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Fall 2020 Sexual and Reproductive Health > Menopause > Flashcards

Menopause Flashcards

1
Q

Objectives

A
  • Define menopause and associated terminology
  • Describe the physiology of menopause and the menopause transition
  • Identify common menopausal symptoms and associated differential diagnosis
  • Identify Rx and Non-Rx opions for the management of menopausal symptoms and Genitourinary Syndrome of Menopause (GSM)
  • Discuss the Women’s Health Initiative Trials and Conclusions
  • Apply the North American Menopause Society APP to cases
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2
Q

Menopause

=

  • Age range __-__, average __
  • Before age __: early menopause, __% of women
A

Prior 12 Consecutive Months of Amenorrhea

  • 40-58, 52
  • 45, 5%
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3
Q

Perimenopause

=

A

2-8 years prior to the final menstrual period, irregular cycles

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4
Q

Post Menopause

  • Early: 1st __ years
  • Late > __ yrs amenorrhea through remaining life-span
A

5

> 6

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5
Q

Primary Ovarian Insufficiency

=

  • 1% of women
  • Dx:
A

Transitory or permanent (premature menopause) Loss of ovarian function age <40

Dx: 2 elevated FSH lvls 1 month apart

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6
Q

Induced Menopause

=

  • Refer CA pts to ____ specialist
A

Permanent cessation of menses/ovulation 2/2 bilateral oopherectomy or chemo/radiation

  • fertility

will need hormonal therapy (chemo -> ovarian malfuntion)

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7
Q

Physiology: HPO Axis Distribution

  • Approx 1 million follicles at birth
  • 300-400 reproductive lifetime ovulatory cycles
  • Rate of ____ increases with age
  • Decreases in available follicles, follicle development
  • Decrease in ovarian ____ to FSH and LH
  • Decrease in ovarian __ and __ production***
  • ___ and ___ remain high
  • Perimenopause: these hormone levels can ___ greatly from day to day resulting in highly ____ cycle
A
  • atresia
  • sensitivity
  • E and P production decreases**
  • FSH and LH remain high (bc of negative feedback system of HPO axis)
  • vary, irregular
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8
Q

Menopause: Etiology of Physiologic Symptoms

E2 Receptors

  • ____: frontal lobe, limbic system, vasomotor center
  • E___, S___, H____
  • V____ system, __ Tract
  • _____ Tissue
  • U_____ tract
  • B
A
  • Brain
  • Eyes, Skin, Heart
  • Vascular, GI
  • Breast
  • Urogenital
  • Bones
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9
Q

Menopause: Etiology of Physiologic Symptoms

Symptoms

  • ___ flashes/night ____
  • H_____/F____fulness/Poor _____
  • M____ disorders
  • Breast ____
  • Vulvar D____, Vaginal _____, _ _ _s (GSM/VVA)
  • _____ Desire/Function
A
  • Hot flashes/Night sweats
  • Headaches/Forgetfullness/Poor concentration
  • Mood disorders
  • Pain
  • Dermatoses/ Vaginal Dryness
  • Sexual
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10
Q

Menopause Sx (Notes)

  • _______ is what decreases once ovulation ceases
  • Receptors in the
    • ____ -> sx of moodiness
    • ____ -> dryness, tingling
    • ____ -> weakening
    • Breast tissue -> ____
    • Urogenitial tract -> ____
  • Basically your ____ body is the point
A
  • Estradiol
    • Brain
    • Skin
    • Bones
    • pain
    • dryness
  • entire
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11
Q

Genitourinary Syndrome of Menopause

AKA Vulvovaginal Atrophy

Hypo_____

  • Leads to decreased (2)
    • Leads to increased (5)
  • Leads to decreased (2)
    • Leads to increased (3)
A

Hypoestrogenism

  • Elasticity, Secretions
    • Dryness, Pruritis, Dyspareunia, Trauma, Infection
  • Glycogen, Lactobacilli
    • Vaginal pH, Bacteria, UTIs
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12
Q

Symptoms Associated with Perimenopause and Postmenopause

A
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13
Q

**Midlife Health Issues**

(Differential Diagnoses when patients come in with menopausal complaints)

  1. O_____ and Over______
  2. ______ Disease (2)
  3. Type 2 ______
  4. C______
  5. O______
  6. T______
  7. D_____/C_____ Function

_______*** is Key (4)

A
  1. Obesity and Overweight
  2. Cardiovascular (Stroke/thrombosis, Heart attack/arrhythmia)
  3. Diabetes
  4. Cancer
  5. Osteoporosis
  6. Thyroid
  7. Depression/Cognitive

PREVENTION**: Diet, Exercise, Sleep, No Smoking**

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14
Q

Peri/Menopausal Sx: Differential Dx

  1. An____ -> Fatigue, cognitive changes
  2. A_____ -> Fatigue, Palpitations
  3. A_____ -> Joint aches, pain
  4. _____ Disorder -> Fatigue, Depression/anxiety, sleep disturbance
  5. D_____-> Hot flashes, heat intolerance
  6. Hyper_____emia -> Amenorrhea
  7. H_____ -> Headaches
  8. Hyper/Hypo _____ -> Anxiety, heat intolerance/fatigue, cognitive changes, dry skin
  9. Infections (____ illness, ___) -> Vasomotor Sx, Urinary Sx, Vaginal discharge/dryness, dyspareunia
  10. P___-C____ -> Menstrual Changes
  11. P_____ -> Amenorrhea, spotting, breast tenderness, fatigue
A
  1. Anemia
  2. Arrythmias
  3. Arthritis
  4. Mood
  5. Diabetes
  6. Hyperprolactinemia
  7. Hypertension
  8. Thyroidism
  9. Viral, STI
  10. PALM-COIEN
  11. Pregnancy
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15
Q

Perimenopause/Menopause Assessment

  • Thorough Hx
    • S___
    • Fhx of c____, ___/___ age of menopause, ____ disorders
    • Menopause specific ____ of Life Questionnaire
  • Physical Exam
    • _____ exam (u_____, endometrial _____ prn)
  • Selected Labs
    • Urine ____ Test
    • C___
    • Fasting ____
    • T___
    • P_____
    • ___ testing: urine culture
A
  • Hx
    • Symptoms
    • cancers, mother/sister (there is a genetic factor), mood
    • Quality
  • PE
    • Bimanual (US, biopsy)
  • Labs
    • UPT
    • CBC
    • Fasting glucose
    • TSH
    • Prolactin
    • STI
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16
Q

Peri/Menopause Diagnosis

  • **Perimenopause: Measuring hormone levels is generally?**
    • ​Anti Mullerian Hormone (AMH): _____ lvls 5 yrs prior to menopause (normal range .5-3.5 ng/mL)
    • Menopause: ____ > __-__ng/mL = menopause (normal range 10-25ng/mL)
  • **Use bleeding pattern**:
    • ​Age > __, amenorrhea x > __ days = menopause transition
      • ​Longer or shorter cycles
      • Longer or shorter duration of bleeding
      • Asctd sx
    • Menopause: ___spective, __ months amenorrhea
A
  • generally not clinically relevant
    • ​undetectable
    • FSH > 30-40
  • bleeding pattern
    • ​>45, > 60
    • retrospective, 12 months amenorrhea
17
Q

Women’s Health Initiative 1991-2005

  • Prevention Study
    • ​Investigated risks and benefits of HT for ______ of heart disease, breast and colorectal ca, and osteoporosis
    • Did NOT investigate symptom ____, ___ of life
  • RCT: Two arms (30,000)
    • 1) Estrogen alone (po CEE) vs. Placebo
    • 2) E and P (po CEE and po MPA) vs. Placebo
    • Mean age: 63 no stratification by age for results
  • 2002: Combined E and P Therapy trial stopped
    • Increased risk of stroke
    • __ effect on CHD, non-sign decrease in Br __ risk, + reduction in _____ fractions

**CONCLUSION: MENOPAUSAL HT is? **

A
  • Prevention Study
    • ​Prevention
    • Symptoms/QOL
  • Combined E and P tiral stopped
    • No effect on CHD, No decrease in Br CA risk, No reduction in osteoporotic fractures

MENOPAUSAL HT is NOT TO BE USED SOLELY FOR PREVENTION OF CHRONIC DISEASE

18
Q

WHI: Estrogen/Progesterone Therapy (MHT)**

Overall the absolute risk of breast cancer, CHD, VTE, stroke with EPT = ______

Effect on Mortality?

Effect on Osteoporotic fractures?

A

Rare

No increased risk

Small reduction in fractures

Very individualized tx after age 60

19
Q

Conclusions from WHI Trials

(2)** since menopause onset are critical modifiers of the adverse effects of systemic HT on CVD, stroke, VTE and Dementia**

  • For which women? is the benefit risk ratio for intiating HT favorable, particularly for those with _____ symptoms or at high risk for ___ loss or ____
  • For which women? does the beenfit risk ratio appear unfavorable

Benefits and risks must be ______ for each patient, based on best ____ available, with periodic re-______

A

Age and Time

  • <60, <10 yrs from menopause
    • Vasomotor (hot flashes, temp reg)
    • bone loss, fractures
  • >60, >10 years from menopause

Individualized, evidence, evaluation

20
Q

Genitourinary Syndrome of Menopause (GSM) Treatment

(1)*

Most effective

A

Local ET (E creams, tabs, rings)

  • New non-E formulations (vaginal suppositories, po tabs)
  • Nonpharm: vaginal moisturizers and lubricants, hyaluronc acid suppositories, CO2 laser tx
21
Q

Vasomotor Sx Treatment + Intact Uterus

(1) - (2)

A

Multihormonal Therapy age 50-59 or within 10 yrs of menopause

  1. Low dose estrogen patch
  2. PO progesterone (prometrium or levonogestrel)

For a women who still have a uterus must give estrogen WITH PROGESTERONE (for endometrial protection)

22
Q

Hormonal Therapy for Menopausal Sx

  • EPT: __-__ yrs: reason for longer duration should be ____
  • ET: more _____
  • POV or Early menopause: EPT up to age __ minimally
  • I______ tx, ____ decision making, periodic ____, routine _____, ***______ ______***
A
  • 3-5 yrs, documented
  • flexible
  • 52
  • Individualized, Shared, Evaluation, Screening, ***ANNUAL MAMMOGRAM***
23
Q

Non-Hormonal Management of Vasomotor Symptoms

  1. Lifestyle changes
    • Dressing in l____, c___ clothing, bedding, f___, ____ aids
    • Minimize _____ - alcohol, smoking, caffeine
  2. S__/Isoflavones
  3. Herbs: Black ____ (OTC estroven-w/melatonin), ___berry, K___, Valerian ____
  4. ____ respiration/relaxation
  5. Ac____
  6. Hy_____
  7. SSRI/SNRI _____ (Effexor, Celexa, Paxil)
  8. Oxy____
  9. G_____
  10. Cl____
A
  1. Lifestyle
    1. layers, cotton, fans, cooling
    2. triggers
  2. Soy
  3. Cohosh, Chastberry, Kava, Root
  4. Paces
  5. Acupuncture
  6. Hypnosis
  7. Antidepressants
  8. Oxybutynin
  9. Gabapentin
  10. Clonidine
24
Q

Pinciples of Menopausal Sx Management

  • D___/Ex___/S___/S___ Reduction
  • __ hormonal, OTC, or herbal formulations
  • When MHT is not contraindicated: NOT necessarily lowers dose for shortest duration but instead?
  • For women with an intact uterus?
  • 1st line for Vasomotor Sx?
  • 1st line when vaginal/GSM Sx are the only Sx?
    • 50% chance sx recur when dc therapy
A
  • Diet/Exercise/Sleep/Stress
  • Non-hormonal
  • Appropriate dose, duration, regimen, and route
  • E always with P
    • 100mg micronized progesterone po qd or 200mg micronized progesterone d1-12 of month
    • LVNG IUD also an option
  • E Patch + PO micronized progesterone
  • Local non-hormonal E therapy
25
Q

Contraindications to MHT

  • Unexplained vaginal _____
  • _____ dysfunction or active disease
  • Active or Hx of ___ or __
  • ____ disorder/thrombophilia
  • Untreated ____
  • Active or Hx of breast, endometrial ____ or other ____ dependent tumor (vaginal E for GSM not contraindicated)
  • Hx of s____ or C _ _
A
  • bleeding
  • Liver
  • DVT, PE
  • Clotting
  • HTN
  • Cancer, estrogen dependent tumor
  • stroke, CHD
26
Q

“Natural” hormones

  • _____: from plant, animal, mineral sources
  • “_____”: chemically identical to those made in human body
  • Several FDA _____ formulations ARE _____ in source and bioidentical: 17b-estradiol (Estrace), micronized progesterone (prometrium)
  • “Custum compounded” ___ FDA approved, often based on salivary hormone lvl testing (unreliable, not evidence based), no evidence that is has less risk than Rx MHT
A
  • Natural
  • “Bioidentical”
  • approved - Natural
  • Custum compounded, NOT FDA approved

Fall 2020 Sexual and Reproductive Health (10 decks)

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