Menopause

Question 1

Menopause transition
Perimenopause
Postmenopause

Answer 1

Menopause transition - time before the final menstrual period when menstrual cycles become irregular (+/- 7 days) /menopause symptoms begin

Perimenopause - starts with menopause transition, throughout 12 months s/p final menstrual period, can last 4-8 years

Postmenopause - starts at 1 year post-menopause

Question 2

Pathophysiology of VMS

Answer 2

KNDY neuron un-regulation
- Estrogen inhibits (low in menopause)
- Neurokinin B stimulates

Question 3

Risk factors for worse VMS, vaginal dryness, depression

Answer 3

Greater risk of VMS:
- AA
- Obese

Greater risk of vaginal dryness:
- Hispanic

Greater risk of depression:
- AA
- Hispanic

Lowest risk of menopausal symptoms:
- Asian

Question 4

WHI findings

Answer 4

• 2002
• Large, long-term RCT of HT in women 50-79 years
• Average age = 63 yo (old! comorbidities!)
• 2 arms:
  1. CEE 0.625 mg (Premarin) + MPA 2.5 mg (Provera) vs placebo
  2. Women without uterus: CEE 0.625 mg (Premarin) alone vs placebo

*Discontinued E+P arm early due to increased risk of breast cancer, stroke, CHD, VTE

*Discontinued E only arm due to increased risk of stroke

Question 5

Follow-up WHI findings

Answer 5

18 year follow-up

If <60 years old or within 10 years of menopause onset, LOWER all cause mortality (protected from CHD!) in women on HRT x 5-7 years

*Transdermal E2 HRT can actually decrease diabetes risk (because estrogen deficiency increases insulin resistance in menopause)

Question 6

Risk of breast cancer may be lower with which form of progesterone in HRT?

Answer 6

Micronized (rather than MPA) aka Prometrium

*Remember has peanut oil

Question 7

What percentage of women will have return of VMS after stopping HRT?

Answer 7

50% (8% will have long-term)

Question 8

FDA approved indications for HRT

Answer 8

1. VMS
2. Osteoporosis
3. Premature hypoestrogenism
4. GSM (Genitourinary)

Question 9

Contraindications to HRT

Answer 9

• Unexplained vaginal bleeding
• Active liver disease
• Personal history of breast/endometrial cancer
• CHD
• Stroke
• Dementia
• Inherited/personal history of high-risk VTE
• Hypertriglyceridemia
• Porphyria cutanea tarda

Question 10

RFs for osteoporosis

Answer 10

• Age
• Low BMI
• Asian
• FH of osteoporosis
• Smoking
• Eating disorder
• Malabsorption
• Cushing, glucocorticoids
• Hyperparathyroidism
• AIs

Question 11

Screening age for osteoporosis?

Answer 11

65 yo for general pop

Earlier if: history of fracture since menopause, known medical reason for fracture

50+ yo if:
- BMI < 21
- Smoker
- Hip fracture in a parent
- Recent discontinuation of estrogen

Question 12

FDA approved for female pattern hair loss?

Answer 12

Minoxidil 5%
Takes 4-6 months