Menopause

Question 1

1. What is menopause?
2. Median age?
3. Elevation of what is not needed for women over 45?

Answer 1

1. Permanent cessation of menses
   - Defined retrospectively after 12 months of no menses (Without any other explanation)
2. Median age around 51.4
3. Elevated FSH not needed for dx in woman over 45

Question 2

NATURAL MENOPAUSE:

1. Represents depletion of what?
2. manifested by what? 3
3. Ovarian continues to make what?
4. _________ is converted from androstenedione in fat cells

Answer 2

1. ovarian follicles
2. • low estrogen production,
   • elevated FSH and
   • loss of natural reproductive ability
3. testosterone
4. Estrone (E1)

Question 3

1. What is surgical menopause?
2. Premature ovarian insufficiency?
3. What is Perimenopause?
4. What is it characterized by? 4

Answer 3

1. SURGICAL MENOPAUSE:
   Removal of both ovaries before natural menopause
2. PREMATURE OVARIAN INSUFFICIENCY:
   Menopause before age 40
3. “Menopausal Transition” of about 4 years beginning around age 47
4. • Wide fluctuations of estrogen,
   • hot flushes,
   • decreased ovulation and
   • irregular menses

Question 4

Menopause: Influences
1. Not influenced by? 5

2. Is influenced by? 2

Answer 4

1. Not influenced by :
   - Age of menarche
   - Number of pregnancies
   - Use of oral contraceptives
   - Race
   - Socioeconomic status
2. Influenced by:
   - Genetics
   - Smoking

Question 5

Menopause: Signs and Symptoms

1. Hallmark? 2

Answer 5

1. • HOT FLUSHES/FLASHES
   • NIGHT SWEATS

Question 6

HOT FLUSHES/FLASHES or NIGHT SWEATS

1. How long may they last?
2. May be accompanied by what?
3. What do these symptoms represent?
4. Symptomatic women trigger mechanisms to dissipate heat at a lower core body temperature with what?
5. Incidence varies widely
   May be more influenced by what?

Answer 6

1. Last 2-4 minutes, sometimes followed by chills
2. May be accompanied by palpitations
3. Represent thermoregulatory dysfunction at hypothalamus
4. inappropriate peripheral vasodilation
5. BMI than race/ethnicity

Question 7

Menopause: Signs and Symptoms
HOT FLASHES
1. Duration of the episode itself?
2. 8-9% may have hot flashes more than when beyond menopause?

Answer 7

1. SWAN study: median duration 7.4 years with 4.5 of those years after the final menstrual period
2. 20 years

Question 8

Other S/S of menopause?

6

Answer 8

1. Mood and Memory Changes
2. Skin, Hair and Nail Changes
3. Osteoporosis
4. Sleep disturbances independent of night sweats
5. Lipid Changes
6. UROGENITAL ATROPHY

Question 9

How are the following manifested in menopause:

1. Skin, Hair and Nail Changes? 2
2. Osteoporosis? 2

Answer 9

1. • Decreased skin thickness and elasticity
   • Increased facial hair
2. • Estrogen receptors present in osteoblasts
   • Bone density decreases 1%-2% per year vs 0.5% in perimenopause

Question 10

What is the increased facial hair in menopause due to?

Answer 10

related to decreased SHBG (due to low estrogen) causing increased free testosterone

Question 11

How are the following manifested in menopause:

1. Sleep disturbances independent of night sweats
2. Lipid Changes? 2
3. UROGENITAL ATROPHY? 4

Answer 11

1. Incidence 30-46%
2. • 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

Question 12

Menopause: Diagnosis
1. Women > 45? 2

2. Women 40-45? 4
3. Women with hysterectomy/endometrial ablation? 2

Answer 12

1. • DX by menstrual hx with/without menopausal symptoms
   • No reliable way to predict final period
2. -DX by menstrual hx but also
   get lab to r/o other explanations for menstrual changes
   -TSH,
   -prolactin and
   -hCG
3. • Assess menopausal symptoms
   • Get FSH

Question 13

Menopause: Hot flashes
-Alternative to estrogen Rx?
4

Answer 13

1. SSRIs and SNRIs
2. Gabapentin with predominately night symptoms
3. Cetirizine (Zyrtec)
4. Clonidine (significant dry mouth, constipation and dizziness)

Question 14

1. How do SSRIs and SNRIs work to help with hot flashes?

2. Which ones show efficacy? 3

Answer 14

1. Some block active metabolite of tamoxifen, clinical significance uncertain
2. Randomized, double blind studies showed efficacy with:
   - Venlafaxine (withdrawal symptoms)
   - Paroxetine (Brisdelle) FDA approved lower dose 7.5 mg
   - Fluoxetine

Question 15

Menopause: Tx Hot Flashes
Integrative Modalities with inconsistent studies

8

Answer 15

1. Soy (isoflavones)
2. Black cohosh
3. Acupuncture
4. Paced respirations
5. Weight loss
6. Mind-body therapies
7. Cognitive behavioral therapy
8. Hypnosis

Question 16

What are the types of administration routes for estrogen therapy?
6

Answer 16

1. Pills

Transdermal

2. Patches
3. Gels and lotions and mist

Intravaginal

4. Creams
5. Tablet
6. Ring

Question 17

Menopause: Benefits of estrogen

3

Answer 17

1. Control of vasomotor symptoms
2. Relief from urogenital atrophy symptoms
3. Maintain bone density

Question 18

Menopause:

1. What are some urogenital atrophy symptoms that estrogen could help with? 3

Answer 18

1. Dyspareunia
2. Recurrent UTI or urethritis
3. Irritation of vestibule

Question 19

Estrogen Hormone Therapy
ORAL Estrogen increases hepatic production of what?
6

Answer 19

1. TBG (Patient may need increased dose of levothyroxine)
2. CBG
3. SHBG (less free testosterone)
4. Triglycerides
5. HDL
6. Clotting factors

Question 20

What are the progestins therapies? 3

Answer 20

1. Medroxyprogesterone acetate
2. Micronized oral progesterone
3. Levonorgestrel-releasing IUD
   (Not approved in US for endometrial protection**)

Question 21

Hormone Therapy

What things would lead to favorable outcome for women? 2

Answer 21

1. Within 10 years of onset of menopause

2. Or less than 60 yo

Question 22

Menopause Hormone Use
1. Risk of CHD appears to be influenced by what?

2. Roles of what in breast cancer uncertain?
3. In WHI trial, no increased breast cancer in which group but was seen in which group?

Answer 22

1. age of exposure to estrogen
   - No excess risk and possible cardioprotection with use immediately after menopause
2. estrogen vs progestin
3. estrogen only, estrogen-progestin

Question 23

Menopause Hormone Use
1. Micronized _________ rather than progestins like medroxyprogesterone acetate is preferred:

2. Why? 2

Answer 23

1. progesterone
2. • Associated with lower risk of thromboembolism, stroke and elevated triglycerides
   • Has not been associated with increased risk of breast cancer or CHD.

Question 24

Menopause Hormone Use
INITIAL CHOICES/DECISIONS
What things should affect our decision?
4

Answer 24

1. Is goal vaginal effect only or helping hot flashes (systemic), too ?

If using “systemic”,

2. cyclic vs continuous?
3. Oral or transdermal delivery of estrogen?
4. Synthetic progestin or natural progesterone if uterus present?

Question 25

1. Nothing works as well as estrogen for __________ symptoms but consider other approaches first 2. If symptoms of urogenital atrophy are the only reason to use estrogen, ______ estrogen rather than systemic is recommended 3. A woman with a uterus using estrogen needs a progestin. Why? 4. Transdermal estrogen is safer than oral. Why?

Answer 25

1. vasomotor 2. local 3. to protect endometrium from unopposed estrogen which increases risk of hyperplasia and cancer 4. Less stimulation of clotting proteins by avoiding the first pass effect thru the liver= lower risk of VTE and stroke

Question 26

1. What do you need to do before you start estrogen therapy?

Answer 26

1. Endometrial Sampling | - Before starting therapy in woman with irregular bleeding

Question 27

When else would you want to do endometrial sampling? 2 Endometrial hyperplasia or cancer can occur within how long of starting unopposed estrogen?

Answer 27

1. Any woman on continuous therapy who spots or bleeds after 6 months 2. Bleeding or spotting after a (year) of amenorrhea in woman not on hormones 6 months