Menopause Flashcards
1
Q
Perimenopause
A
- the ovary function starts to wane and decrease – you get a change in menstrual bleeding patterns
- Defined as the 2-8 years preceding menopause
- Ends one year after the last menstrual period
- Ovarian function waxes and wanes
- Less frequent ovulation – usually means irregular bleeding
- If youre continuing to ovulate, YOU CAN STILL GET PREGNANT
- Normal cycles interspersed w anovulatory cycles
- Irregular menses, breakthrough bleeding, DUB
- Fluctuating FSH, estradiol, progesterone
- FSH begins to rise, Inhibin B concentrations fall
- Progesterone low in luteal phase – if women do get pregnant in perimenopause, often times the pregnancy does not progress past the first trimester because of the low progesterone
- Estradiol low
- Less frequent ovulation – usually means irregular bleeding
2
Q
declining ovarian function
A
- Major source of estrogen in menopausal women is conversion of androstendione to estrone
- Estrone is a less potent estrogen than estradiol
- Can lead to ovarian disorders including:
- Functional cysts
- Hemorrhagic cysts
- Diagnosis may be achieved using ultrasound, laparoscopy or laparotomy
3
Q
clinical manifestations of menopause
A
- Change in bleeding patterns
- Vasomotor symptoms – hot flashes – usually last a couple years after the start of menopause
- Sleep disturbance – may be related to hot flashes
- Genitourinary symptoms
- Vaginal dryness/urogenital atrophy; dyspareunia
- Urogenital atrophy and dryness usually occurs about 5 years after menopause
- Sexual dysfunction – may happen depending on the patient and their relationship, may happen later with vaginal dryness
- Depression – as estrogen declines, depression increases
- This is also the case with post-partum
- Long-term issues
- Osteoporosis – steep decline in bone density
- Cardiovascular disease – women are at a higher risk post menopause for dying of an MI than men
- Dementia
4
Q
changes in bleeding pattern
A
- Anovulatory bleeding/Chronic anovulation
- Due to progesterone deficiency
- Long periods of unopposed estrogen exposure can cause anovulatory bleeding
- Oligomenorrhea lasting 6 months or more
- Heavy dysfunctional uterine bleeding
- Endometrial biopsy
- Transvaginal ultrasound
5
Q
vasomotor symptoms
A
- Most common acute change
- Sleep disturbance secondary to hot flashes
- fatigue, irritability, depression, difficulty concentrating
- Up to 75% of women
- Only 20% seek medical attention
- Self-limited
- Pathophysiology: unknown
- Thermoregulatory dysfunction?
6
Q
genitourinary symptoms
A
- Vaginal dryness/urogenital atrophy
- Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy
- Atrophic Vaginitis, Atrophic Urethritis
- Symptoms can include itching, irritation and dyspareunia
- May predispose to both stress and urge urinary incontinence
- Recurrent urinary tract infections
7
Q
genitourinary symptoms
A
- Findings on exam:
- Pale, dry vagina
- Lack of the normal vaginal folds
- Petechiae on mucosa
- Vaginal pH 6.0 to 7.5
- Increased pH and vaginal atrophy may impair protection against vaginal and urinary tract infection
8
Q
sexual dysfunction
A
- 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
- Continuing sexual activity may prevent these changes
- Responsive to estrogen therapy
9
Q
depression
A
- Prior history of depression or PMS is strong predictor
- Characterized by frequent mood changes, irritability, nervousness
- Depression during the perimenopausal years
- Nonhormonal events contribute
- aging parents, empty nest
- chronic illness, physical limitations
10
Q
long-term issues
A
- Osteoporosis
- Cardiovascular disease
- Dementia
11
Q
secondary amenorrhea
A
- Pregnancy
- Premature Ovarian Failure (consider <45)
- Thyroid dysfunction – always check TSH
- Irregular menses, sweats, mood changes
- Hyperprolactinemia
- Atypical hot flashes and night sweats – if hot flashes are happening only at night
- Medications
- Malignancies
12
Q
making the menopause diagnosis
A
- Definition: 12 months of amenorrhea
- Women over age 45 in the absence of other biological or physiological causes
- No further diagnostic evaluation for women in this group
- Women <45 years: Blood work for HCG, prolactin, TSH, FSH
- Usually FSH goes up and estrogen goes down
- If you have an FSH over 25, it’s probably menopause or perimenopause
- Assessment/History
- menstrual cycle history
- menopausal symptoms: vasomotor flushes, vaginal dryness
13
Q
post menopausal bleeding
A
- Bleeding that occurs after 12 months of amenorrhea
- Not associated with hormone replacement
- Prolonged (10-14 days) or heavy bleeding associated with hormone replacement
- This can be a result of an undiagnosed fibroid
- Bleeding associated with non-phasic hormone replacement after 3-6 months
- Unopposed oral estrogen (without progesterone) in women with a uterus can cause hyperplasia and endometrial carcinoma
- IF THEY HAVE A UTERUS, THEY NEED TO BE ON PROGESTERONE
- All methods of HRT may yield bleeding
- Breakthrough bleeding ranges 10-40%
- Most women will bleed the first three months
- Vaginal administration of estrogen for urogenital symptoms of estrogen deficiency may rarely stimulate the endometrium
- Patients using HRT who require evaluation:
- On hormones for 6 months or more and bleeding
- Bleeding is irregular, prolonged or heavy
- Patients with intact uterus on unopposed estrogen
- Evaluation should include:
- Yearly endometrial biopsies (preferred)
- Transvaginal ultrasound to check endometrial stripe
14
Q
hormone therapy treatment
A
- Don’t start hormones (estrogen and progesterone) if they are over 60 or if they are 10 years post menopausal – DON’T EVER EVER EVER DO THIS
15
Q
Indications for HRT
A
- Vasomotor symptoms (perimenopause, early menopause)
- Urogenital atrophy (postmenopausal)
- Symptomatic after oophorectomy – within a short period of time, you can still put them on hormones
- Osteoporosis prevention and treatment
- Not recommended as 1st line therapy
