menopause Flashcards
menopause beings
no period for 12 months the first day after that year
average age of menopause
Menopause is the cessation of menstrual periods occurring at about 51.4 years in normal women
impacts of not having estrogen for 30 years
cardiovascular bone density sexual function memory dementia
late postmenopause takes place
about 5-6 years after menopause begins
Perimenopause is defined as
no period for 12 months
Defined as the 2-8 years preceding menopause
and up to 10 years
technically ends one year afte the least mentraul period
ovarian function waxes and wanes
what occurs during perimenopasue
less frequent or more frequent bleeding
might get normal ovulary cycles interspersed with regular cycles
irregular menses but still need to be on contraception
hormone cycles seen in perimenopause
Fluctuating FSH, estradiol, progesterone
FSH begins to rise, Inhibin B concentrations fall
Progesterone low in luteal phase
Estradiol low (more estrone)
CM of peri menopause (early)
changes in bleeding patterns- pretty common
vasomotor symptoms-hot flashes
sleep disturbances-1st complaint
sexual dysfunction
CM of peri menopause (late)
genitourinary sxs-later
Vaginal dryness/urogenital atrophy; dyspareunia
sexual dysfunction can also be a problem later
as estrogen declines we frequently see these mood changes
depression
what are vasomotor sxs associated with peri menopause
most common acute change
vasomotor sxs
75% of women experience hot flashes
sleep disturbance
fatigue irritability, depression and difficulty concentrating
Genitourinary symptoms associated with menopause
Vaginal dryness/urogenital atrophy
Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy
Atrophic Vaginitis, Atrophic Urethritis
Recurrent urinary tract infections
Dyspareunia
Sexual Dysfunction CM
Decreased vaginal lubrication
Decrease in blood flow to vagina/vulva
Vaginal atrophy, dryness and dyspareunia
Decrease in elasticity of the vaginal wall
? Decreased sensation in the clitoral and vulvar area
Shortening and narrowing of the vaginal vault
what predisposes pts to depression
Prior history of depression or PMS is strong predictor
Depression during the perimenopausal years
ddx of menopause
pregnancy
premature ovarian failure women <45
thyroid (always check TSH with fatigue or weight changes)
hyperprolactinemia
atypical hot flashes
bone pain
weight loss
early satiety with hot flashes or atypical hot flasshes
suspect malignancies
atypical hot flashes only at night and during the day)
labs for women under 45 with sxs of menopause
Blood work for HCG, prolactin, TSH, FSH
probably estradiol too (would be low if FSH up )
FSH of 8, 9, 10 = ovary shut down
over 25 probably peri menopause
increasing FSH in the presence of decreasing estradiol is indicative of menopause
what would you want to do in a pt over 45 with really heavy bleeding
endometrial biopsy
Post Menopausal Bleeding
Bleeding that occurs after 12 months of amenorrhea
never normal and always needs a work up (unless ot is on hormones)
HCT bleeding usually looks like
Prolonged (10-14 days) or heavy bleeding associated with hormone replacement
takes about 3 months for women to adjust
Unopposed oral estrogen is a bad idea because
Unopposed oral estrogen (without progesterone) in women with a uterus can cause hyperplasia and endometrial carcinoma
if there is a uterus need progesterone!!!!!
Major source of estrogen in menopausal women
is conversion of androstendione to estrone
Estrone compared to estrogen
Estrone is a less potent estrogen than estradiol
what are the effects of estrone on the body
estrone because it is less potent will be accompanied by hot flashes and our typical menopausal symptoms
also can lead to cysts (adnexal mass or pain)
Functional cysts
Hemorrhagic cysts
Diagnosis may be achieved using ultrasound, laparoscopy or laparotomy
lifestyle modifications for peri menopausal women
exercise regularly and sleep regularly
hydration for regulation of the hypothalamus
pH change with menopause
between 3.8 and 4.5 is normal
during menopause
Vaginal pH 6.0 to 7.5
Increase in pH and vaginal atrophy may impair protection against vaginal and urinary tract infection
Inhibin B concentrations fall due to
to a decline in follicle number
FSH levels begin to rise
what labs would indicate menopause
High FSH and low estradiol values may be suggestive of menopause
how topical estrogen is rx
every day for two weeks
to two to three times a week
functional vs hemorrhagic cysts
functional cysts do not secrete anything
anovulation is the result of
Due to progesterone deficiency
other than EMB what else can be done to evaluate DUB in a post menopausal woman
TVS
To look at the endometrial stripe <5mm
Vaginal dryness/urogenital atrophy
Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy
sxs of atrophic vaginitis
Symptoms can include itching, irritation and dyspareunia (painful intercourse)
long term complications
Osteoporosis
Cardiovascular disease
Dementia
Osteoporosis is of significant risk in
more common in women with low estrogen levels
cardiovascular disease is seen
seen as early as 2 years post menopause especially in women w/out hormone replacement
women at higher risk than men after menopause due to the loss of estrogen
when would you need to do a workup for post menopausal tx
if there is any bleeding at all and the pt is not on HRT
hx of fibroids maybe do a TUS instead
If bleeding for >6 mos on HRT
(usually normal in first 3 months)
OR on HRT and bleeding Prolonged (10-14 days) or heavy bleeding associated with hormone replacement
maybe the fibroid was asleep before and now super heavy bleeding
OR on unopposed oral estrogen
everyone with a uterus needs to be on this type of HRT
progesterone and estrogen
can lead to hyperplasia and endometrial carcinoma
why do we workup a pt who is bleeding a lot on HRT
first thing we are worried about is endometrial cancer
when can HRT not be considered
over the age of 60 or 10 years post menopause
can use vaginal estrogen
cardiovascular risk is too high
indications for HRT
Osteoporosis prevention and treatment
(not first line)
Urogenital atrophy
Vasomotor symptoms
Symptomatic after oophorectomy
what is the first line for osteoperosis
bisphosphinates
probable benefits of estrogen
Improves mood, libido -Decreases skin aging -Decreases incontinence -Reduced osteoarthritis -Prevents cataracts -Prevents macular degeneration Hormone replacement NO LONGER FOR PREVENTION of CAD (Coronary Artery Disease)
known benefits of HRT
Decreases hot flashes Improves bone mineral density (BMD) -Decreases fracture risk Improves sexual function -Improves symptoms of vaginal atrophy -Decreases risk of colon cancer Reduction of benign breast disease Prevention of ovarian cancer and endometrial cancer
IUD would not work for these sxs of menopause
hot flashes
just irregular bleeding
would want OCP (enough estrogen to decrease hotflasshes)
CI to HRT
Hypertension Atypical breast lesions Diabetes mellitus Hx of gall bladder disease or stones Migraines Endometriosis Fibrocystic breast disease Uterine fibroids Obesity Seizures Past history of deep venous thrombosis or pulmonary embolism
when can you use OCP as opposed to HRT
OCP until age 51 if no contraindications
then you can switch without testing
however if you have a woman coming in with sxs and w/out BC probably want to test FSH first if over 25= menopausal and switch to HRT
can say with confidence hormone users who develop breast cancer have better outcomes then those not on hormones probably because
more regualr screening
if you have a woman with a 10 year CVD rish of 4% when could you use HRT
anywhere from 5-10 years after menopause
if you have a woman with a 10 year CVD risk of 6% when could you use HRT
Trandermal only
when would you avoid HRT if worried about her cardiovascular risk
if greater than 10%
CI to HRT
such as a history of breast cancer, coronary heart disease [CHD], a previous venous thromboembolic event or stroke, or active liver disease
what type of progesterone should be used in pts interested in oral HRT
micronized progesterone
because it is effective for endometrial hyperplasia, is metabolically neutral, and does not appear to increase the risk of either breast cancer or CHD, although data are limited.
HRT should be used for the length of time .
Suggest limiting to 5 years
but can be used for longer if time permits
