Menopause Flashcards
- What is menopause?
- Median age?
- Elevation of what is not needed for women over 45?
- Permanent cessation of menses
- Defined retrospectively after 12 months of no menses (Without any other explanation) - Median age around 51.4
- Elevated FSH not needed for dx in woman over 45
NATURAL MENOPAUSE:
- Represents depletion of what?
- manifested by what? 3
- Ovarian continues to make what?
- _________ is converted from androstenedione in fat cells
- ovarian follicles
- low estrogen production,
- elevated FSH and
- loss of natural reproductive ability
- testosterone
- Estrone (E1)
- What is surgical menopause?
- Premature ovarian insufficiency?
- What is Perimenopause?
- What is it characterized by? 4
- SURGICAL MENOPAUSE:
Removal of both ovaries before natural menopause - PREMATURE OVARIAN INSUFFICIENCY:
Menopause before age 40 - “Menopausal Transition” of about 4 years beginning around age 47
- Wide fluctuations of estrogen,
- hot flushes,
- decreased ovulation and
- irregular menses
Menopause: Influences
1. Not influenced by? 5
- Is influenced by? 2
- Not influenced by :
- Age of menarche
- Number of pregnancies
- Use of oral contraceptives
- Race
- Socioeconomic status - Influenced by:
- Genetics
- Smoking
Menopause: Signs and Symptoms
1. Hallmark? 2
- HOT FLUSHES/FLASHES
- NIGHT SWEATS
HOT FLUSHES/FLASHES or NIGHT SWEATS
- How long may they last?
- May be accompanied by what?
- What do these symptoms represent?
- Symptomatic women trigger mechanisms to dissipate heat at a lower core body temperature with what?
- Incidence varies widely
May be more influenced by what?
- Last 2-4 minutes, sometimes followed by chills
- May be accompanied by palpitations
- Represent thermoregulatory dysfunction at hypothalamus
- inappropriate peripheral vasodilation
- BMI than race/ethnicity
Menopause: Signs and Symptoms
HOT FLASHES
1. Duration of the episode itself?
2. 8-9% may have hot flashes more than when beyond menopause?
- SWAN study: median duration 7.4 years with 4.5 of those years after the final menstrual period
- 20 years
Other S/S of menopause?
6
- Mood and Memory Changes
- Skin, Hair and Nail Changes
- Osteoporosis
- Sleep disturbances independent of night sweats
- Lipid Changes
- UROGENITAL ATROPHY
How are the following manifested in menopause:
- Skin, Hair and Nail Changes? 2
- Osteoporosis? 2
- Decreased skin thickness and elasticity
- Increased facial hair
- Estrogen receptors present in osteoblasts
- Bone density decreases 1%-2% per year vs 0.5% in perimenopause
What is the increased facial hair in menopause due to?
related to decreased SHBG (due to low estrogen) causing increased free testosterone
How are the following manifested in menopause:
- Sleep disturbances independent of night sweats
- Lipid Changes? 2
- UROGENITAL ATROPHY? 4
- Incidence 30-46%
- Decreased “good” HDL
- Increased “bad” LDL
3.
- Vaginal dryness contributes to dyspareunia
- Atrophic urethritis causing dysuria and frequency
- Vulvar and vaginal tissues more easily irritated
- Loss of pelvic organ support and increased prolapse
Menopause: Diagnosis
1. Women > 45? 2
- Women 40-45? 4
- Women with hysterectomy/endometrial ablation? 2
- DX by menstrual hx with/without menopausal symptoms
- No reliable way to predict final period
- -DX by menstrual hx but also
get lab to r/o other explanations for menstrual changes
-TSH,
-prolactin and
-hCG - Assess menopausal symptoms
- Get FSH
Menopause: Hot flashes
-Alternative to estrogen Rx?
4
- SSRIs and SNRIs
- Gabapentin with predominately night symptoms
- Cetirizine (Zyrtec)
- Clonidine (significant dry mouth, constipation and dizziness)
- How do SSRIs and SNRIs work to help with hot flashes?
2. Which ones show efficacy? 3
- Some block active metabolite of tamoxifen, clinical significance uncertain
- Randomized, double blind studies showed efficacy with:
- Venlafaxine (withdrawal symptoms)
- Paroxetine (Brisdelle) FDA approved lower dose 7.5 mg
- Fluoxetine
Menopause: Tx Hot Flashes
Integrative Modalities with inconsistent studies
8
- Soy (isoflavones)
- Black cohosh
- Acupuncture
- Paced respirations
- Weight loss
- Mind-body therapies
- Cognitive behavioral therapy
- Hypnosis
What are the types of administration routes for estrogen therapy?
6
- Pills
Transdermal
- Patches
- Gels and lotions and mist
Intravaginal
- Creams
- Tablet
- Ring
Menopause: Benefits of estrogen
3
- Control of vasomotor symptoms
- Relief from urogenital atrophy symptoms
- Maintain bone density
Menopause:
1. What are some urogenital atrophy symptoms that estrogen could help with? 3
- Dyspareunia
- Recurrent UTI or urethritis
- Irritation of vestibule
Estrogen Hormone Therapy
ORAL Estrogen increases hepatic production of what?
6
- TBG (Patient may need increased dose of levothyroxine)
- CBG
- SHBG (less free testosterone)
- Triglycerides
- HDL
- Clotting factors
What are the progestins therapies? 3
- Medroxyprogesterone acetate
- Micronized oral progesterone
- Levonorgestrel-releasing IUD
(Not approved in US for endometrial protection**)
Hormone Therapy
What things would lead to favorable outcome for women? 2
- Within 10 years of onset of menopause
2. Or less than 60 yo
Menopause Hormone Use
1. Risk of CHD appears to be influenced by what?
- Roles of what in breast cancer uncertain?
- In WHI trial, no increased breast cancer in which group but was seen in which group?
- age of exposure to estrogen
- No excess risk and possible cardioprotection with use immediately after menopause - estrogen vs progestin
- estrogen only, estrogen-progestin
Menopause Hormone Use
1. Micronized _________ rather than progestins like medroxyprogesterone acetate is preferred:
- Why? 2
- progesterone
- Associated with lower risk of thromboembolism, stroke and elevated triglycerides
- Has not been associated with increased risk of breast cancer or CHD.
Menopause Hormone Use
INITIAL CHOICES/DECISIONS
What things should affect our decision?
4
- Is goal vaginal effect only or helping hot flashes (systemic), too ?
If using “systemic”,
- cyclic vs continuous?
- Oral or transdermal delivery of estrogen?
- Synthetic progestin or natural progesterone if uterus present?
- Nothing works as well as estrogen for __________ symptoms but consider other approaches first
- If symptoms of urogenital atrophy are the only reason to use estrogen, ______ estrogen rather than systemic is recommended
- A woman with a uterus using estrogen needs a progestin. Why?
- Transdermal estrogen is safer than oral. Why?
- vasomotor
- local
- to protect endometrium from unopposed estrogen which increases risk of hyperplasia and cancer
- Less stimulation of clotting proteins by avoiding the first pass effect thru the liver= lower risk of VTE and stroke
- What do you need to do before you start estrogen therapy?
- Endometrial Sampling
- Before starting therapy in woman with irregular bleeding
When else would you want to do endometrial sampling? 2
Endometrial hyperplasia or cancer can occur within how long of starting unopposed estrogen?
- Any woman on continuous therapy who spots or bleeds after 6 months
- Bleeding or spotting after a (year) of amenorrhea in woman not on hormones
6 months
