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Menopause and Perimenopause Flashcards

1
Q

Provider Role for Midlife Women

A
  • Empower each woman to make healthy, positive life choices
  • Assist women to assess her individual health status, strengths, risks, etc.
  • Help each woman listen to her wisdom
  • Provide updated, accurate information
  • Advocate ongoing research issues facing women
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2
Q

Estrogen Functions

A
  • Female sex characteristics
  • 400+ receptor sites in body
  • Increases NO, dilating blood vessels and mediating vasoactive effects of angiotensin
  • Improves HDL, lowers total and LDL
  • Improves CHO metabolism
  • Mediates serotonin release and inhibits uptake of norepi
  • Increases growth of new dendrites and new synapses
  • Increases production of acetyltransferase leading to acetylcholine
  • Inhibits MAO
  • Regulates sleep centers
  • Enhances concentration
  • Maintains bone density, skin, and hair
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3
Q

Estrogens Native to Women (Bioidentical)

A
  • Estrone (E1): Dominant post-menopausal
  • Estradiol (E2): Dominant pre-menopausal; activates alpha and beta
  • Estriol (E3): Highest in pregnancy; antagonizes stimulation by stimulating beta
  • Estrogens effects by 2 mechanisms:
    • Alpha: Promotes cell proliferation; may be contributing factors to some cancers
    • Beta: Inhibits breast cell prolieration
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4
Q

Effects of Progesterone

A
  • regulates menstrual flow
  • Stabilizes lining o uterus to allow for implantation of embryo
  • Decreases intestinal motility
  • Bone building
  • Calming, sedating
  • Can balance estrogen
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5
Q

Effects of testosterone

A
  • Enhances libido and mood
  • Increases energy, lean body muscle, and bone density
  • Decreases fat
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6
Q

Definition: Perimenopause

A
  • Period of fluctuating hormonal changes 5-15yrs before menopause
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7
Q

Early Perimenopause

A
  • Longer/heavier cycles

- Often more frequent

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8
Q

Late Perimenopause

A
  • Skipped periods

- Shorter/lighter

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9
Q

Premature menopause

A
  • <40yo
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10
Q

Early Menopause

A
  • <45yo
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11
Q

Effects of Perimenopause on Cycles

A
  • fertility decreases with age but birth control still essential
  • High unintended pregnancy rate
  • Impact on childbearing choices
  • Fibroids: Effects on bleeding; only a problem if they cause bleeding or big enough to cause bulk symptoms or pressure
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12
Q

Balance upset in perimenopause

A
  • Can be higher E2/lower P
  • Can be lower E2/higher P
  • Can have both low
  • Testosterone becomes more dominant as E2 decreases -> can lead to increased acne, facial hair, ABD fat
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13
Q

Severity of symptoms from hormonal changes

A
  • Rate of decline in hormones affects severity of symptoms

- Surgery vs. natural

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14
Q

Symptoms of decreased ovarian functions: Vasomotor Instability

A
  • Caused by decreased estrogen
  • Hot flashes (sensation)
  • Hot flushes (redness, diaphoresis)
  • Night sweats
  • Palpitations
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15
Q

Symptoms of decreased ovarian functions: Sleep disruption

A
  • Caused by decreased estrogen
  • Leads to low serotonin
  • Decreased REM sleep/deep sleep
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16
Q

Symptoms of decreased ovarian functions: Vaginal changes

A
  • atrophy of skin
  • decreased moisture
  • dyspareunia
  • pH more alkaline -> more UTIs
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17
Q

Symptoms of decreased ovarian functions: skin

A
  • dryness
  • sagging
  • Increased central fat deposition
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18
Q

Symptoms of decreased ovarian functions: Mood

A
  • Increased risk of depressive/anxiety symptoms
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19
Q

Symptoms of decreased ovarian functions: Others

A
  • Fuzzy thinking
  • Worsening PMS
  • Energy level changes: up or down
  • Sexual responses: decreased orgasmic response; increase or decrease libido
  • joint pains/achiness
  • Increased incontinence (may be due to general aging and obesity)
  • decreased bone formation / increased resorption
  • Increased cholesterol: Up LDL, Down HDL
  • Increased BP
  • Increased pain syndromes (fibromyalgia)
  • Increased CAD
  • Decreased muscle strength
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20
Q

Factors to consider in deciding whether to Rx HRT

A
  • Know medical Hx: Breast Ca
  • reasons for choosing
  • balance risks and benefits
  • make patients know all options
  • doesn’t have to be right decision for always, may be reversed
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21
Q

Reasons to start HRT

A
  • Symptoms relief

- Prevention/Attenuation of chronic Dz (cardiac, osteoporosis)

22
Q

Definitions for HRT

A
  • ERT or ET: Estrogen-replacement therapy
  • EPT: combined estrogen/progesterone replacement
  • HRT: any hormone at all
23
Q

Bioidentical Hormones: Facts

A
  • Exact copies of endogenous human hormone
  • Does not mean not synthesized in lab
  • Many confuse with term “natural”
  • Natural may mean from a horse like premarin, from a source in ground, or bioidentical
  • Does not have to come from compounding pharmacy
  • Synthetic: different chemical structures or non-human versions (aka horse)
24
Q

Bioidentical Estrogens (17-beta Estradiol)

A
  • TD Patches: Vivelle-dot, Climara, Mylan (generic)
  • TD Gels: Divigel, Estrogel, Elestin
  • Topical spray mists: Evamist
  • Topical lotion: Estrasorb
  • Oral: Estrace, Estradiol (generic)
  • Vaginal: Estrace cream, Estring ring (Vag dose), Femring (systemic dose), Vagifem pill
25
Compounding Pharmacy: Bioidentical estrogens
- 17b Estradiol oral, TD, vaginal - Biestrin: Estradiol + estriol - Estriol oral, TD, vaginal - Subdermal pellets
26
Synthetic Estrogens
- Conjugated equine estrogens (CEE): Premarin (oral or vaginal only; NONE TD) - Conjugated estrogens (Cenestin) - Fem HRT: Ethinyl estradiol + northindrone; oral; all contraceptive estrogens contain this estrogen
27
Bioidentical Progesterone
- Regular pharmacies: * Oral Prometrium (micronized natural progesterone; from peanut-oil; not for those with peanut allergies) * Vaginal: Crinone - From compounding pharmacies: * Progesterone oral, TD, creams, vaginal
28
Synthetic Progestins
- Medroxyprogesterone acetate (MPA): provera - Northindrone (mild) - Levonorgestrel (stronger) - Drospironone: Yaz, available with 17-b - Norgestimate
29
Mixed Bioidentical/Synthetic Compounds
- Combined oral preps: * Activella = Estradiol (17b) + northindrone * Ortho Pre-Fest: estradiol + norgestimate - Combined TD patches: * Angelic: estradiol + Drospironone * Climara Pro: estradiol + levonorgestrel * CombiPatch: estradiol + northindrone
30
Sympomatic Benefits of HRT/ERT
- highly effective - Decreased vasomotor symptoms - Increased vaginal moisture, comfort, infections - Improvement in sleep, mood
31
CVD in Women
- Leading cause of mortality in women - Increase in women after menopause - within 6yr after 1st MI, 35% will have another - Higher fatality rate in 1st yr post-MI
32
HRT and CVD
- HRT decreases CVD by 35-50% in healthy women - HRT are not helpful & probably harmful if already have CVD - Do NOT use as primary or secondary prevention for CAD
33
Why increased risk in 1st yr after MI
- Without heart disease, estrogen: * Decreases oxidation of LDL * blood vessels dilate * Inhibits development of atherosclerosis - With underlying heart disease, estrogen: * Induces inflammation in existing plaque * Can cause stable plaque to rupture * Can lead to blockage of artery
34
MPA and CAD
- MPA negates more of estrogen's benefits on lipids - Greater decrease in HDL - Vasoconstriction vs. maintenance of vasodilation - Promotes atherosclerotic plaque formation - Can increase insulin resistance much more
35
HRT and Memory
- 40-60% decrease in risk of AD in women taking estrogen vs. never taken - No benefit when used as treatment for AD, timing important - Estrogen selectively improves executive function
36
HRT and Breast CA
- E + P = significant increase in risk (RR=1.25) - No risk with E alone - Bioidentical Progesterone may help risk as opposed to synthetic P, which increases risk
37
Estriol and Breast CA
- ER-alpha: Promotes proliferation - ER-beta: inhibits proliferation - Estradiol equally activates ER-a and ER-b - Estriol binds ER-b in 3:1 ratio -> potential for breast CA prevention - In cell cultures estriol acts as anti-estrogen if given with estradiol
38
HRT: Other risks
- OCPs decrease risk for ovarian cancer - Gall bladder disease increased with oral E x3 over non-users - Increased endometrial cancer 4-10x with unopposed E - Oral E increases risk of VTE (still small) - TD E has no increased risk for VTE
39
Possible side effects of HRT
- HA and nausea - Mood worsening - especially with progestins - Increased weight more with progestins, bloating - Breast tenderness - Irregular uterine bleeding
40
Progesterone vs. Provera
- Better QoL | - Fewer side effects in: depression; sleep problems; menstrual bleeding
41
Recommendations for HRT
- Complete H&P prior to use - Mammography within previous 12mo - Use primarily for moderate-to-severe symptoms - Vaginal ET if solely for vaginal symptoms - Consider EPT for osteoporosis risk reduction in high risk women - Do NOT use ET/EPT for secondary CAD prevention
42
Change in 2010 recommendations
- ET may decrease CHD risk when initiated in younger and more recently menopausal - 50-59: significant decrease in risk of MI and coronary death - EPT significantly increases risk of CHD if started >10yrs after menopause; lower risk <10yrs after
43
Low-Dose OCPs in Perimenopause
- Helps regulate cycles - Controls heavy bleeding - Helps preserve and potentially build bone - Alleviate symptoms - Contraception - Decreased risk of ovarian cancer - Safe in non-smokers - can switch to HRT at 50yo Different dose strength from HRT
44
How to use HRT
- Dosing: Oral, TD, Vaginal - Cyclic vs. Continuous * Estrogen: q day * Progesterone: cyclical or continuous
45
Contraindications to EPT/ET
- Presence or suspicion of breast/endometrial cancer - Hx of unexplained vaginal bleeding - Hx of MI or stroke - Active thrombosis/thrombophlebitis - Known or suspected pregnancy - Acute liver Dz
46
Screening Tests: Mammograms
- 40-50yo: Yearly (ACS) vs. q1-2yrs (CDC & ACOG) - >50yo: Yearly (ACOG/ACS); q2yr (USPSTF) - Family Hx: Baseline at 35 or r/t age of Dx in family member - >20-25% risk of breast Ca: to breast clinical annual mammogram + MRI
47
Paps: 2012 Guidelines
- Regs. apply regardless of sexual Hx - 21-65yo Cytology q 3yrs or if 30-65 and want to lengthen screening, can do cytology + HPV q5yr - None >65 if 3 consecutive normal Pap or 2 consecutive negative HPV tests - None after hysterectomy unless Hx of CIN 2, 3, or cervical Ca - No HPV testing in <30yo, even reflex
48
Calcium
- may increase bone density - decreased vertebral Fx - Can slow rate of endogenous resorption - 9-18yo 1200-1500mg - 19-50yo: 1g - >50yo: 1200-1500mg - Men: 800mg - >1500mg: limited benefit potential - >2g/d may increase risk of kidney stones
49
Vitamin D
- Enhances calcium absorption - 50yo: 800-1000IU/d; kids: 400IU/d - 1000-1200IU/d if at increased risk for deficiency - Doses up to 2000IU/d considered safe - If Vd deficiency: treat with D3 (Cholecalciferol) 50,000IU/wk x 3mo
50
Immunizations
- Flu q yr - Tdap q 10yrs - Pneumococcal X1 >65yo; If got one before 65, get one more at 65 - Zoster vaccine at age 60 x1 - Varicella x 2 doses if not immune - Meningococcal x1 dose if at risk - Hep A and Hep B if risk factors present - MMR born >1956 - if not vaccinated need 1 dose; 2nd dose if health worker or international travel

N825 (16 decks)

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