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Women's Health 1 > Menopause > Flashcards

Menopause Flashcards

1
Q

Define menopause

A

point in time after 12 consecutive months of amenorrhea with no obvious pathologic cause (avg. 52)

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2
Q

Peri-menopause/menopause transition

A

span of time when cycle and endocrine changes occur a few years before and 12 months after final menses resulting from natural menopause

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3
Q

What age does primary ovarian insufficiency occur?

A
  • less than or equal to age 40, whether natural or induced

- ~1% of women

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4
Q

What is induced menopause?

A

permanent cessation of menses after BSO or iatrogenic ablation of ovarian function

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5
Q

Menopause Physiology

A
  • Loss of follicles, most from atresia, accelerated in our late 30’s
  • Elevated FSH and LH**
  • Ovarian estrogen and inhibin production/feedback decreases
  • Androgen availability increases with age
  • Adrenals decrease DHEA/DHEAS and ovaries decrease androstenedione
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6
Q

List the midlife changes

A
  • Changes in bleeding patterns
  • Vasomotor/hot flushes
  • Sleep disturbances
  • Vulvovaginal dryness and discomfort
  • Urinary changes
  • Sexual/decreased libido
  • Cognition concerns
  • Weight gain
  • Skin and hair changes
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7
Q

Routine evaluation

-office exam

A
  • Measured height and weight; BMI or hip/waist ratio
  • BP
  • Pelvic and indicated pap smear
  • Breast exam?
  • Lifestyle concerns
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8
Q

What breast changes happen in menopause?

A
  • Breasts decrease in size due to less estrogen stimulation
  • Supportive connective tissue decreases
  • Ratio of fat to fibrous tissue increases which makes breasts less firm but easier to evaluate with mammography
  • Increased density considered a risk factor
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9
Q

What are the colon cancer screening?

A
  • Colonoscopy every 10 years beginning at 50
  • Fecal occult blood testing (FIT, guaiac) yearly
  • Sigmoidoscopy every 5 years; this can be done in combination with FOBT every 5-10 years as an alternative to colonoscopy
  • Barium enema with air contrast every 5 years
  • CT
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10
Q

What lab screenings should you consider?

A
  • Lipids
  • Chemistry/HbA1c
  • -Fasting glucose, renal/liver function
  • -Test all pregnant women with A1c on first visit
  • TSH
  • Vitamin D
  • STI, HIV, and Hep C as indicated (esp. baby boomers 1946 – 1964)
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11
Q

What is the frequency of irregular bleeding in menopause?

A
  • 90% of women experience 4-8 years of menstrual cycle changes before menopause
  • Must consider and evaluate for numerous causes, assess risk factors (reproductive tract, systemic, meds)
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12
Q

What is the main cause of irregular bleeding in menopause?

A

-Main cause is irregular ovulation especially in early perimenopause; lack of ovulation in late perimenopause

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13
Q

What is the work-up for irregular bleeding

A

-EMB, ultrasound for endometrial thickness, hysteroscopy, labs, STD screening

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14
Q

Why hot flashes with menopause?

A
  • Etiology is unclear but could be related to estrogen withdraw, other diseases and medications; also a more narrow thermoneutral zone
  • Average lasts 1-5 minutes; occurs over months to years especially right before and after the LMP
  • Affects up to 75% of women
  • Varies by ethnicity: African American > Hispanics > Caucasian > Asian
  • Increased in obesity
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15
Q

Vasomotor Symptom Treatment

A
  • Treatment of moderate to severe vasomotor symptoms (VMS) remains the primary indication for systemic hormone therapy
  • Hormone therapy is the most successful treatment (a complete list of products available in the US and Canada is on the NAMS website at menopause.org)
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16
Q

What drug is used to treat vasomotor symptoms?

A

Brisdelle 7.5 mg paroxetine approved 2013 for VMS

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17
Q

What are the alternative treatments for hot flashes

A
  • Cooler environment
  • Weight loss/exercise
  • Acupuncture
  • Phytoestrogens/soy/isoflavone
  • Black cohash
  • Decrease smoking
  • Vitamin E, omega-3
  • Progesterone
  • Medications used off-label such as Gabapentin, Lyrica, Clonidine, and SSRIs
  • Cognitive behavioral treatment and hypnotherapy have evidence of benefit to decrease bothersome level of symptoms
  • Weight loss and s-equol of soy have evidence of benefit also, though less
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18
Q

What causes the Genitourinary Syndrome of Menopause (GSM) & vulvavaginal atrophy (VVA)?

A
  • Up to 75% of women have atrophic symptoms

- Lack of estrogen leads to decrease lactobacilli, increased pH, epithelial thinning

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19
Q

What are the symptoms of genitourinary syndrome of menopause?

A

Ulcerations, petechiae, trauma, pain and dyspareunia can result

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20
Q

What other etiologies should you rule out for GSM/VVA?

A

Rule out other etiologies such as infection and vulvar dystrophy

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21
Q

What urinary changes are associated with GSM and VVA?

A

Urinary changes include urgency and increased urinary tract infections

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22
Q

What is the most effective treatment moderate to severe symptoms of vulvar and vaginal atrophy?

A

Estrogen - topical recommended if this is the only indication for estrogen

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23
Q

How does estrogen treatment improve symptoms?

A

Treatment increases blood flow, epithelial maturity, decreases pH, and increases secretions; urethral benefits of decreased UTIs and urgency

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24
Q

List the non-prescription treatments for menopause

A
  • Lubricants: usually water-based and used with sexual activity
  • Vaginal moisturizers: used at any time to provide comfort to vaginal tissues
  • Vaginal rejuvenation/laser procedures (in the long run there seems to be more pain issues)
  • Sex
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25
Q

What other symptoms are relieved with hormonal therapy or local estrogen therapy?

A

dyspareunia, which is a common cause of intercourse avoidance
*hormonal therapy not recommended as sole treatment of other sexual function problems (such as decreased libido)

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26
Q

Should you supplement testosterone for sexual dysfunction?

A

Testosterone does not continue to decline at menopause and limited benefit to supplements

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27
Q

Which drug can you use for sexual dysfunction in premenopausal women?

A

Flibanserin (Addyi) for treatment of HSDD in premenopausal women

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28
Q

What is the etiology of breast cancer?

A
  • 1 out of 8 risk in US; 2% of women by age 50

- Most important risk factors are age and gender

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29
Q

What are the screening tools for breast cancer?

A
  • SBE (self breast exam)
  • mammogram
  • MRI
  • ultrasound
  • ductal lavage
30
Q

What are the potential risks for breast cancer?

A

BRCA gene, personal cancer hx, first degree relative with breast cancer, menarche < 12, menopause > 55, nulliparity or first child after age 30, obesity after menopause, alcohol > 2 drinks/day, lack of exercise, low vitamin D, poor diet, radiation exposure

31
Q

Breast cancer risk reduction

A
  • Lifestyle changes: decrease weight, decrease alcohol
  • Chemoprevention: women at increased risk benefit from SERM treatment to prevent primary breast cancer (ex. tamoxifen and raloxifene)
  • Aromatase inhibitors reduce breast cancer recurrence (anastrazole)
  • Prophylactic mastectomy
32
Q

Explain the relationship between hormone therapy and breast cancer

A
  • *Breast cancer risk increases with estrogen-progestin use beyond 3-5 years**
  • Estrogen only therapy for up to 7 years had no increase on cancer risk
  • No increased risk if wait for 5 years after menopause to start HRT**
  • Unclear if HT risk differs between continuous and sequential progestogen therapy or choice of progestogen
33
Q

Etiology of osteoporosis

A
  • MC bone disorder affecting humans
  • Peak bone mass achieved in third decade
  • 80 % of osteoporosis diagnoses are women
  • 12th leading cause of death in women
34
Q

Relationship between hip fracture and mortality

A

Average age of hip fracture is 82 with 25% increase mortality in the next year

35
Q

Which type of fracture allows you to diagnose osteoporosis?

A

Fragility fracture allows the diagnosis clinically

36
Q

What are the criteria for diagnosis of osteoporosis > 5o years old?

A

DXA measurements include total hip, femoral neck and posterior-anterior lumbar spine and can define the diagnosis with T-score 2.5 SD below the mean

37
Q

What is a T-score?

A

T score is comparison of patient to normal young adult female

38
Q

What is a normal T-score?

A

BMD > or = -1.0

39
Q

What is a low bone mass (osteopenia) T-score?

A

BMD > -2.5 and < -1.0

40
Q

What is a T-score for osteoporosis?

A

BMD < or = to -2.5

41
Q

What is a T-score for severe (established) osteoporosis?

A

BMD < or = -2.5 with h/o fragility fracture

42
Q

List the Osteoporosis Risks

A
  1. Age – increases with age
  2. Genetics – affects peak bone mass
  3. Lifestyle – poor nutrition, smoking, alcohol, decreased activity
  4. Thinness – BMI < 21
  5. Menopausal status – decreases 2% per year during perimenopause
43
Q

What are the bone mineral density testing indications?

A

All women > 65 years old
Postmenopausal with fragility fracture
Postmenopausal <65 years old with one or more risk factor

44
Q

List the postmenopausal <65 years old with one or more risk factor

A
  • Previous fracture after menopause
  • Thinness or BMI < 21
  • Parental hip fracture or family h/o osteoporosis
  • Smoker
  • Rheumatoid arthritis
  • Excessive alcohol intake
  • Long term high risk medications
45
Q

What is the MC fracture type?

A

Vertebral fractures

46
Q

Vertebral fractures etiology

A
  • Often silent
  • Insidious, progressive nature
  • Associated with significant morbidity
  • Predict future spine and hip fractures
  • Associated with 2-fold increase in risk of death
47
Q

What does FRAX calculate?

A

Calculates 10 year risk of major osteoporotic fracture and risk of hip fracture
*Used to guide appropriate patients for therapy

48
Q

What does FRAX use?

A
  • Uses risk factors identified by WHO

- Uses g/cm2 measurement of BMD at femoral neck

49
Q

When does NAMS recommend tx?

A

If postmenopausal with:

  • vertebral or hip fracture
  • BMD diagnosis of osteoporosis
  • osteopenia and FRAX calculator fracture risk of major osteoporotic fx of at least 20% and hip fx of at least 3%
50
Q

What is the daily calcium recommendation?

A

Institute of Medicine recommends 1200 mg daily total from food and supplements for women over 50 to maintain bone health

51
Q

What effects calcium absorption?

A

Absorption affected by estrogen, Vitamin D, foods

52
Q

Relationship between calcium and kidney stones

A

Dietary calcium does not appear to increase kidney stones or risk for CVD

53
Q

What is the importance of vitamin D? Who is deficient?

A
  • Active form mediates the absorption of calcium in the intestines
  • Approximately 50% of the population is thought to be deficient
54
Q

What is the recommended daily dose of vitamin D?

A

~600-1000 IU daily for women

55
Q

List the risk factors for decreased vitamin D levels.

A
  • Increased age
  • Northern climate
  • Limited sun exposure
  • Obesity
  • Poor dietary intake
  • Dark skin
  • Various medical conditions (poor absorption)
56
Q

What is the #1 killer of women?

A

Cardiovascular Disease

57
Q

Relationship between estrogen therapy and cardiovascular disease

A

-ET does not increase the risk of CHD when initiated in women recently menopausal (within 10 years) and may even reduce the risk (age 50-59)
HOWEVER:

*CVD prevention is not an indication for estrogen treatment

58
Q

How does long-term HRT decrease CVD risk?

A

Long term HRT use associated with less accumulation of coronary artery calcium and reduced CHD risk and mortality

59
Q

Relationship between colon cancer and E+P therapy

A

Decreased risk of colon cancer in E+P treated patients

60
Q

Relationship between gallbladder disease and E+P therapy

A
  • Gallbladder disease 2x as frequent in women
  • HRT and OCs increase risk for gallstones with E+P more risk than Estrogen alone and oral HRT has greater risk than transdermal
61
Q

Relationship between menopause and diabetes mellitus

A

Hormonal changes at menopause may contribute to worsening glucose metabolism (relative increase in cortisol) and HT may reduce new onset DM though not approved as prevention
*Glucose metabolism worsens with weight gain and aging

62
Q

What considerations should you make for women with DM starting HRT?

A
  • More risk of CVD in women with DM; statin tx recommended for age 40-75
  • Screening for DM in women age 45 or older (HbA1c, fasting glucose)
63
Q

Relationship between HT and cognition

A
  • Evidence mixed on effect of HT on cognition at time of menopause but overall no negative effects
  • Not recommended at any age for prevention or treatment
  • May increase dementia if begun after age 65
64
Q

What is the therapeutic goal for HRT?

A

Therapeutic goal is lowest effective estrogen dose consistent with individual treatment goals, benefits, and risks plus corresponding low progestogen dose for women with a uterus

65
Q

What dose should you start HRT?

A

Lower doses may be better tolerated and have a more favorable benefit-risk ratio than standard doses

66
Q

What are the benefits of HT??

A
  • May reduce total mortality when initiated soon after menopause (< 10 years); ET and EPT may reduce mortality by 30% in those < 60
  • Women > 60 who had natural menopause at the median age and never used HT should not start without compelling indication/counseling
  • No clear indication that longer HT duration improves or worsens the benefit-risk ratio in postmenopausal women
67
Q

HT in premature/surgical menopause patients

A
  • Use of HT or COC’s for hormone replacement recommended until median age of menopause
  • Women under age 50 likely have smaller risks and greater benefits than women over 50 for same estrogen replacement
68
Q

Relationship between HT and Venous Thromboembolism

A
  • Oral E+P increases risk 2-5 times and ET up to 1.5 times in postmenopausal women
  • Risk emerges soon after therapy began (1-2 years) and decreases over time
69
Q

How can you lower risk for VTE?

A

Possible lower risk with transdermal than oral and lower doses may be safer but no randomized controlled evidence for either

70
Q

What may increase risk of VTE?

A

Synthetic progestins may increase risk compared to natural progesterone

71
Q

List the Venous Thromboembolism risk

A
  • Baseline risk increases with age
  • BMI >30 increases risk 3 fold
  • Other risk factors include immobilization, CVD, thrombophilic disorders, prothrombotic mutations, etc.
  • This is a coagulation event
72
Q

List the Rx Hormone therapy options

A
  • Oral contraceptives
  • Estrogen
  • Progesterone
  • Estrogen/progesterone
  • Agonists/antagonists
  • Androgens

Women's Health 1 (17 decks)

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