and SNRIs** - Paroxetine, citalopram/escitalopram, venlafaxine/desvenlafaxine
* **paroxetine** if pt takes **tamoxifen for breast cancer** - Increased risk of breast cancer recurrence or death
46
Known Benefits of MHT
**Reduced menopausal sx** - Improves vasomotor and GU sx
**Reduced risk of osteoporosis** - Improved bone density; Reduced fracture risk; Benefit seen from estrogen (no added benefit from combo tx)
47
For GU sx alone - ____ estrogen as efficacious as oral or transdermal
vaginal
48
Possible Benefits of MHT
1. Improved thickness and collagen of skin
1. Reduced recurrent UTI risk - Vaginal estrogen only
1. Reduced risk of falls
1. Reduced risk of cataracts
1. Reduced risk of osteoarthritis
1. Reduced risk of diabetes
1. Reduced risk of colon and lung cancer
1. Reduced risk of coronary heart disease; Controversial - timing of MHT may play a role
49
5 known risks of MHT
1. endometrial CA
2. Breast Ca
3. thromboembolic dz
4. stroke
5. gallbladder dz
50
how does MHT have endometrial CA risk?
When will they develop endometrial hyperlasia?
how to reduce risk?
* **Unopposed estrogen** → proliferation, hyperplasia, and neoplasia
* 20-50% on unopposed estrogen will have endometrial hyperplasia after **1 year**
* 3x increase in short term (1-5 yrs), 10x increase in long term (10+ yrs)
* Giving **progesterone in combo with estrogen therapy mitigates risk**
51
breast CA is only seen in what MHT?
what else increases RF?
what type of MHT is associated with mild decr risk of breast CA?
* **combo MHT**
* Risk factors include early menarche, late menopause
* _Long-term use of estrogens_ alone associated with mild decreased risk of breast cancer
52
thromboembolic dz has 2x increase with what type of MHT, and 33% increase with what other MHT?
which form of MHT has a lower incidence?
* **Combo** MHT
* **estrogen-only** MHT
* **transdermal** MHT vs. oral MHT
53
Stroke risk is increased in what kind of MHT?
what form has a lower incidence?
* **BOTH** estrogen-only & combo
* **transdermal** vs oral
54
How is gallbladder dz a risk with MHT?
which MHT has a greater risk?
* 2-3x increased risk of gallstones or cholecystectomy
* Greater risk with **estrogen-only** MHT
*4 F's: female, fat, forty, and fertile*
55
Other effects of MHT
1. Lipid metabolism: May have favorable effects on lipids (lower LDL, higher HDL); Can cause increase in triglycerides
1. Other: Similar s/s seen in pts during menstrual cycle!
- Edema and/or abdominal bloating
- Mastodynia and breast enlargement
- Premenstrual syndrome
- HA (esp “menstrual migraine”)
- Excessive cervical mucus
- Other possible SE: Dry eye, Increased seizure risk, Bronchospasm, Increased urinary incontinence
56
CI to MHT
1. **Breast CA** - known, suspected, or history of
1. **Estrogen-dependent CA** - known, suspected, or history of
- endometrial cancer
- undiagnosed abnml vaginal bleeding
1. **DVT/PE** - known or h/o
2. **Arterial thromboembolic dz** - active or recent (< 1 year ago) - MI, stroke
3. **Liver** - dysfunction or disease
4. Hypersensitivity to MHT components
5. **Pregnancy** - known or suspected
57
MHT cautions
1. Gallbladder disease
1. Hypertriglyceridemia
1. Prior cholestatic jaundice
1. Hypothyroidism
1. Fluid retention + cardiac or renal dysfunction
1. Severe hypocalcemia
1. Prior endometriosis
1. Hepatic hemangiomas
58
recommended as 1st-line MHT for vasomotor s/s
1. transdermal - less risk of major SE
0.625 mg of PO conjugated estrogen considered “standard daily dose”
59
starting MHT - If pt still has intact uterus, must add what agent?
progestin
* Medoxyprogesterone acetate (MPA) - most studied
* Micronized progesterone - may have lower risk of breast CA and CHD
* combo in PO & transdermal available
60
Standard recommendation - do not use MHT for more than _____
5 years
61
MHT regimen one
* Estrogen on days 1-25 of each calendar month
* 5-10 mg of progesterone on days 14-25
* Withhold hormones from day 26-end of month
* Will produce **light, generally painless monthly period**
* **Older method - falling out of favor**
62
MHT regimen 2
* Daily estrogen and progestin together without stopping
* Initial bleeding or spotting is common
* Eventually will produce atrophic endometrium
63
Other forms of MHT
1. tibolone
2. progesterone only
3. tissue selective estrogen complexes
4. oral estrogen + levnorgestrel IUD
64
synthetic steroid - estrogenic, progestogenic and androgenic properties
Concerns over CA risk and stroke risk
Not recommended currently for use in most pts
which other form of MHT
Tibolone
65
depot MPA injections or oral norethindrone
May be more effective than SNRI therapy
which other form of MHT
progesterone only
66
* **SERM + estrogen**
* Duavee or BZA/CE - bazedoxifine (SERM) + conjugated estrogen
* _Agonist effects on bone, antagonist effects on endometrium_, neutral on breast
* _minimize risk of breast and endometrial CA and avoiding SE of mastodynia_
* Still has other associated risks (**VTE and liver dz**)
which other form of MHT
Tissue Selective Estrogen Complexes
67
meant to avoid systemic effects of progesterone but prevent endometrial hyperplasia and cancer
Not thoroughly studied; one study - still an increased risk of breast cancer
which other form of MHT
Oral estrogen + levonorgestrel IUD
68
Pharm alt for MHT
1. **SSRIs** - citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil)
- _Paroxetine_ - caution w/ tamoxifen for breast CA
- Can see improvement in days
1. **SNRIs** - venlafaxine (Effexor) or desvenlafaxine (Pristiq)
1. **Anticonvulsants** - Gabapentin (Neurontin), pregabalin (Lyrica)
- _Gabapentin_ - cheaper, more well-studied, may have more SE
1. **Clonidine** - effective > placebo; limited due to SE
1. **Oxybutinin** - effective > placebo; limited due to SE
69
CAM alternatives to MHT
Conflicting reports for most methods
1. **Isoflavones/Phytoestrogen**s - soy, lentils, chickpeas
- Natural SERMs - estrogenic and anti-estrogenic effects
- potential increase breast CA risk or worsen estrogen-receptor + breast CA
1. **Black Cohosh** - natural estrogenic effects
- potential stimulation of breast and endometrium - May also adversely affect liver
- Not shown to be more effective than placebo
1. **Vitamin E** - minimal side effects, ~30% reduction in hot flashes
1. **CBT/Mindfulness/Relaxation techniques** - not much data, but promising; low risk
1. **Wt loss** - not extensively studied; promising early findings
1. **Exercise** - Can trigger hot flashes (ineffective alone)
1. _Not recommended d/t lack of evidence_: evening primrose oil, flaxseed, ginseng, reflexology, acupuncture, magnets
70
for atrophic vaginitis - what type of preparation is preferred?
which ones include nightly dosing?
**Vaginal** > systemic
* **Cream** - conjugated equine estrogens or estradiol; 0.25-2 g given _nightly_ x 2 wks, then 2x per week
* **Rings** - estradiol releasing; 7.5 mcg; remain in place for 3 months at a time; Some prefer rings > cream - more reliable absorption
* **Tablet** - estradiol 4 mcg, 10 mcg; PV _nightly_ x 2 weeks, then 2x per week
71
May use what other cream if estrogen is CI for atrophic vaginitis
testosterone 1-2%
