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WOMEN'S HEALTH > MENOPAUSE > Flashcards

MENOPAUSE Flashcards

1
Q

natural menopause

A

the permanent cessation of menses

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2
Q

natural menopause is defined after ___________ of no menses

A

Defined retrospectively after 12 months of no menses without any other explanation

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3
Q

median age of menopause

A

51

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4
Q

with menopause = will have an elevated FSH level, however

A

Elevated FSH not needed for dx in woman over 45 ( Dx based on hx and symptoms)

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5
Q

LH acts on ____________ to release __________

A

theca cells to release progesterone

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6
Q

FSH acts on __________ to release ___________

A

granulosa cells to release estradiol

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7
Q

Natural menopause represents the depletion of _________________ and is therefore manifested by low ____________, high ___________, and _________________________

A

ovarian follicles

low estrogen
high FSH
loss of natural reproductive ability

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8
Q

in menopause, the ovaries continue to make

A

testosterone

Estrone (E1) is converted from androstenedione in fat cells

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9
Q

surgical menopause

A

the removal of both ovaries before natural menopause

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10
Q

premature ovarian insufficiency

A

menopause before age 40

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11
Q

perimenopause

A
  • “menopausal transition” of about 4 years, beginning around age 47
  • have wide fluctuations of estrogen, hot flashes, decreased ovulation & irregular menses
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12
Q

MENOPAUSE IS INFLUENCED BY

A

⦁ Genetics

⦁ Smoking (smokers have an earlier menopause than non-smokers)

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13
Q

MENOPAUSE IS NOT INFLUENCED BY

A 
⦁	Age of menarche (age of first period)
⦁	Number of pregnancies
⦁	Use of oral contraceptives
⦁	Race
⦁	SES
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14
Q

SIGNS/SYMPTOMS OF MENOPAUSE

A
  • hot flashes
  • night sweats
  • mood changes
  • memory changes
  • hair / skin / nail changes
  • osteoporosis
  • urogenital atrophy
  • sleep disturbances independent of night sweats
  • lipid changes
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15
Q

HOT FLASHES / NIGHT SWEATS

can last ___________
May be accompanied by ____________

incidence varies widely; may be more influenced by _________ than by __________

A

2-4 minutes

palpitations

may be more influenced by BMI than race/ethnicity

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16
Q

hot flashes / night sweats represent thermoregulatory dysfunction at hypothalamus

A

Symptomatic women trigger mechanisms to dissipate heat at a lower core body temperature with inappropriate peripheral vasodilation

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17
Q

duration of hot flashes / night sweats

A

⦁ 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

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18
Q

HAIR SKIN NAIL CHANGES

decreased skin __________ & ___________

increased _________________

A

decreased skin thickness & elasticity

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

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19
Q

osteoporosis occurs because

A

estrogen receptors are present in osteoblasts

(decreased estrogen –> decreased osteoblast function)

⦁ bone density decreases 1-2% / year vs 0.5% / year in perimenopause

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20
Q

LIPID CHANGES IN MENOPAUSE

  • increased ____________ & decreased __________
A

decreased HDL (good)

increased LDL (bad)

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21
Q

UROGENITAL ATROPHY

A

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

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22
Q

DIAGNOSIS OF MENOPAUSE

A

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

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23
Q

DIAGNOSIS OF MENOPAUSE IN WOMEN > 45

A

can diagnose based on menstrual history
with or without menopausal symptoms

there is no reliable way to predict the final period

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24
Q

DIAGNOSIS OF MENOPAUSE IN WOMEN 40-45

A

diagnosis by menstrual history, but also need labs to rule out other explanations for menstrual changes

labs: TSH, prolactin, and hCG

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25
Q

what labs are needed to diagnose menopause in women aged 40-45

A

TSH
Prolactin
hCG

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26
Q

DIAGNOSIS OF MENOPAUSE IN WOMEN WHO HAVE HAD A HYSTERECTOMY / ENDOMETRIAL ABLATION

A

Assess menopausal symptoms

Get FSH

27
Q

HORMONE REPLACEMENT THERAPY IS NOW CALLED

A

MENOPAUSE HORMONE THERAPY

28
Q

MENOPAUSE HORMONE THERAPY includes the replacement of

A

⦁ Estrogen
⦁ Progesterone
⦁ Testosterone

29
Q

THE BENEFITS OF ESTROGEN

A

1) control of vasomotor symptoms (VMS) (hot flashes / night sweats)
2) relief from urogenital atrophy symptoms
3) maintain bone density (decreased hip fractures)

30
Q

the many options to initiating drug therapy for menopause

A
  • 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
31
Q

tamoxifen is an

A

estrogen agonist

32
Q

drug therapy depends on whether they still have a uterus or not

if they still have a uterus = _______

if no uterus = __________

A

still have a uterus = need both estrogen & progesterone; can’t just give estrogen → sets them up for endometrial cancer

no uterus = just estrogen

33
Q

giving just estrogen to a menopausal women with a uterus = sets her up for

A

endometrial cancer

34
Q

alternatives to estrogen = SSRIs & SNRIs

A

Venlafaxine (withdrawal symptoms)*
Paroxetine (Brisdelle) FDA approved lower dose 7.5 mg
Fluoxetine (Prozac)

Some recommendations for citalopram/escitalpram

35
Q

issue with venlafaxine =

A

withdrawal symptoms

SNRI

36
Q

other alternatives to estrogen other than SSRIs and SNRIs

A
  • Gabapentin
  • Cetirizine (Zyrtec)
  • Clonidine
37
Q

clonidine SE

A

dry mouth
constipation
dizziness

38
Q

integrative modalities with inconsistent studies

A 
Soy (isoflavones)
Black cohosh
Acupuncture
Weight loss
Mind-body therapies 
Cognitive behavioral therapy
Hypnosis
Vitamin E
39
Q

RISK OF CVD WITH ESTROGEN

A
  • 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

40
Q

risk of breast cancer

A

with estrogen + progesterone

not with just estrogen therapy

41
Q

rather than progestins like medroxyprogesterone acetate, ________________ is preferred

A

micronized progestin (natural)

42
Q

why is micronized progestin preferred over medroxyprogesterone acetate?

A

Associated with lower risk of thromboembolism, stroke and elevated triglycerides

Has not been associated with increased risk of breast cancer or CVD

43
Q

the slight decrease in testosterone production that accompanies menopause can cause a

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)
44
Q

SE OF TESTOSTERONE

A

⦁ Acne & Hirsutism
⦁ Decreased HDL
⦁ Testosterone is aromatized to estrogen**

45
Q

goal of free testosterone level

A

5-10

46
Q

why do free testosterone levels need to be checked

A

because of decreased SHBG (sex hormone binding globulin) due to decreased estrogen, leads to increased free testosterone levels

47
Q

how often to check free testosterone levels

A

every 6 weeks until stable, then every 6 months

48
Q

with testosterone therapy, there is some concern about long-term _____________ effects

A

CV

49
Q

If symptoms of urogenital atrophy are the only reason to use estrogen, is it recommended to use local estrogen or systemic estrogen?

A

local estrogen

50
Q
  • if systemic symptoms, will usually need a systemic approach - oral hormones or non-hormonal therapy (SSRIs/SNRIs / Gabapentin / Clonodine)
A

⦁ Nothing works as well as estrogen for vasomotor symptoms but consider other approaches first

51
Q

give synthetic progestin or natural progesterone if the uterus is present?

A

natural progesterone (micronized)

52
Q

A woman with a uterus using estrogen NEEDS ___________________ to protect the endometrium from unopposed estrogen, which increases the risk of hyperplasia & cancer

A

A PROGESTIN

53
Q

unopposed estrogen increases the risk of

A

endometrial cancer

hyperplasia & cancer

54
Q

how does estrogen cause a risk of clotting?

A

increases plasma fibrinogen and the activity of coagulation factors, especially factors VII and X;

antithrombin III, the inhibitor of coagulation, is usually decreased

55
Q

why is transdermal estrogen safer than oral

A

Less stimulation of clotting proteins by avoiding the first pass effect thru the liver = lower risk of VTE and stroke

56
Q

forms of estrogen

A
  • pills
  • transdermal
    ⦁ patches
    ⦁ gels / lotions / mist
  • Intravaginal
    ⦁ creams
    ⦁ tablet
    ⦁ ring
57
Q

if ONLY treating vaginal dryness/atrophy =

A

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)

58
Q

should you be concerned about endometrial hyperplasia in women with a uterus using topical estrogen?

A

no, not enough is absorbed systemically to worry about endometrial hyperplasia

59
Q

if someone with a uterus is being put on estrogen, now have to give progesterone too:

Progesterone forms =

A

⦁ 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

60
Q

in terms of progesterone forms, there is less cancer risk associated with ___________ than with ____________

A

Less cancer (breast cancer) is associated with micronized oral progesterone than with medroxyprogesterone acetate

61
Q

the benefit to risk ratio is FAVORABLE for hormone therapy for women who are:

A

1) within 10 years of menopause onset
or
2) less than 60

62
Q

WOMEN WHO SHOULD NOT BE GIVEN HRT

A 
⦁	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
63
Q

endometrial hyperplasia or cancer can occur within ________ months of starting unopposed estrogen

A

6

64
Q

who needs an endometrial biopsy

A
  • 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

WOMEN'S HEALTH (13 decks)

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