Menopause Flashcards
Agents that reliabily improve \_\_\_\_\_\_\_\_\_\_\_: estrogen acupuncture venlafaxine (Effexor) placebo
hot flashes
the most reliable determinant of whether a woman has reached menopause
LMP 12 full months ago or longer
estrogen+progestin ___________ the risk of colorectal cancer
reduces
most effective therapy for hot flashes
estrogen
dyspareunia can often be resolved with:
vaginal estrogen
normal physiologic change in the HPO axis which causes the ovaries to stop functioning and periods to stop marking the end of reproductive years
menopause
usual age of menopause =
average age of menopause =
48-55
average 51
Diagnostics for ___________
Periods stop for 12 consecutive months w/o taking exogenous hormones (using LMP)
Age
Lab hormone testing (not recommended during perimenopause)
menopause
Hormone Changes during ____________:
Fewer ovarian follicles develop w/ each cycle →
those follicles less responsive to FSH
ovaries have less estradiol, progesterone, and androgens →
negative feedback loop is lost
anterior pituitary production of FSH and LH continues
Perimenopause
Eventually, ___________ stops which causes hormone levels to stop fluctuating making periods stop
follicle production
FSH during ____________:
follicles less responsive to FSH → eventually remains high
Perimenopause
FSH during ____________:
HIGH in response to decreased estrogen → ovarian stromal tissues to increase testosterone production
Increase to >/=30– likely indicates menopause (not required for dx)
Postmenopause
LH during ___________:
eventually remains HIGH
Perimenopause
LH during ___________:
HIGH in response to decreased estrogen → ovarian stromal tissues to increase testosterone production
Postmenopause
Estrogen during ___________:
Ovaries produce less estradiol, progesterone, and androgens so estrogen eventually remains LOW
Perimenopause
most potent form of estrogen, mainly in reproductive years, low in postmenopausal years following the peripheral conversion of androstenedione
Estradiol - E2
estrogen form secreted by the placenta, synthesized from fetal androgens during pregnancy
(Small amounts in nonpregnant women)
By-product of estradiol and estrone
Estriol - E3
weakest form of estrogen, mostly found in postmenopausal women, children, and men. Postmenopause produced by adipose conversion of androstenedione secrete by adrenals (95%) and ovaries (5%) also by the metabolism of estradiol
Estrone - E1
Ovaries no longer produce estrogen or functional follicles when?
after menopause
After menopause, coricostromal and hilar cells of stromal tissue are steroidogenic which leads to significant levels of ___________ and ____________ for many years
androstenedione and testosterone
Circulating levels of this hormone remain relatively constant in PRE and POST menopause partly due to presence of high FSH and LH that cause ovarian stromal tissues to increase production
testosterone
vasodilation that causes hot flashes is result of a surge of ______
LH
increased body temp followed by decreased core temp causes:
night sweats
night sweats along with normal aging lead to less time in sleep stage ___ and ___
3 and 4
causes vaginal dryness, dyspareunia, and UTI predisposition
Urogenital atrophy
\_\_\_\_\_\_\_\_\_\_ of Menopause: longer time to lubrication less overall vag secretions and elasticity petechiae and bleeding fewer lactobacilli → more infections tissue atrophy
Sexual Dysfunctions
___________ Symptoms of Menopause:
More common in obese
Begin in perimenopausal period
Peak in first 2 years after final LMP
Most symptomatic women will experience s/s on average of 5 yrs after menopuase
⅓ will experience s/s for 10 years or more
Vasomotor
Hormonal Treatment for __________:
Standard treatment if appropriate
ET or EPT
Micronized P 300 mg/night → less hot flashes/night sweats, increased sleep
Vasomotor Symptoms
Lifestyle Mods for ___________:
avoid hot drinks/spicy food/ETOH/caffeine/smoking; stress, anxiety management; increase water, breathable clothes, decrease room temp, fans, layers, paced respirations, cold drinks, exercise (start before menopause), chill towels & pillows, decrease stress, soy isoflavones
Vasomotor Symptoms
Nonhormonal Medical Treatment for \_\_\_\_\_\_\_\_\_\_\_\_\_: Vitamin E- up to 800 IU Soy isoflavones - for 6 wks - 1 yr Black cohosh St john’s - often w/ cohosh Antidepressants Anticonvulsants Antihypertensives
Vasomotor Symptoms
CAM for ______________:
Acupuncture
Mindfulness
CBT
Vasomotor Symptoms
Hormonal Therapy for \_\_\_\_\_\_\_\_\_\_: Low-dose ET or EPT Oral Progestin (mildly sedating)
Sleep Disturbances
Lifestyle Mods for \_\_\_\_\_\_\_\_\_\_\_: Regular exercise - especially yoga Sleep hygiene Avoid caffeine, ETOH, nicotine Decrease stress Mindfulness Manage hot flashes
Sleep Disturbances
Nonhormonal Medical Treatment for _____________:
Valerian
Sleep Disturbances
CAM for ______________:
acupuncture
relaxation techniques
Sleep Disturbances
Hormonal Treatment for \_\_\_\_\_\_\_\_\_\_: Vaginal estrogen (consider cancer hx - topical preferred)
Vaginal Symptoms
Nonhormonal Medical Treatment for _____________:
Dyspareunia - Ospemifene & intravaginal DHEA
Lubes - water, silicone, oil
Unscented moisturizers to support normal pH - several times/week and between sex
Vaginal Symptoms
CAM for ______________:
Mindfulness
CBT
Vaginal Symptoms
Hormonal Treatment for __________:
ET- vaginal or transdermal
Urogenital Symptoms
CAM for ______________:
Pelvic floor training
Pessaries
Surgery
Urogenital Symptoms
Lifestyle Mods for ___________:
Exercise
Stress management
Relaxation techniques
Mood Symptoms
Nonhormonal Medical Treatment for \_\_\_\_\_\_\_\_\_\_\_\_\_: Valerian Kava (anxiety, hepatotoxic) Ginseng St.John’s Wort
Mood Symptoms
Lifestyle Mods for \_\_\_\_\_\_\_\_\_\_\_: Social networking Nind engagement Stimulating work Puzzles Not smoking ETOH moderation Exercise
Mental Function
Nonhormonal Medical Treatment for _____________:
Omega-3 fatty acids
Mental Function
Lifestyle Mods for ___________:
Stop smoking
Osteoporosis
Nonhormonal Medical Treatment for _____________:
Calcium supplement
Vitamin D
Osteoporosis
___-___% of women experience s/s of vulvovaginal atrophy (VVA) due to decreased estrogen
20-50%
Moisturizers don’t replace ________ at time of sex
lubrication
Not recommended for __________:
Petroleum jelly products
Fragrances (including products with them)
Douching
Vaginal Dryness
For vaginal ___________, consider silicone based iso osmolar product or propylene glycol free product
irritation
unopposed estrogen hormal therapy given to those WITHOUT a uterus recommended when only vaginal symptoms are present
Estrogen therapy (estrogen only) (ET)
causes increased endometrial cancer due to proliferating endometrial lining if given to woman with a uterus
Estrogen therapy (estrogen only) (ET)
Transdermal and low-dose oral ET associated w/ lower risk for __________
VTE and stroke
may be given oral, transdermal, topical, creams, or via vaginal tablets
Estrogen therapy (estrogen only) (ET)
hormonal therapy for those WITH a uterus
BUT Limited to 3-5 years of use due to increased risk of breast cancer
Estrogen Plus Progestogen Therapy (EPT)
only included in the hormonal therapy for endometrial protection for women w/ a uterus to decrease endometrial carcinoma risk
progestogen
there is an option to place LNG IUD along with giving ET so woman is receiving:
progestogen
progestogen added is not needed when ET is:
local (NOT systemic)
hormone therapy is used during ___________ and ______________
perimenopause and postmenopause
for premature or early menopause, used until median menopause age of 52
Menopause Hormone Therapy (MHT)
CS-EPT – Estrogen daily + Progestofen cyclicly usually day 1-12 of cycle (will have a withdrawal bleed)
Sequential HT
CC-EPT everyday to avoid withdrawal bleeding
Continuous HT
Progestogen taken 2 days on then 1 day off (more breakthrough bleeding)
Pulsed HT
Estrogen taken day 1-12 then Progestogen taken day 12-21 then nothing taken day 22-28 (withdrawal bleeding and menopause s/s rebound)
Cyclic HT
cannot use _______ for progestogen therapy because they have more than needed
Depo or Nexplanon
Forms of __________”
oral
gel
IUD
Progestogen
\_\_\_\_\_\_\_\_\_ forms of Estrogen: oral patch creams sprays gels Femring (only one)
Systemic
___________ forms of Estrogen:
vaginal creams
vaginal tablets
rings (Estring lower dose than Femring)
Local
Progestogen-only form of HT is a ______ because cream is not FDA approved
pill
Systemic HT doses treat:
vasomotor symptoms
Local HT doses treat:
genitourinary symptoms (atrophic vaginitis)
EPT use should be limited to ___-___ years due to increased risk of breast cancer
3-5
could be used longer than 3-5 years in the absence of adverse effects or known risk factors
ET (Estrogen-only Therapy)
most effective treatment for vulvar and vaginal atrophy
ET (Estrogen-only Therapy)
_______ ET is recommended when only vaginal sympotoms are present
Low-dose, Local
data is lacking to support ET in women with history of:
breast cancer
HT can be used in women who experience premature menopause until age:
52 (median age of menopause)
transdermal and low-dose oral ET have been associated with lower risk of:
VTE and stroke
all women with intact uterus receiving systemic ET should receive:
(decreases risk of endometrial cancer)
systemic progestogen or
LNG IUD placement
Contraindications of \_\_\_\_\_\_\_\_\_\_\_\_: Hx breast cancer Estrogen-dependent neoplasia Hx uterine cancer Hx ovarian cancer Hx biliary tract disorder Undiagnosed abnormal genital bleeding Hx of or active thrombophlebitis/thromboembolic disorder
Estrogen Therapy
Contraindications of \_\_\_\_\_\_\_\_\_\_\_\_: Active thrombophlebitis/thromboembolic disorder Liver dysfunction/disease Hx breast cancer Undiagnosed abnormal vaginal bleeding Pregnancy
Progestogen Therapy
Adverse Effects of \_\_\_\_\_\_\_\_\_\_: Uterine bleeding Breast tenderness Nausea Bloating Fluid retention in extremities HA Dizziness Hair loss
Estrogen Therapy
Adverse Effects of __________:
Mood changes
Possible increased uterine bleeding (higher chance than if taking estrogen alone)
Progestogen Therapy
Adverse Effects of ________:
All the same as ET & P-only
Plus Weight Gain
Hormone Therapy
Risks of \_\_\_\_\_\_\_\_\_\_: breast cancer (if started age<60 or within 10 years of onset) endometrial cancer (if E taken unnopposed) VTE biliary issues MI stroke dementia
Hormone Therapy
Do not start HT over ___ years after menopause
10
Management of \_\_\_\_\_\_\_\_\_\_ caused by HT: take w/ meals change estrogen change to transdermal lower dose
nausea
Management of __________ caused by HT:
low dose transdermal E
lower dose or micronized P
bloating
Management of \_\_\_\_\_\_\_\_\_\_ caused by HT: salt restriction adequate water intake exercise herbal or Rx diuretic
fluid retention
Management of \_\_\_\_\_\_\_\_\_\_ caused by HT: (P related) lower P dose CC-EPT adequate water intake restrict salt, caffeine, ETOH
mood changes
Management of \_\_\_\_\_\_\_\_\_\_ caused by HT: transdermal E CC-EPT low dose E or P adequate water restrict salt, caffeine, ETOH
HA
Management of __________ caused by HT:
lower E dose
change P dose
restrict salt, caffeine, ETOH, chocolate
breast tenderness
symptomatic time leading up to menopause plus for about a year after last LMP
perimenopause
Use continuous birth control method until age ____ then assume menopausal unless another period happens
55
Fertility stops at typical age of ___ - so use backup and draw serial FSH labs over several months
51
may be used in perimenopause (usually ages 45-55) for hot flashes and irregular bleeding
CHCs
If woman cannot take CHCs for vasomotor symptoms/irregular bleeding due to smoking or other contraindications, give:
progestogen-only contraceptive + ET systemic
OTC Non-hormonal ____________ :
Water-based: KY jelly, Astroglide liquid/gel, slippery stuff
Silicone: Astroglide X, KY intrigue, pink, ID, Millenium,
Oil: coconut oil, olive oil, vitamin E oil, etc
Lubricants
OTC Non-hormonal \_\_\_\_\_\_\_\_\_\_\_\_ : Feminease KY SILK-E luvena me again replens silken secret vagisil
Moisturizers
_________ for vaginal dryness:
Most effective
First line for s/s in those w/o contraindications
Femring
HT
Femring also prevents:
bone loss/fracture
systemic estrogen therapy for vaginal dryness consisting of estradiol over 3 months - only local tx for HF, has slightly more systemic absorption
Femring
_________ treatments for vaginal dryness:
Vag preps of E creams - Estrace and Premarin
Tablets - vagifem
Rings - estring and femring
P products - gels, IUD
Local
prescribed first for isolated GU symptoms of menopause
low-dose vaginal ET
Local vaginal treatments do not help with:
vasomotor symptoms
Bone density that is lower than normal peak density, but not low enough to be classified as osteoporosis
T-score -1.1 to -2.49
Osteopenia
The most common human bone disease characterized by low bone mass, deterioration of the bone tissue, and disruption of bone architecture resulting in reduced bone strength that increases the risk for fracture
T-score -2.5 or less
Osteoporosis
most common cause of morbidity among menopausal women
Osteoporosis
Peak bone mass occurs in late ___ - mid ____ and then rates of bone resorption and formation become relatively stable
20s-30s
type of osteoporosis associated with aging and affects women much more than men. After mid 30s, women’s bone resorption rate slowly begins to exceed formation; d/t loss of estrogen bone loss is especially rapid after menopause
primary
type of osteoporosis due to medicaitons such as corticosteroids, anticonvulsants, or methotrexate or other dx such as hyperthyroidism, chronic liver disease or GI diseases like malabsorption
secondary
type of osteoporosis where low bone density or fracture in young adults when no other cause is identified
idiopathic
Prevention of ___________:
**Prevention starts at menarche
Weight bearing resistance exercise
Fall prevention
Avoid tobacco
Moderating ETOH intake - < 2 drinks/day for women
Screening
Identify risk factors and modify what you can
Use FRX to make decisions about medical treatment
Young & low BMI? Menstruating? If not, consider estrogen tx due to not laying down enough bone
Adequate calcium and vitamin D intake
–Vitamin D: 800-1000IU/day for adults >50
-Calcium: 1200mg/day in postmenopausal
–Dietary intake is best!! - supplementation not recommended for prevention
Osteoporosis
bone mineral density test by dual-energy x-ray absorptiometry that looks at spine and hip - bone density and reports densities of posterior-anterior lumbar spine, total hip, and/or femoral neck **international criteria for dx of osteoporosis
**results reported in T-scores and z-scores
DXA scan
osteoporosis diagnosed when T-score is < ___
-2.5
T-scores are used for men > age ___ and __________ women
men > 50 and postmenopausal
comparisons to the BMD of an age, sex, and ethnicity matched reference population – used for premenopausal women, children and men <50
Z-scores
Z-score < _____ is “less than expected range” and should be evaluated for secondary cause of osteoporosis
-2.5
Labs to consider and rule out \_\_\_\_\_\_\_\_\_\_\_\_\_\_: CBC TSH CMP urine calcium 25-hydroxyvitamin
secondary osteoporosis
computer generated model using clinical factors and BMD to calculate future fracture risk for individuals
- -Provides 10-year probability for both hip and major osteoporotic fracture - spine, forearm, hip, or shoulder
- -Aids in identifying those at increased fracture risk and would benefit from medical treatment
FRAX
Osteopenia is T score ____-____
-1.0 – -2.5
compares woman’s bone density to 28 yr old woman so score of 0 means equivalent
T score
comparisons to the BMD of an age, sex, and ethnicity matched reference population
Z score
First Line treatment for postmenopausal w/ osteoporosis that is an antiresorptive
Biophosphonates (alendronate, risedronate)
medication best offered to postmenopausal women w/ osteoporosis at high risk for fracture
–Daily SQ injections for no more than 24 months
Teriparatide (PTH 1-34)
most often considered treatment for postmenopausal women with low bone mass or younger postmenopausal women with osteoporosis
SERM (Raloxifine- estrogen agonist-antagonist)
osteoporosis medication whose primary indication is to treat moderate to severe menopause symptoms (eg, vasomotor symptoms)
- When symptoms are controlled or cease, continued treatment can still be considered for bone effects while weighing its benefits and risks against those of alternative therapies
- May be a treatment option for a few years of early postmenopause
Systemic ET/EPT
Reasons for \_\_\_\_\_\_\_\_\_\_\_\_: T-scores of -2.5 or less women with hip or vertebral fractures T-scores in the low bone mass range (-1.0 to -2.5) +fractures or +high risk for fractures immobilized glucocorticoids use high fall risk FRAX >/= 3% OR any major osteoporotic fx >/= 20%
medication management of osteoporosis
Lifestyle changes for ___________:
Eat a balanced diet
Adequate calcium and vitamin D
Appropriate exercise and activity - weight bearing to preserve bone mass, maintain muscle mass, and improve balance
Avoid smoking and excessive alcohol consumption
Fall prevention
Vision
Balance and mobility
Household hazards
**May be all that is needed for postmenopausal at low risk for fracture but all should be encouraged
osteoporosis
Used to estimate risk and determine who to screen early and risk of fracture
Low scores = used to identify those who would have a cost-effective benefit from starting medication therapy
FRAX
Once treatment for osteoporosis is initiated, how often do we check bone density?
q 2 years
