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menopause Flashcards

1
Q

what is menopause

A

cessation of menstruation dg by 12 months of amenorrhoea

physical sx d/2 reduction of estrogen &; progesterone

betw/ 45-55

precceded by perimenopause (transition)

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2
Q

when is menopause premature

A

before 40 years of age

-smokers- 2 years early

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3
Q

define perimenopase

A

period from the first occurrence of climacteric irregular menstruation cycles to the last menstrual period

begins 45-55 years

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4
Q

define menopause

A

Time at which menstruation ceases permanently

Confirmed after 12 months of amenorrhea

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5
Q

define postmenopause

A

12 months after the last menstrual period and onwards

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6
Q

what is surgical menopause

A

amenorrhea d/2 removal of the ovaries after a hysterectomy w/ bilateral salpingoophorectomy typical in endometrial cancer

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7
Q

RF for early menopause

A

Smoking

Hysterectomy/oophorectomy

Living at high altitude

History of previous chemo/radiotherapy

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8
Q

PP/ how does menopause happen

A

ovarian follicles make estrogen then progesterone both of which have a -ve on FSH and LH in ant pit

no of ovarian follicles are fixed and decline w/ age and their quality decreases also

leading to reduced ovarian func and reduced lvls of estrogen and progesterone

FSH & LH lvls increase in estrogen abscence -> down reg of follicle receptors To FSH

causes HYPERGONADOTROPIC HYPOGONADISM
(lack of sex hormones d/2 pit/hypothalamus// 2ndary&tertiary)

hormonal imbalance causes irregular menstruation d/2 loss of progesterone and esterogen regulated activites

eventual loss of all ovarian follicles and ovarian function

amenorrhea

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9
Q

where does the mmajority of estrogen come from in menopausal women

A

conversion of androgens into estrogen by AROMATASE

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10
Q

sx of menopause (9)

A&A

↓ estrogen diseases

vessel & (psych)

w&b

long term: heart 💓& bone 🦴

A

1) amennorhea or irregular menses leafing to amenorrhea

2) atrophy
- smaller tender breasts (mastodynia)
- vulvovaginal atrophy -vaginal dryness= DYSPAREUNIA
- bladder and urethral atrophy-INFEC/INCONTINENCE

3) autonomic sx
- sweating, hit flashes, heat intol 75%

4) psychiatric sx
- insomnia/nightsweats
- mood swings/ depressh

5) weight gain and bloating
6) Ischaemic Heart Disease increases

7) alleviation of estrogen mediated diseases
- endometriosis, adenomyositis, fibroids

8)pathological fractures

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11
Q

When do sx 1st occur

A

(begin up to 6 years before the final menstrual period and continue for a variable number of years after the final menstrual period)

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12
Q

Cause of hot flush

A

starting on the face and spreading down the neck and chest.

begins from the umbilical area and moves upward toward the head, followed by sweating of the head and upper body.

Can be severe enough to prevent sleep (psych)

Can accompany palpitations likening it to HYPERTHYROIDSM

These are associated with peripheral vasodilation and a transient rise in body temperature. The exact mechanism is unknown but it is thought to be due to pulsatile LH release influencing central temperature control.

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13
Q

Why is there bladder atrophy

A

bladder and urethra share embryological derivation with the uterus and vagina so is affected by lack of estrogen in the same way

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14
Q

Why IHD In menopause

A

oestrogen reduces levels of LDL cholesterol whilst raising HDL cholesterol. After menopause women experience the same frequency of cardiovascular disease as men.

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15
Q

Why osteoporosis in menopause

A

Oestrogen protects bone mass and density through reducing the activity of oesteoclasts.

With the drop in oestrogen this balance is tipped and there is an increase in bone reabsorption resulting in an acceleration of age related loss of bone density and increased frequency in fractures especially of the wrist and hip.

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16
Q

Investigations for menopause

A

history of typical clinical sx

LAB

  • ↓ progesterone ↓ estradiol and ↓ inhibin are early signs starting 2 years before the final menstrual period and stabilizing approximately 2 years after the final period)
  • ESTRONE which is aromatized from androstenedione is predominant estrogen in menopause
  • reduced renal clearance of FSH in comparison with LH so FSH levels are higher than luteinizing hormone (LH) levels, and both rise to even higher values than those seen in the surge during the menstrual cycle. FSH ELEVATION IS DG but LH isn’t
  • lipid profile: ↑ total cholesterol, ↓ HDL

Dx. 1) HTHserum TSH d/2 sim presentation. 2) atrophic cystitis presents sim to uti => urine analysis

US of endometrial thickness

Endometrial biopsy- thickness and any hyperplasia above 5cm

DEXA SCAN for
osteoporosis screening w/ in women over 65

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17
Q

How often should FSH be checked in menopause

A

every 2- to 3-months
- helpful for establishing whether the woman is progressing through menopause.

Women with elevated, but not postmenopausal, FSH levels are still at risk for pregnancy, and contraception should continue to be used until FSH levels remain in the postmenopausal range.

18
Q

Pelvic exam in menopause

A

Loss of vaginal rugged leaving smooth walls

older women, a general loss of pelvic muscle tone occurs, sometimes manifested as prolapse

uterus becomes smaller and Fibroids, if present, become less symptomatic, and can shrinking to the point where they can no longer be palpated on manual pelvic examination

ovary diminishes in size and is no longer palpable during gynaecological exam

19
Q

indications for rx of menopause

A

1) if sx are severe enough to affect QOL
2) premature menopause (before 40)
3) surgical menopause( oophorectomy)

20
Q

Dx in menopause

A

PREGNANCY- decreased infertility not infertile

Atrophic cystitis can mimic UTI

Hyperthyroidism

endometrial hyperplasia, or endometrial cancer -menopausal women are often exposed to unopposed estrogen for long periods, and this exposure can lead to endometrial hyperplasia, a precursor of endometrial cancer.

21
Q

Speculum obs during menopause

A

vaginal epithelium
INITIALLY redder as the epithelial layer thins and the small capillaries below the surface become more visible
later then eventually turns pale when caps reduce in number

decrease in vaginal pH leading to a change in bacterial flora may result in pruritus and a malodorous discharge

22
Q

Forms of HRT

A

Local: creams, pessaries, rings

Systemic: Oral drugs, implants, transdermal patches

23
Q

rx for menopause

A

lifestyle changes

  • exercise for insomnia
  • acupuncture for hot flushes
  • stop smoking to prevent osteoprosis
  • vitamin D supplements for osteoporosis

medical therapy
-vaginal oestrogen creams/ tablets to rx ATROPHIC

VAGINAL SX
- ospemifene (Osphena),

hormone replacement therapy
-estrogen only / plus progesterone
-Gonadomimetics (tibolone) which contain estrogen, progestogen, and an androgen 
-selective estrogen receptor modifiers
#TAMOXIFEN
#RALOXIFEN

OTC MEDICATIONS- phytoestrogens

for vasomotor (hot flushes)
#PAROXITENE- ssri, 6wks 2 work, w/draw all
# venlaflexine- snri 
#CLONIDINE- alpha 2 agonist decreases sympathetic activity - sedation and hypotension
24
Q

Why biopsy b4 HRT

A

uterine polyps, endometrial hyperplasia, or endometrial cancer, which becomes more prevalent during this time, must be excluded through endometrial sampling (eg, with endometrial biopsy [EMB] or dilatation and curettage [D&C]). especially B4 admin HRT

25
Q

HRT principles

A

given during the end of perimenipause period
as late presicroption increases risk of VTE

conjugated estrogens (mixture of estrogen hormones) = 17β estradiol, and ethinyl estradiol.

Taken daily alone for pts w/ hysterectomy(no risk of endo met cancer)

or w/ progesterone daily women w/ uterus(reduce risk of endomet hyperplsia)

Cyclically = w/ progesterone for 10-14 days every 4 weeks

26
Q

contraindications of hormonal therapy

No absolute only relative
gyne (4)
CV (3)
other (2): porphyria

A 
GYNAE CI
Pregnancy!!!!
Undiagnosed vaginal bleeding
Breast cancer/endometrial cancer w/in last 5 years
FIBROIDS

CV CI => increases blood viscosity & thrombogenicity
Coronary artery disease Chronic liver disease
Hyperlipidemia
Recent DVT/stroke

other
Porphyria

27
Q

Indications of menopause use

A

provide relief of vasomotor symptoms

avoid the irregularity of menstrual cycles

preserve bone-osteoporosis

improve quality of life- insomnia etc

28
Q

how does raloxifen rx menopause

🦴 +ve

breast?endo -ve

A

A selective estrogen receptor modulator (SERM)
acts as an estrogen agonist/ antagonist on receptors

ANTAGONIST

  1. breast - prevents breast cancer
  2. endometrium (prevents growth stimulation of estrogen-receptor positive cells)

acts as an AGONIST
on receptors in bone (inhibits bone resorption).

29
Q

ADR’s of HRT

A

ESTROGEN
bloating, mastodynia, vaginal bleeding, and headaches.
-endometrial hyperplasia and endometrial cancer d/2 prolonged exposure of unnoposed estrogen

CDV diseease with estrogen only
-dvt
-pte
stroke

Selective estrogen receptor modulators (SERMs) and estrogen

  • increase the risk of thromboembolic events
  • increased risk of acute pancreatits
  • slight increased risk of breast cancer only after 5 Years of continuous use
30
Q

Rx of osteoporosis

A

SERM

BISPHOSPHONATES- alendronate or risedronate

Calcitonin-
inhibiting osteoclasts, which are involved in bone resorption activity- monitor calcium LVLS

Calcium

vitamin D

Estrogen therapy= SECOND LINE

31
Q

What is tibolone

A

Gonadomimetic which contain estrogen, progestogen, and an androgen

32
Q

what is ospemifene

A

an oral estrogen agonist used for vaginal sx in meno II

PRO’S
-acts like estrogen on the vaginal lining, but w/decreased risk for harmful effects on the endometrial or breast tissues.
CON
-Disadvantages to this particular therapy include hot flashes risk of stroke or blood clots.

33
Q

what is paroxetine

A

ssri,

pro’s: rx of vasomotor

cons:takes 6wks 2 work, causes w/drawal

34
Q

effect of estrogen on hemostasis

A

↑ hemostasis by

↑clotting factors (VII, VIII, X, fibrinogen) and plasminogen,

↓antithrombin III and protein S levels,

35
Q

why do PMS SX leave w/ menopause

A

no progesterone

36
Q

what is examined in a dexa scan

A

Spine and Hip

37
Q

how long should HRT be give for menoII rx

A

less than 5 years

38
Q

effectof obesity on menoII

A

hot flushes worsened: fat acts as a strong heat insulator, making heat dissipation more difficult

IHD: risk increased d/2 increased atherosclerotic risk

Endometrial/breast cancer; risk increased as more fat available for steroidgenesis by mitochondria

no dff in psych sx

39
Q

MOA of tamoxifen
+ve bone
+ve uterus

A

reduces osteoporosis but increases risk of endometrial hyperplasia & cancer

40
Q

what are the risks of phytoestrogens

A

at least the same as HRT

O&G (43 decks)

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