Menopause And Sexual Dysfunction Flashcards
What is the best evidence based medicine?
Randomized controlled trials results
- best eliminates bias
History of hormone therapy
Started in 1930s when scientists realized that females were intuitively protected against CAD/MIs compared to males.
- once they hit menopause though, the risks for CAD/MI rose drastically
- **this was proven by Framingham study (but this was a selective bias in the study)
- **implies that estrogen is protective against heart disease.
However, use of prempro/estrogen for CAD showed excessive breast cancer rates and that the difference between CAD/MI rates aren’t that dramatic
- this was found in a WHI study in 2008
The WHI study however showed that estrogens ALONE showed a decrease in CAD/MI without a statistically significant increase in breast cancer
Menopause
Usually 52 years of average age
Is no menses for 12 months
- remember 6 months is only amenorrhea, you have to wait for 12 months to make menopause diagnosis
Perimenopause (time period before the last menstrual period)
- wanning level of estrogen/estradiol from the granulosa cells
- the first bio marker that determines the perimenopause initiation = inhbin**
- estrogen is still supplied enough to where its drop is not as apparent, however inhibin is ONLY produced by granulosa cells which begin to fail and are the cause of perimenopause**
there is also excessive testosterone build up due to increased FSH/LH which causes luteal cells to secrete more androstenedione and testosterone
How do hormonal changes occur in during menopause
Increased FSH/LH (due to no inhibin)
Decreases estradiol (due to failure of granulosa cells)
Decreases in progesterone (due to failure of granulosa cells)
Complications during menopause
Vasomotor instability
Urogential atrophy (atrophic vaginitis and postcoitus bleeding)
Osteoporosis
CAD
Dementia
QOL in general
Vasomotor instability in menopause
“Hot flashes”
Definition = subjective increase sensitivity to heat associated with cutaneous vasodilation and compensatory decreases in core body temperature that lasts 4 minutes
Casues
- changes in the thermal regulatory center in the hypothalamus due to decreasing levels of estrogen rather than pure low estrogen
- is associated with LH surge (BUT not tied to it)
- also serotonin and dopamine levels get out of wake
Symptoms
- hot flashes
- night sweats
- moodiness
- anxiety
Treatment
- decrease alcohol/cafifne
- induce relaxation techniques
- use of SSRIs (not as efficacious 50% roughly)
- Estrogen therapy = BEST TREATMENT (90% efficacy)
Vulvo-vaginal atrophy
“Genitourinary syndrome”
Vaginal epithelium becomes thin and excoriated with diminished rugae
- can effect other pelvic organs also, just vagina is most affected
- caused by waning levels of estrogens leading to increased basal and parabasal cells with decreased superficial cells (ratio wise)
Symptoms
- increased pH of vagina (lactobacillus species die off so pH is raised)
- pruritus
- dryness
- burning
- dyspareunia
- postcoitus bleeding (even touching it with a q-tip can cause the vagina to bleed)
- high risk of UTIs (with streptococcus and bacteroidies species due to increased pH)
affects 84% of menopausal women
Treatment = estrogen therapy and lubricants for sex
Osteoporosis
THE MOST IMPORTANT COMPLICATION OF MENOPAUSE
Pathology = decreasing estrogens leads to greater osteoclastic:osteoblastic activity
- decreases bone density and bone quality
- *Peak bone density in women is 18**
- gradually decreases throughout a women’s life, but rapidly falls off starting at menopause
- if untreated = 50% is loss in 20 years
Symtpoms
- asymptomatic until fractures
- vertebral fracture, collies fracture, hip fractures = most common
- tooth loss is also common
Modifiable risk factors
- decreased estrogen
- smoking
- excess alcohol consumption
- sedentary lifestyle
- calcium and vitamin D consumption
- weight bearing exercise
if you give estrogen, 1500mg calcium and 1,000 IU vitamin D a day = 90% chance the women never achieves osteoporosis
Diagnosis of osteoporosis
DEXA scan (must get by age 65) - BMD is
Coronary artery disease and estrogen
Loss of Estrogens decreases HDL and raises LDL lipoproteins in both blood and vessels
- with estrogen = higher HDL
Also estrogens increase NO production in endothelial cardiac vessels
Dementia and estrogen
Estrogens reduce neuro-fibrillation tangles and tau protein build up
- MUST start estrogen in menopause (NOT after it started)
Why does progestin need to often be mixed with estrogen
It reduces the risks for endometrial cancer
however the combo therapy increases risks for breast cancer and coronary heart disease, so need to weight benefits vs risks
Sexual dysfunction in post menopause women
60% = atrophic vaginitis
20% = PID and endometriosis
20% = hypoactive sexual desire syndrome
