Menopause Flashcards
1
Q
Agents that reliabily improve \_\_\_\_\_\_\_\_\_\_\_: estrogen acupuncture venlafaxine (Effexor) placebo
A
hot flashes
2
Q
the most reliable determinant of whether a woman has reached menopause
A
LMP 12 full months ago or longer
3
Q
estrogen+progestin ___________ the risk of colorectal cancer
A
reduces
4
Q
most effective therapy for hot flashes
A
estrogen
5
Q
dyspareunia can often be resolved with:
A
vaginal estrogen
6
Q
normal physiologic change in the HPO axis which causes the ovaries to stop functioning and periods to stop marking the end of reproductive years
A
menopause
7
Q
usual age of menopause =
average age of menopause =
A
48-55
average 51
8
Q
Diagnostics for ___________
Periods stop for 12 consecutive months w/o taking exogenous hormones (using LMP)
Age
Lab hormone testing (not recommended during perimenopause)
A
menopause
9
Q
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
A
Perimenopause
10
Q
Eventually, ___________ stops which causes hormone levels to stop fluctuating making periods stop
A
follicle production
11
Q
FSH during ____________:
follicles less responsive to FSH → eventually remains high
A
Perimenopause
12
Q
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)
A
Postmenopause
13
Q
LH during ___________:
eventually remains HIGH
A
Perimenopause
14
Q
LH during ___________:
HIGH in response to decreased estrogen → ovarian stromal tissues to increase testosterone production
A
Postmenopause
15
Q
Estrogen during ___________:
Ovaries produce less estradiol, progesterone, and androgens so estrogen eventually remains LOW
A
Perimenopause
16
Q
most potent form of estrogen, mainly in reproductive years, low in postmenopausal years following the peripheral conversion of androstenedione
A
Estradiol - E2
17
Q
estrogen form secreted by the placenta, synthesized from fetal androgens during pregnancy
(Small amounts in nonpregnant women)
By-product of estradiol and estrone
A
Estriol - E3
18
Q
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
A
Estrone - E1
19
Q
Ovaries no longer produce estrogen or functional follicles when?
A
after menopause
20
Q
After menopause, coricostromal and hilar cells of stromal tissue are steroidogenic which leads to significant levels of ___________ and ____________ for many years
A
androstenedione and testosterone
21
Q
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
A
testosterone
22
Q
vasodilation that causes hot flashes is result of a surge of ______
A
LH
23
Q
increased body temp followed by decreased core temp causes:
A
night sweats
24
Q
night sweats along with normal aging lead to less time in sleep stage ___ and ___
A
3 and 4
25
causes vaginal dryness, dyspareunia, and UTI predisposition
Urogenital atrophy
26
```
__________ of Menopause:
longer time to lubrication
less overall vag secretions and elasticity
petechiae and bleeding
fewer lactobacilli → more infections
tissue atrophy
```
Sexual Dysfunctions
27
___________ 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
28
Hormonal Treatment for __________:
Standard treatment if appropriate
ET or EPT
Micronized P 300 mg/night → less hot flashes/night sweats, increased sleep
Vasomotor Symptoms
29
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
30
```
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
31
CAM for ______________:
Acupuncture
Mindfulness
CBT
Vasomotor Symptoms
32
```
Hormonal Therapy for __________:
Low-dose ET or EPT
Oral Progestin (mildly sedating)
```
Sleep Disturbances
33
```
Lifestyle Mods for ___________:
Regular exercise - especially yoga
Sleep hygiene
Avoid caffeine, ETOH, nicotine
Decrease stress
Mindfulness
Manage hot flashes
```
Sleep Disturbances
34
Nonhormonal Medical Treatment for _____________:
| Valerian
Sleep Disturbances
35
CAM for ______________:
acupuncture
relaxation techniques
Sleep Disturbances
36
```
Hormonal Treatment for __________:
Vaginal estrogen (consider cancer hx - topical preferred)
```
Vaginal Symptoms
37
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
38
CAM for ______________:
Mindfulness
CBT
Vaginal Symptoms
39
Hormonal Treatment for __________:
| ET- vaginal or transdermal
Urogenital Symptoms
40
CAM for ______________:
Pelvic floor training
Pessaries
Surgery
Urogenital Symptoms
41
Lifestyle Mods for ___________:
Exercise
Stress management
Relaxation techniques
Mood Symptoms
42
```
Nonhormonal Medical Treatment for _____________:
Valerian
Kava (anxiety, hepatotoxic)
Ginseng
St.John’s Wort
```
Mood Symptoms
43
```
Lifestyle Mods for ___________:
Social networking
Nind engagement
Stimulating work
Puzzles
Not smoking
ETOH moderation
Exercise
```
Mental Function
44
Nonhormonal Medical Treatment for _____________:
| Omega-3 fatty acids
Mental Function
45
Lifestyle Mods for ___________:
| Stop smoking
Osteoporosis
46
Nonhormonal Medical Treatment for _____________:
Calcium supplement
Vitamin D
Osteoporosis
47
___-___% of women experience s/s of vulvovaginal atrophy (VVA) due to decreased estrogen
20-50%
48
Moisturizers don’t replace ________ at time of sex
lubrication
49
Not recommended for __________:
Petroleum jelly products
Fragrances (including products with them)
Douching
Vaginal Dryness
50
For vaginal ___________, consider silicone based iso osmolar product or propylene glycol free product
irritation
51
unopposed estrogen hormal therapy given to those WITHOUT a uterus recommended when only vaginal symptoms are present
Estrogen therapy (estrogen only) (ET)
52
causes increased endometrial cancer due to proliferating endometrial lining if given to woman with a uterus
Estrogen therapy (estrogen only) (ET)
53
Transdermal and low-dose oral ET associated w/ lower risk for __________
VTE and stroke
54
may be given oral, transdermal, topical, creams, or via vaginal tablets
Estrogen therapy (estrogen only) (ET)
55
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)
56
only included in the hormonal therapy for endometrial protection for women w/ a uterus to decrease endometrial carcinoma risk
progestogen
57
there is an option to place LNG IUD along with giving ET so woman is receiving:
progestogen
58
progestogen added is not needed when ET is:
local (NOT systemic)
59
hormone therapy is used during ___________ and ______________
perimenopause and postmenopause
60
for premature or early menopause, used until median menopause age of 52
Menopause Hormone Therapy (MHT)
61
CS-EPT -- Estrogen daily + Progestofen cyclicly usually day 1-12 of cycle (will have a withdrawal bleed)
Sequential HT
62
CC-EPT everyday to avoid withdrawal bleeding
Continuous HT
63
Progestogen taken 2 days on then 1 day off (more breakthrough bleeding)
Pulsed HT
64
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
65
cannot use _______ for progestogen therapy because they have more than needed
Depo or Nexplanon
66
Forms of __________"
oral
gel
IUD
Progestogen
67
```
_________ forms of Estrogen:
oral
patch
creams
sprays
gels
Femring (only one)
```
Systemic
68
___________ forms of Estrogen:
vaginal creams
vaginal tablets
rings (Estring lower dose than Femring)
Local
69
Progestogen-only form of HT is a ______ because cream is not FDA approved
pill
70
Systemic HT doses treat:
vasomotor symptoms
71
Local HT doses treat:
genitourinary symptoms (atrophic vaginitis)
72
EPT use should be limited to ___-___ years due to increased risk of breast cancer
3-5
73
could be used longer than 3-5 years in the absence of adverse effects or known risk factors
ET (Estrogen-only Therapy)
74
most effective treatment for vulvar and vaginal atrophy
ET (Estrogen-only Therapy)
75
_______ ET is recommended when only vaginal sympotoms are present
Low-dose, Local
76
data is lacking to support ET in women with history of:
breast cancer
77
HT can be used in women who experience premature menopause until age:
52 (median age of menopause)
78
transdermal and low-dose oral ET have been associated with lower risk of:
VTE and stroke
79
all women with intact uterus receiving systemic ET should receive:
(decreases risk of endometrial cancer)
systemic progestogen or
| LNG IUD placement
80
```
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
81
```
Contraindications of ____________:
Active thrombophlebitis/thromboembolic disorder
Liver dysfunction/disease
Hx breast cancer
Undiagnosed abnormal vaginal bleeding
Pregnancy
```
Progestogen Therapy
82
```
Adverse Effects of __________:
Uterine bleeding
Breast tenderness
Nausea
Bloating
Fluid retention in extremities
HA
Dizziness
Hair loss
```
Estrogen Therapy
83
Adverse Effects of __________:
Mood changes
Possible increased uterine bleeding (higher chance than if taking estrogen alone)
Progestogen Therapy
84
Adverse Effects of ________:
All the same as ET & P-only
Plus Weight Gain
Hormone Therapy
85
```
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
86
Do not start HT over ___ years after menopause
10
87
```
Management of __________ caused by HT:
take w/ meals
change estrogen
change to transdermal
lower dose
```
nausea
88
Management of __________ caused by HT:
low dose transdermal E
lower dose or micronized P
bloating
89
```
Management of __________ caused by HT:
salt restriction
adequate water intake
exercise
herbal or Rx diuretic
```
fluid retention
90
```
Management of __________ caused by HT:
(P related)
lower P dose
CC-EPT
adequate water intake
restrict salt, caffeine, ETOH
```
mood changes
91
```
Management of __________ caused by HT:
transdermal E
CC-EPT
low dose E or P
adequate water
restrict salt, caffeine, ETOH
```
HA
92
Management of __________ caused by HT:
lower E dose
change P dose
restrict salt, caffeine, ETOH, chocolate
breast tenderness
93
symptomatic time leading up to menopause plus for about a year after last LMP
perimenopause
94
Use continuous birth control method until age ____ then assume menopausal unless another period happens
55
95
Fertility stops at typical age of ___ - so use backup and draw serial FSH labs over several months
51
96
may be used in perimenopause (usually ages 45-55) for hot flashes and irregular bleeding
CHCs
97
If woman cannot take CHCs for vasomotor symptoms/irregular bleeding due to smoking or other contraindications, give:
progestogen-only contraceptive + ET systemic
98
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
99
```
OTC Non-hormonal ____________ :
Feminease
KY SILK-E
luvena
me again
replens
silken secret
vagisil
```
Moisturizers
100
_________ for vaginal dryness:
*Most effective*
*First line for s/s in those w/o contraindications*
Femring
HT
101
Femring also prevents:
bone loss/fracture
102
systemic estrogen therapy for vaginal dryness consisting of estradiol over 3 months - only local tx for HF, has slightly more systemic absorption
Femring
103
_________ treatments for vaginal dryness:
Vag preps of E creams - Estrace and Premarin
Tablets - vagifem
Rings - estring and femring
P products - gels, IUD
Local
104
prescribed first for isolated GU symptoms of menopause
low-dose vaginal ET
105
Local vaginal treatments do not help with:
vasomotor symptoms
106
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
107
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
108
most common cause of morbidity among menopausal women
Osteoporosis
109
Peak bone mass occurs in late ___ - mid ____ and then rates of bone resorption and formation become relatively stable
20s-30s
110
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
111
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
112
type of osteoporosis where low bone density or fracture in young adults when no other cause is identified
idiopathic
113
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
114
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
115
osteoporosis diagnosed when T-score is < ___
-2.5
116
T-scores are used for men > age ___ and __________ women
men > 50 and postmenopausal
117
comparisons to the BMD of an age, sex, and ethnicity matched reference population -- used for premenopausal women, children and men <50
Z-scores
118
Z-score < _____ is “less than expected range” and should be evaluated for secondary cause of osteoporosis
-2.5
119
```
Labs to consider and rule out ______________:
CBC
TSH
CMP
urine calcium
25-hydroxyvitamin
```
secondary osteoporosis
120
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
121
Osteopenia is T score ____-____
-1.0 -- -2.5
122
compares woman’s bone density to 28 yr old woman so score of 0 means equivalent
T score
123
comparisons to the BMD of an age, sex, and ethnicity matched reference population
Z score
124
*First Line* treatment for postmenopausal w/ osteoporosis that is an antiresorptive
Biophosphonates (alendronate, risedronate)
125
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)
126
most often considered treatment for postmenopausal women with low bone mass or younger postmenopausal women with osteoporosis
SERM (Raloxifine- estrogen agonist-antagonist)
127
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
128
```
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
129
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
130
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
131
Once treatment for osteoporosis is initiated, how often do we check bone density?
q 2 years
