menopause Flashcards
what is menopause
cessation of menstruation dg by 12 months of amenorrhoea
physical sx d/2 reduction of estrogen &; progesterone
betw/ 45-55
precceded by perimenopause (transition)
when is menopause premature
before 40 years of age
-smokers- 2 years early
define perimenopase
period from the first occurrence of climacteric irregular menstruation cycles to the last menstrual period
begins 45-55 years
define menopause
Time at which menstruation ceases permanently
Confirmed after 12 months of amenorrhea
define postmenopause
12 months after the last menstrual period and onwards
what is surgical menopause
amenorrhea d/2 removal of the ovaries after a hysterectomy w/ bilateral salpingoophorectomy typical in endometrial cancer
RF for early menopause
Smoking
Hysterectomy/oophorectomy
Living at high altitude
History of previous chemo/radiotherapy
PP/ how does menopause happen
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
where does the mmajority of estrogen come from in menopausal women
conversion of androgens into estrogen by AROMATASE
sx of menopause (9)
A&A
↓ estrogen diseases
vessel & (psych)
w&b
long term: heart 💓& bone 🦴
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
When do sx 1st occur
(begin up to 6 years before the final menstrual period and continue for a variable number of years after the final menstrual period)
Cause of hot flush
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.
Why is there bladder atrophy
bladder and urethra share embryological derivation with the uterus and vagina so is affected by lack of estrogen in the same way
Why IHD In menopause
oestrogen reduces levels of LDL cholesterol whilst raising HDL cholesterol. After menopause women experience the same frequency of cardiovascular disease as men.
Why osteoporosis in menopause
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.
Investigations for menopause
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
How often should FSH be checked in menopause
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.
Pelvic exam in menopause
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
indications for rx of menopause
1) if sx are severe enough to affect QOL
2) premature menopause (before 40)
3) surgical menopause( oophorectomy)
Dx in menopause
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.
Speculum obs during menopause
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
Forms of HRT
Local: creams, pessaries, rings
Systemic: Oral drugs, implants, transdermal patches
rx for menopause
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
Why biopsy b4 HRT
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
HRT principles
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
contraindications of hormonal therapy
No absolute only relative
gyne (4)
CV (3)
other (2): porphyria
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
Indications of menopause use
provide relief of vasomotor symptoms
avoid the irregularity of menstrual cycles
preserve bone-osteoporosis
improve quality of life- insomnia etc
how does raloxifen rx menopause
🦴 +ve
breast?endo -ve
A selective estrogen receptor modulator (SERM)
acts as an estrogen agonist/ antagonist on receptors
ANTAGONIST
- breast - prevents breast cancer
- endometrium (prevents growth stimulation of estrogen-receptor positive cells)
acts as an AGONIST
on receptors in bone (inhibits bone resorption).
ADR’s of HRT
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
Rx of osteoporosis
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
What is tibolone
Gonadomimetic which contain estrogen, progestogen, and an androgen
what is ospemifene
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.
what is paroxetine
ssri,
pro’s: rx of vasomotor
cons:takes 6wks 2 work, causes w/drawal
effect of estrogen on hemostasis
↑ hemostasis by
↑clotting factors (VII, VIII, X, fibrinogen) and plasminogen,
↓antithrombin III and protein S levels,
why do PMS SX leave w/ menopause
no progesterone
what is examined in a dexa scan
Spine and Hip
how long should HRT be give for menoII rx
less than 5 years
effectof obesity on menoII
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
MOA of tamoxifen
+ve bone
+ve uterus
reduces osteoporosis but increases risk of endometrial hyperplasia & cancer
what are the risks of phytoestrogens
at least the same as HRT
