MENOPAUSE Flashcards
natural menopause
the permanent cessation of menses
natural menopause is defined after ___________ of no menses
Defined retrospectively after 12 months of no menses without any other explanation
median age of menopause
51
with menopause = will have an elevated FSH level, however
Elevated FSH not needed for dx in woman over 45 ( Dx based on hx and symptoms)
LH acts on ____________ to release __________
theca cells to release progesterone
FSH acts on __________ to release ___________
granulosa cells to release estradiol
Natural menopause represents the depletion of _________________ and is therefore manifested by low ____________, high ___________, and _________________________
ovarian follicles
low estrogen
high FSH
loss of natural reproductive ability
in menopause, the ovaries continue to make
testosterone
Estrone (E1) is converted from androstenedione in fat cells
surgical menopause
the removal of both ovaries before natural menopause
premature ovarian insufficiency
menopause before age 40
perimenopause
- “menopausal transition” of about 4 years, beginning around age 47
- have wide fluctuations of estrogen, hot flashes, decreased ovulation & irregular menses
MENOPAUSE IS INFLUENCED BY
⦁ Genetics
⦁ Smoking (smokers have an earlier menopause than non-smokers)
MENOPAUSE IS NOT INFLUENCED BY
⦁ Age of menarche (age of first period) ⦁ Number of pregnancies ⦁ Use of oral contraceptives ⦁ Race ⦁ SES
SIGNS/SYMPTOMS OF MENOPAUSE
- hot flashes
- night sweats
- mood changes
- memory changes
- hair / skin / nail changes
- osteoporosis
- urogenital atrophy
- sleep disturbances independent of night sweats
- lipid changes
HOT FLASHES / NIGHT SWEATS
can last ___________
May be accompanied by ____________
incidence varies widely; may be more influenced by _________ than by __________
2-4 minutes
palpitations
may be more influenced by BMI than race/ethnicity
hot flashes / night sweats represent thermoregulatory dysfunction at hypothalamus
Symptomatic women trigger mechanisms to dissipate heat at a lower core body temperature with inappropriate peripheral vasodilation
duration of hot flashes / night sweats
⦁ median duration = 7.4 years, with 4.5 of those years after the final menstrual period
⦁ 8-9% may have hot flashes more than 20 years after menopause
HAIR SKIN NAIL CHANGES
decreased skin __________ & ___________
increased _________________
decreased skin thickness & elasticity
increased facial hair - related to decreased SHBG (due to low estrogen) causing increased free testosterone
osteoporosis occurs because
estrogen receptors are present in osteoblasts
(decreased estrogen –> decreased osteoblast function)
⦁ bone density decreases 1-2% / year vs 0.5% / year in perimenopause
LIPID CHANGES IN MENOPAUSE
- increased ____________ & decreased __________
decreased HDL (good)
increased LDL (bad)
UROGENITAL ATROPHY
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
DIAGNOSIS OF MENOPAUSE
o Women > 45
⦁ diagnosis by menstrual history - with or without menopausal symptoms
⦁ no reliable way to predict the final period
o Women 40-45
⦁ diagnosis by menstrual history, but also need labs to rule out other explanations for menstrual changes
⦁ TSH, prolactin, and hCG
o Women with hysterectomy / endometrial ablation
⦁ assess menopausal symptoms
⦁ FSH
DIAGNOSIS OF MENOPAUSE IN WOMEN > 45
can diagnose based on menstrual history
with or without menopausal symptoms
there is no reliable way to predict the final period
DIAGNOSIS OF MENOPAUSE IN WOMEN 40-45
diagnosis by menstrual history, but also need labs to rule out other explanations for menstrual changes
labs: TSH, prolactin, and hCG
what labs are needed to diagnose menopause in women aged 40-45
TSH
Prolactin
hCG
DIAGNOSIS OF MENOPAUSE IN WOMEN WHO HAVE HAD A HYSTERECTOMY / ENDOMETRIAL ABLATION
Assess menopausal symptoms
Get FSH
HORMONE REPLACEMENT THERAPY IS NOW CALLED
MENOPAUSE HORMONE THERAPY
MENOPAUSE HORMONE THERAPY includes the replacement of
⦁ Estrogen
⦁ Progesterone
⦁ Testosterone
THE BENEFITS OF ESTROGEN
1) control of vasomotor symptoms (VMS) (hot flashes / night sweats)
2) relief from urogenital atrophy symptoms
3) maintain bone density (decreased hip fractures)
the many options to initiating drug therapy for menopause
- Regimens containing estrogen with or without the addition of a progestin
- Nonhormonal options such as SSRIs & Gabapentin
- Estrogen agonist / antagonist agents & tissue selective estrogen complexes
tamoxifen is an
estrogen agonist
drug therapy depends on whether they still have a uterus or not
if they still have a uterus = _______
if no uterus = __________
still have a uterus = need both estrogen & progesterone; can’t just give estrogen → sets them up for endometrial cancer
no uterus = just estrogen
giving just estrogen to a menopausal women with a uterus = sets her up for
endometrial cancer
alternatives to estrogen = SSRIs & SNRIs
Venlafaxine (withdrawal symptoms)*
Paroxetine (Brisdelle) FDA approved lower dose 7.5 mg
Fluoxetine (Prozac)
Some recommendations for citalopram/escitalpram
issue with venlafaxine =
withdrawal symptoms
SNRI
other alternatives to estrogen other than SSRIs and SNRIs
- Gabapentin
- Cetirizine (Zyrtec)
- Clonidine
clonidine SE
dry mouth
constipation
dizziness
integrative modalities with inconsistent studies
Soy (isoflavones) Black cohosh Acupuncture Weight loss Mind-body therapies Cognitive behavioral therapy Hypnosis Vitamin E
RISK OF CVD WITH ESTROGEN
- The risk of CVD (cardiovascular disease) appears to be influenced by age of exposure to estrogen (usually cardioprotective when young)
⦁ no excess risk, and possible cardioprotection with use immediately after menopause. Jen says studies show about 4 years out, should start to d/c estrogen and switch to alternative
⦁ risk of CVD was only when using estrogen 10 years out of menopause; can use estrogen during that time period, however, if pt then has a heart attack, she is now at increased risk of CVD from the estrogen
risk of breast cancer
with estrogen + progesterone
not with just estrogen therapy
rather than progestins like medroxyprogesterone acetate, ________________ is preferred
micronized progestin (natural)
why is micronized progestin preferred over medroxyprogesterone acetate?
Associated with lower risk of thromboembolism, stroke and elevated triglycerides
Has not been associated with increased risk of breast cancer or CVD
the slight decrease in testosterone production that accompanies menopause can cause a
significant decrease or complete loss of libido in some women
⦁ testoserone can be added in doses of 1.25 - 2.5 mg methyltestosterone
⦁ wouldn’t ever give testosterone alone; ass add on therapy - usually for decreased libido, but also see an increase in energy as well
- the ovarian androgen production (testosterone) decreases at menopause –> can lead to decreased sexual function in postmenopausal women
- can use testosterone replacement (usually 1 or 2% cream)
SE OF TESTOSTERONE
⦁ Acne & Hirsutism
⦁ Decreased HDL
⦁ Testosterone is aromatized to estrogen**
goal of free testosterone level
5-10
why do free testosterone levels need to be checked
because of decreased SHBG (sex hormone binding globulin) due to decreased estrogen, leads to increased free testosterone levels
how often to check free testosterone levels
every 6 weeks until stable, then every 6 months
with testosterone therapy, there is some concern about long-term _____________ effects
CV
If symptoms of urogenital atrophy are the only reason to use estrogen, is it recommended to use local estrogen or systemic estrogen?
local estrogen
- if systemic symptoms, will usually need a systemic approach - oral hormones or non-hormonal therapy (SSRIs/SNRIs / Gabapentin / Clonodine)
⦁ Nothing works as well as estrogen for vasomotor symptoms but consider other approaches first
give synthetic progestin or natural progesterone if the uterus is present?
natural progesterone (micronized)
A woman with a uterus using estrogen NEEDS ___________________ to protect the endometrium from unopposed estrogen, which increases the risk of hyperplasia & cancer
A PROGESTIN
unopposed estrogen increases the risk of
endometrial cancer
hyperplasia & cancer
how does estrogen cause a risk of clotting?
increases plasma fibrinogen and the activity of coagulation factors, especially factors VII and X;
antithrombin III, the inhibitor of coagulation, is usually decreased
why is transdermal estrogen safer than oral
Less stimulation of clotting proteins by avoiding the first pass effect thru the liver = lower risk of VTE and stroke
forms of estrogen
- pills
- transdermal
⦁ patches
⦁ gels / lotions / mist - Intravaginal
⦁ creams
⦁ tablet
⦁ ring
if ONLY treating vaginal dryness/atrophy =
may use topical estrogen cream
The woman inserts 2-3 grams with a syringe into the vagina usually 2-3 x a week
(at night, so gravity doesn’t make it come out during the day)
should you be concerned about endometrial hyperplasia in women with a uterus using topical estrogen?
no, not enough is absorbed systemically to worry about endometrial hyperplasia
if someone with a uterus is being put on estrogen, now have to give progesterone too:
Progesterone forms =
⦁ Medroxyprogesterone acetate
⦁ Micronized oral progesterone
⦁ Levonorgestrel - releasing IUD (mirena) - not FDA approved in US for this purpose of endometrial protection, but is still used sometimes
in terms of progesterone forms, there is less cancer risk associated with ___________ than with ____________
Less cancer (breast cancer) is associated with micronized oral progesterone than with medroxyprogesterone acetate
the benefit to risk ratio is FAVORABLE for hormone therapy for women who are:
1) within 10 years of menopause onset
or
2) less than 60
WOMEN WHO SHOULD NOT BE GIVEN HRT
⦁ hx of breast cancer ⦁ hx of endometrial cancer ⦁ coronary heart disease ⦁ previous thromboembolic event ⦁ stroke ⦁ acute liver disease ⦁ uncontrolled HTN ⦁ or at high risk of complications
endometrial hyperplasia or cancer can occur within ________ months of starting unopposed estrogen
6
who needs an endometrial biopsy
- before starting HRT in women with irregular bleeding
- for any woman on continuous therapy who spots or bleeds after 6 months
- bleeding or spotting after a year of amenorrhea in women not on hormones
