Menopause Flashcards
What is natural menopause?
The permanent cessation of menses of 1 year’s duration secondary to lack of estrogen production by the ovaries
What is perimenopause?
The time period prior to menopause which is characterized by menstrual cycle irregularity, increased frequency of anovulatory cycles, and symptoms similar to menopause
What is the average age at which women in North America reach menopause?
51yo
What are the three types of early natural menopause?
Primary ovarian insufficiency: before 40, but can still have irregular or transient menstruation
Early menopause: Before age 45
Premature menopause: Before age 40
What are some precipitating factors for early-onset menopause?
- Smoking
- Exposure to toxins
- Chemotherapy
- Hysterectomy
- Lower socioeconomic status, childbirth, and CHC use
What is the most significant hormonal changes during menopause?
Ovarian secretion of estradiol ceases, and ovulation doesn’t occur. As a result, progesterone concentrations also stay low. The pituitary secretes FSH and LH, but the ovaries are unresponsive
Higher FSH and LH
Lower estrogen and progesterone
What are some symptoms associated with menopause?
- Vasomotor symptoms (hot flashes and night sweats)
- Sleep pattern changes
- Mood and cognition changes
- Genitourinary changes (urethra and vagina)
- Bleeding changes
What are some of the vasomotor symptoms experienced in menopause?
Hot flashes and night sweats are the classic sign and major complaint of menopause
VMS effects up to 80% of women (start pre-menopause, peak in the the first 2 years, and persist for 7-8 years)
How can hot flashes be characterized?
Sudden onset of intense warmth that begins in the chest and may progress to the neck and face
Accompanied by visible red flushing, sweating
Typically episodic and last, on average, for 4 minutes
VMS associated with diminished sleep quality, irritability, difficulty concentrating, decreased QOL
What causes menopausal women to experience hot flashes?
Narrowing of thermoregulatory system due to changes in estrogen levels, which causes small changes in temp to stimulate sweating or shivering
What treatment strategies are used to treat vasomotor symptoms of menopause?
Non-pharm:
CBT/Lifestyle
Pharmaological therapies:
Menopausal Hormonal Therapy (MHT)
- Estrogen only
- Estrogen+progestogen
- Estrogen+bazedoxifene
- Tibolone
Non-hormonal therapies
What are some lifestyle modifications that can reduce the frequency of VMS?
Stay cool (fans/AC, cool drinks, avoid hot/humid temps)
Avoidance of triggers (caffeine, alcohol, spicy foods)
Exercise, yoga, relaxation training
Weight loss in overweight pts
Smoking cessation
Reduced fat, vegan diet supplemented with soybeans caused an 80% reduction in hot flashes
What are the most effective pharmacological treatment options for VMS in menopause?
Estrogen-only and Estrogen-progestogen therapies are the most effective
Reduce hot flash frequency by 80% and severity by 90%
In which patient group is estrogen-only MHT initiated for VMS in menopause?
Used alone for VMS in women with a hysterectomy
In which patient group is estrogen-progestogen MHT initiated for VMS in menopause?
In patients with a uterus (no hysterectomy)
Why does MHT in women with a uterus need to include progestogen?
Unopposed estrogen therapy is associated with endometrial hyperplasia or cancer
When estrogen dose is matched with progestogen dose, the risk of endometrial hyperplasia is no higher than in untreated women
What are some lower risk estrogen formulations for treating VMS in menopause?
Transdermal patches are reccomended due to lower CV and VTE risk
Transdermal estrogen also sees fewer ADRs like nausea, headache
How to dose and monitor estrogen therapy for VMS in menopause?
Also use most appropriate, often lowest effective doses (titrate based on symptom relief)
Assess for response at 4 weeks at standard dose, and 6-12 weeks for lower doses
Review slide 22 for dosing of different systemic estogen products used to treat VMS in menopause
Review slide 23 for dosing of different EPT combined products used to treat VMS in menopause
Review slide 25 for dosing of different progestogen products used to treat VMS in menopause
What are the advantages of using micronized progesterone vs. regular progesterone?
Lower risk of VTE and breast cancer
What is the utility of bazedoxifene in treatment of VMS in menopause?
It is a selective estrogen receptor modulator (SERM) acts as an antagonist of estrogen receptor on endometrial and breast tissue while acting as an agonist in the bone
Therefore this drug provides endometrial protection without the need for a progestogen (avoids ADRs associated with progestogens, ex. breast tenderness and uterine bleeding)
Progestogen alternative
What is the utility of tibolone in VMS treatment in menopause?
Not a hormone, but synthetic steroid (progestogen analogue)
More effective than placebo, but slightly less than EPT
When is contraception considered in menopause?
If last menses was less than 1 year ago (safe to use in the peri-menstrual period, but do not use once in full menopause as the doses are too high for VMS management and bone benefit)
Options for contraception and VMS management:
- Low dose CHC
- Estrogen+LNG IUS
- MHT+barrier
- Nonhormonal VMS tx option+progestogen only contraception
How are EPT regimens structured?
Estrogen is taken continuously every day
Progestogens can be taken either:
- daily
- cyclically for 12-14 days per month
What are the advantages and disadvantages of taking both estrogen and progestogen components of EPT therapy for VMS in menopause?
Advantages:
Avoids withdrawal bleeding and reduces risk for endometrial hyperplasia
Disadvantages:
May cause unpredictable bleeding
When does withdrawal bleeding occur with EPT therapy (with cyclic progestogen dosing)?
Begins after the last progesterone dose (within 1-2 days)
What are some common side effects associated with estrogen therapy for VMS in menopause?
- Nausea
- Breast tenderness
- Headache
- Bloating
Vaginal bleeding is common in the first 3-6 months
What are some common side effects associated with progestogen therapy for VMS in menopause?
- Irritability
- Breast tenderness
- Bloating
- Headache
- PMS-like symptoms (mood swings, bloating, fluid retention, sleep disturbance, decreased libido)
Vaginal bleeding is common in the first 3-6 months
What are some contraindications for MHT in menopause?
- Unexplained vaginal bleeding
- Active liver dysfunction
- Estrogen-dependent cancer (breast, endometrial, and cervical cancer)
- Pregnancy
- DVT, PE, stroke, MI
- Untreated or unstable CVD
What risk factors should cause HCPs to consider non-oral formulations of MHT over oral formulations?
Patch formulations are preferred in the following patient groups:
- High TGs
- Liver dysfunction
- Migraines
- Established CVD
- Past VTE
- DIabetes
- Advanced age and no previous MHT
What is the role of SSRIs in treatment of VMS in menopause?
Alternative to standard (MHT is CI or not desired)
Less effective than MHT, byut still efficacious (reduces VMS by 35-69%)
Which SSRIs are indicated in treatment of VMS in menopause?
Paroxetine
Citalopram
Escitalopram
Venlafaxine
Desvenlafaxine
They work sooner (2-4 weeks) vs depression
What is the utility of fezolinetant in treatment of VMS in menopause ?
Indicated in moderate to severe VMS
modulates activity directly in the thermoregulatory centres in the brain
What is the impact of menopause on bone health?
Low estrogen levels during menopause and post-menopause causes reduced bone turnover and resorption. This leads to accelerated bone loss.
What is the impact of MHT on bone health?
Estrogen component of MHT can reduce fracture risk by 25-40% in postmenopausal women
Indicated for the prevention of osteoporosis only, not for treatment
In which populations is MHT for osteoporosis prevention a safe medical treatment?
In women under 60 or those who had onset of menopause less than 10 years ago
What is the impact of estrogen on the CV system?
It causes vasodilation with short-term use
With long-term use it lower LDL, fibrinogen, and increase HDL
In younger women (under 60) and less than 10 years since menopause transition there is no increased CHD risk
In older women (over 60) and more than 10 years since menopause transition, there is increased risk of CHD, VTE, and stroke
Can MHT be initiated in women with a history of breast cancer?
No, systemic HT is not advised
Need to consult with specialist to initiate estrogen therapy in these patients
Review slide 59 for benefits and risks of MHT
Besides VMS, what are some other symptoms experienced during menopause?
- Sleep pattern changes
- Mood and cognition changes
- Genitourinary changes
- Bleeding changes
What is the impact of menopause on sleep?
Sleep difficulty is a hallmark sign of menopause transition
Time until sleep onset and insomnia are increased during (peri-)menopause
Negative impact on QOL
What is the impact of menopause on mood?
In women with moderate-severe VMS, they are 3x more likely to have moderate-severe depressive symptoms
Need to use antidepressants and CBT to treat
What is genitourinary syndrome of menopause (GSM)?
GSM refers to the signs/symptoms resulting from estrogen deficiency on the genitourinary tract
Common symptoms:
- Vaginal dryness
- Vaginal itching/irritation
- Burning
- Painful intercourse
- Lower urinary tract symptoms (polyuria, urgency, UTIs)
- Nocturia, dysuria
These symptoms may last for a couple of years after menopause
What are some treatment options for genitourinary syndome of menopause?
1st line:
- Non-hormonal lubricants (use with intercourse)
- Moisturizers (use regularly)
Other options:
- Vaginal estrogen preparations (use for at least 3 months)
- Vaginal creams (estrogen)
- Vaginal rings (estrogen)
- Vaginal estrogen tablets
What are some non-hormonal pharmacological treatments for GSM?
Prasterone (no hormonal activity, but is locally converted by vaginal cells into E and P, very limited systemic absorption)
Ospemifene (non-hormonal SERM, do not give with estrogen or progesterone)
What are some nuissance symptoms associated with menopause?
- Gradual weight gain due to reduced resting metabolic rate
- Skin changes (thinner, and less elastic, more facial hair, acne)
- Irregular menstrual cycles during menopause transition period (dysfunctional uterine bleeding, endometrial hyperplasia, benign lesions)
How is abnormal uterine bleeding treated in menopausal patients?
Low dose OCPs or Progestin therapy
Treatment is aimed at regulating bleeding patterns
