Menopause Flashcards
1
Q
Menopause
A
- Cessation of menses for 12 months; with no obvious pathologic or physiologic cause
- Diagnosed retroactively
- Avg. age is 51.4
- Occurs due to programmed loss of ovarian follicles during aging process
2
Q
Menopause NAMS Definition
A
- Menopause is a normal, natural event defined as the final menstrual period (FMP)
- It represents the permanent cessation of menstruation resulting from loss of ovarian follicular function usually due to aging
3
Q
Cause of Menopause
A
- Aging of female reproductive tract is a continuum that begins at birth
- Loss of oocytes from atresia does not occur at steady rate (increases at 37)
- Reflective of nearly complete depletion of ovarian follicles, and near cessation of ovarian estrogen production
4
Q
Types of Menopause
A
- Natural or spontaneous (12 consecutive months of amenorrhea)
- Induced:
*surgical (B/L oopherectomy/BSO)
*chemo
*radiation therapy
- Premature: <40 y/o natural or induced
5
Q
Premature Ovarian Insufficiency
A
- Loss of ovarian function <40 y/o resulting in amenorrhea (usually permanent)
6
Q
Premature Ovarian Insufficiency Cause
A
- Etiology:
*idiopathic
*autoimmune
*turner’s syndrome
*fragile X syndrome (FMR1)
7
Q
Premature Ovarian Insufficiency Diagnosis
A
- FSH>40 mIU/ML (x2 a month apart)
8
Q
Age of Menopause
A
- Avg: 51.4
- Late: >55
- Early: 40-45
- Premature ovarian faiure and deserves workup: <40
- Genetics, ethnicity, smoking and reproductive history all play a role
9
Q
Genetic variants affecting age of menopause
A
- BRSK1, MCM8
- Variations in estrogen receptor gene
- Family history of early menopause confers higher risk
10
Q
Factors that result in earlier menopause
A
- Genetics
- Earlier in hispanics, later in japanese americans compared to caucasian americans
- Smoking reduces age of menopause by 2 years
- Nulliparas (no kids) will tend toward earlier menopause
- Galactose consumption, DM1, DES exposure may also cause earlier menopause
11
Q
Perimenopause
A
- Occuring right before menopause
- Decreased # of follicles
- Decreased production of inhibin B
- Increased production FSH
- Remaining follicles response poorly to FSH
- Shorter follicular phase
- Estradiol variable
- Decrease luteal phase progesterone
- Erratic ovulation results in menstrual cycle irregularity
- Hot flashes
12
Q
Perimenopausal Treatment
A
- Low-dose OCPs, if not contraindicated
- Higher dose hormone than menopausal HT
- Stop OCPs early 50’s
- FSH unreliable
13
Q
Menopausal Transition
A
- Elevated FSH
- Variable cycle lengths
- Progresses to skipped cycles. At least 2 skipped cycles and at least 60 days of amenorrhea, +/- hot flashes
- Ends w/ final menstrual cycle (cannot be recognized until 12 months later)
14
Q
Postmenopause
A
- First 5 years after the final menstrual period, and includes further ovarian function dampening, hot flashes and accelerating bone loss
15
Q
Chronic anovulation + progesterone deficiency results in?
A
- Endometrial hyperplasia
16
Q
Endometrial biopsy
A
- Standard surveillance when women present w/ abnormal bleeding regardless of whether you think they’re just going through perimenopause
17
Q
Heavy or irregular bleeding treatment
A
- After ruling out cancer w/ biopsy can treat w/ low dose OCP or intermittent progestins
18
Q
2 major symptoms of menopause
A
- Vasomotor (VMS)
*hot flashes (mild, moderate, severe)
*night sweats
- Vulvovaginal atrophy (VVA)
*genitourinary symptoms; vaginal dryness, etc.
19
Q
Menopausal Vasomotor Symptoms
A
Hot Flashes
- Very common; 75% of women
- Usually limited to 1-5 years duration, but some may persist beyond age 70
- Last 2-4 min. ea. w/ sweating, palpitations and anxiety; occur mostly during the night, up to several times in 24hrs
- Exact cause is unknown
20
Q
Menopausal vulvovaginal symptoms
A
- Vaginal Dryness
*Hypestrogenic state leads to thinning of vaginal epithelium, itching, dyspareunia
- Pale mucosa w/ loss of rugae, pH increased to 6.0-7.5 from normal of 4.0-4.5
- Dysuria
- Urgency
- Dyspareuenia
21
Q
Urinary symptoms of menopause
A
- Hpoestrogenism results in atrophy of the urethral epithelium
- Atrophic urethritis
- Diminished urethral mucosal seal
- Loss of urethral compliance
- Urethral irritation
- UTI is more common postmenopausal
All predispose to and urge urinary incontinence
22
Q
Hypoestrogenism beneficial effects
A
- Fibroids will usually decrease in size and symptoms
- Adenomyosis will decrease in symptoms
- Endometriosis will decrease in symptoms
23
Q
Chief complaints from menopausal women
A
- Palpitations
- Panic attacks
- Depression
*incidence 20%
*increased sx during menopause transition
*decreased sx after menopause
24
Q
Menopausal Side Effects
A
- Palpations
- Panic attacks
- Depression
- Breat pain: common in early menopause then tends to fade; ultimately will decrease in glandular tissue w/ fatty replacement
- Menstrual migraines: cluster at the onset of menses; tend to worsen during menopausal transition
- Skin changes: collagen content of teh skin is reduced by estrogen deficiency, leading to wrinkles
- Joint pain
- Bone loss
- Dementia
- Cardiovascular disease
25
Menopausal Bone Loss
- Begins during the transition
- Early postmenopausal bone mass loss approx. 2%/yr in spine and 1%/yr in hip
26
Menopausal Bone Loss Treatment
- At least 1200mg/day calcium and 800 iu/day Vitamin D dietary intake or supplements
- DEXA beginning at age 65, or younger w/ increased personal risk factors
- Raloxifene, bisphosphonate, calcitonin, estrogen, PTH all therapies for more severe bone mass depletion
27
Menopausal dementia
- Estrogen receptors are found densely within the basal forebrain, an area relevant to cognitive function
- Estrogen protects neurons from excitotoxicity and shields them from free radicals
- BUT... it is also linked to inflammation and risk of stroke
- Estrogen certainly plays a role in supporting cognitive function, but complex
28
Menopause and Cardiovascular disease
- Earlier age of menopause may be assoc. w/ increased CHD
29
WHI Study
- Controversial, polarizing RCT forever changed OB/GYN and women's health care
- Primary endpoint CHD
- Stopped prematurely: breast ca \> stopping rules
- Impact
\*discontinuation of HRT
\*confusion
\*fear
\*litigation
30
Diagnosing Menopause
- Best approach is menstrual cycle journal or thorough history
- Serum markers (FSH, estradiol, inhibin, etc) can be helpful, but are not recommended for making a firm diagnosis
- Serum markers can be affected by timing of ovulation and cycle day, or even hour-to-hour changes, and are not always reliable
31
Menopause Differentials
- Hyperthyroidism; irregular menses, sweating, mood changes
- Pregnancy, hyperprolactinemia
- Medication reaction or side effect
- Carcinoid, pheochromocytoma, malignancy
32
Mild VMS Treatmet
Lifestyle modifications
- Regular exercise
- Weight management
- Smoking cessation
- Avoidance of known triggers
33
Moderate to Severe VMS Treatment
Treatment of hot flashes, night sweats
- Hormonal treatment
- Estrogen therapy most effective treatment for mod to severe symptoms of vulvar and vaginal atrophy
34
Timing of Hormonal Therapy
- Soon after menopause
- Starting HT remote from menopause may increase CHD risk
- Both ET and EPT appear to
\*increase ischemic stroke risk
\*have no effect on hemorrhagic stroke risk
35
Hormonal Therapy Risk
- Venous thromboembolism (VTE)
- VTE risk emerges soon after HT initiation (1-2yr); decreases over time
- Lowe VTE risk w/ either EPT or ET in women \<60
- Possible lower VTE risk w/ transdermal than with oral ET
- Lower HT doses may be safer than higher doses
36
Estrogen Therapy Risk
- Unopposed systemic ET assoc. w/ increased endometrial cancer risk related to dose and duration of use
- Concomitant progestogen recommended for women w/ intact uterus
37
Off-Label Use for VMS medication
- SSRI
- SNRI
- Clonidine
- Gabapentin
