Menopause - Exam 2 Flashcards
______ phase of the aging process during which a woman passes from reproductive to nonreproductive stage
climacteric
______ part of climacteric before menopause occurs when menstrual cycle is irregular and when other climacteric symptoms or complaints may be experienced. What is another name for it? How long does it last?
Menopausal Transition
perimenopause
usually lasts 1-3 years
What is the average age of menopause? What is considered premature menopause?
51
age 40 or younger
Most women live at least ____ of lives in postmenopausal state. When do you have the most oocytes? How many oocytes are actually ovulated?
⅓
20 weeks gestation
400-500 oocytes are actually ovulated
as ovaries lose oocytes, levels of _____ slowly decrease which results in higher levels of _____
inhibin
FSH
aka decreased inhibin from decreased amount of oocytes = higher levels of FSH
**What happens as a result of the aging ovary/ decreased oocyte?
Oocytes responsive to gonadotropins disappear from the ovary over time, less responsive to FSH and LH which leads to a irregular follicle response to gonadotropins -> irregular length of follicular phase which leads to irregular menses
Why do you see bursts of estradiol in menopause?
recruitment of multiple follicles from high FSH
2-3X above normal
What is considered premature ovarian failure? What causes it?
Spontaneous cessation of menses before age 40
Often idiopathic:
Genetics, autoimmune disease
What are some predisposing factors for menopause? ** What is the underlined one?
**Smoking - advances age by 2 years
Reproductive tract disease
Severe GU infections or tumors
Exposure to radiation or chemo
Surgical procedures that impair ovarian
blood supply
Possible endocrine or chromosomal abnormality
What is artificial menopause?
Permanent cessation of ovarian function due to surgical removal of ovaries or by radiation therapy
can be intentionally induced to improve endometriosis or prophylactically for cancer
What is the primary androgen in women? What happens to it in the postmenopausal women?
androstenedione
Decreased production
What 3 things does mildly decreased levels of testosterone cause?
Androstenedione converted to testosterone
Decreased sex hormone-binding globulin levels
Ovary secretes more testosterone after menopause
_____ is believed to be the cause of virilization symptoms after menopause
Ovary secretes more testosterone after menopause
Which form of estrogen decreases the most in postmenopause?
greatest decrease in estradiol and no longer has circadian variation of estradiol after menopause
after menopause, where is estradiol mainly secreted from?
adrenal glands
_____ levels decrease after menopause but not significantly. Adrenal glands continue to secrete ________ and is converted into ______ peripherally. What kind of women have higher conversion rates?
estrone
androstenedione -> estrone
heavy women have higher conversion rates
measurement of _______ is helpful to confirm diagnosis of menopause. _____ is NOT helpful
estradiol
estrone is NOT helpful
Major source of progesterone in young women is _____ after ovulation. After menopause, there is no functional follicles and thus ______ overall. Where is progesterone found PM?
corpus luteum
low progesterone overall
adrenal glands
Is it helpful to measure progesterone levels in PM women?
NOT helpful!!
What are FSH and LH doing PM?
FSH and LH rise substantially
FSH usually higher than LH
Measurement of what 3 hormones can help to dx menopause?
Measurement of FSH and LH, along with estradiol
high FSH and LH and low estradiol
**What are the 8 highlighted symptoms of menopause?
irregular bleeding
irritability and mood swings
vaginal dryness
decreased libido
hot flashes
hair loss
hirsutism
weight gain
What do you think happens to the female reproductive tract due to the loss of estrogen due to menopause?
everything atrophies and dries out!!!
estrogen also helps to maintain epithelium of _____ and _____. So may see _____ PM
epithelium of bladder and urethra
atrophy of lower urinary tract epithelium
______ is characterized by urinary urgency, frequency, incontinence, dysuria. What is it called when it is seen with loss of urethral tone?
atrophic cystitis
“Genitourinary syndrome of menopause”
What can happen due to loss of urethral tone?
may see urethral caruncle with dysuria, meatal tenderness, and hematuria
What happens to the breast as a result of menopause?
regress in size and flatten
Vaginal burning, soreness, dyspareunia, dryness or thin watery or serous discharge may occur
What am I?
What will you see early vs late?
What does the pH do?
atrophic vaginitis
early: Diffuse or patchy reddening, +/- scattered petechiae, flattened rugae
late: smooth, shiny, pale surface
Increased vaginal pH to 5.0-7.0
What am I?
early atrophic vaginitis
What am I?
late atrophic vaginitis
**What is first line tx for atrophic vaginitis?
**ROUTINE Vaginal moisturizers
PRN lubricants with sex
What is the tx for moderate/severe atrophic vaginitis?
vaginal estrogen therapy
What are the benefits for vaginal estrogen therapy?
Restored vaginal pH and microflora
Increased vaginal secretions and thickened vaginal epithelium
Diminished overactive bladder symptoms, fewer UTIs
**When would vaginal estrogen NOT be recommended?
May be harmful if pt has hx of breast cancer or takes aromatase inhibitors for breast cancer
What would you recommend for a pt who has atrophic vaginitis and vasomotor symptoms?
systemic and vaginal estrogen
What is the alternative tx options for atropic vaginitis for pts not responsive to conservative therapy and unable or unwilling to use topical estrogens?
oral Ospemifene (Osphena)
Prasterone (Vaginal DHEA)
Testosterone
Pelvic PT
What is the MOA for Ospemifene (Osphena)? What is the MC SE?
SERM that mimics estrogen only in the vaginal tissue
hot flashes
What is the MOA for Prasterone (Vaginal DHEA)?
Converts androstenedione and testosterone locally to estrone and estradiol via suppository instead of cream
_____ is the MC and characteristic symptom of menopause
hot flashes
Where on the body do hot flashes tend to effect the most? How long do they typically last? Frequency?
heat or burning in head, face, neck, upper chest and back
from seconds up to 10 min (average - 4 min)
1-2 per hour to 1-2 per week
Will hot flashes effect heart rhythm or BP?
NO!!
What are risk factors for hot flashes?
Obesity
Lower physical activity
Smoking
Genetic predisposition
Socioeconomic status
Ethnicity/Race
African American women report more frequently
Japanese and Chinese women report less frequently
What is the mainstay of tx for hot flashes?
estrogen!
Estrogen/Progestin combo - if pt cannot take estrogen
addition of ______ in PM women is associated with higher risk of breast cancer
progestins
_____ is used in the tx of hot flashes for women who cannot take estrogens
Progestin alone
What drug class is Bazedoxifene/Conjugated Estrogen (Duavee)? When is it used?
Selective Estrogen Receptor Modulator (SERM) + Estrogen
tx of hot flashes, Shown to help vasomotor symptoms; may also reduce osteoporosis risk
also as a form of MHT
**_______ are first line tx for hot flashes in women do cannot take or do not want to take hormone replacement therapy. Which one does Jensen like specifically?
SSRIs and SNRIs
Paroxetine, citalopram/escitalopram, venlafaxine/**desvenlafaxine-> Jensen likes this one
**What pt population do you need to use caution with when prescribing and SSRI for hot flashes? Why?
Use caution with paroxetine if pt takes tamoxifen for breast cancer
Increased risk of breast cancer recurrence or death
What is important to note about the timing of SSRIs/SNRIs when used in the tx of hot flashes?
Clinical improvement within a few days as compared to weeks when used as an antidepressant
_____ and ____ are non-hormonal options for hot flashes and is more effective than placebo
oxybutinin and clonidine
Which SSRI is the only FDA indicated one for the tx of hot flashes?
Paroxetine
_____ can be used in the tx of hot flashes and has shown to decrease them by 50-80%
gabapentin
What 2 CAM alternatives may have modest effect on hot flashes? What is the caution?
Black Cohosh or Phytoestrogens
Can stimulate breast and uterine tissue
______ are the newest drug class of non-hormonal hot flash treatment. What is the major SE?
Neurokinin-3 receptor (NK3R) antagonist
Hepatotoxicity
What is Fezolinetant (Veozah) indicated for? What is the associated monitoring? When are they CI?
Neurokinin-3 receptor (NK3R) antagonist for the tx of hot flashes
Check AST/ALT and bilirubin at baseline, monthly x 3 months, then at 6 and 9 months
do NOT start if any result is greater than 2X ULN
Hx of cirrhosis/liver failure; significant CKD (GFR <30)
What is the difference in menopausal hormone therapy and true hormone replacement therapy?
menopausal hormone therapy is given at much LOWER doses to get rid of the vasomotor symptoms NOT trying to truly replace
hormone replacement therapy is given AT the level in which you would see a pt of reproductive age
What are 2 known benefits of MHT?
reduced menopausal symptoms
reduced risk of osteoporosis
What are the 5 known risks of MHT?
endometrial cancer
breast cancer
thromboembolic dz
stroke
gallbladder disease
What aspect of MHT would increase a pt’s risk of endometrial cancer? What specifically happens?
Unopposed estrogen
proliferation, hyperplasia, and neoplasia of the endometrium. 20-50% of women on unopposed estrogen will have endometrial hyperplasia after 1 year**
How do you reduce the risk of endometrial cancer in a pt using MHT?
give progesterone alongside estrogen
What does combination MHT increase your risk of? What are 2 risk factors?
Breast Cancer
early menarche and late menopause
Long-term use of estrogens alone associated with____ risk of breast cancer
mild decreased
So which hormone is increasing the risk of breast cancer?
progesterone increases risk of breast cancer and estrogen decreases risk of breast cancer
When comparing thromboembolic and stroke risk in MHT, is transdermal or oral preferred?
both have lower incidence with transdermal MHT
Is gallbladder disease associated with combo or estrogen only MHT?
Greater risk with estrogen-only MHT
What are the CI to MHT?
breast cancer
estrogen-dependent cancer (endometrial cancer)
DVT or PE
active or recent stroke/MI within a year
liver dysfunction/dz
pregnancy
** When starting MHT, _______ is first line for vasomotor symptoms. What is considered “standard daily dose” of conjugated estrogen?
transdermal
0.625 mg of PO
When should MHT dosing be evaluated?
Increase at 1 month intervals if still symptomatic
If pt still has an intact uterus, need to add ______. ______ may have lower risk of breast cancer and CHD
progestin
Micronized progesterone
What is the standard recommendation with regards to length of tx? How do you stop MHT?
Standard recommendation - do not use for more than 5 years
Taper gradually whenever MHT is discontinued
What is the MC SE that you might see with clonidine? Oxybutinin?
decreased BP
anticholinergic side-effects: cant see, pee, spit, or shit
What are the MHT alternative drug classes that might be considered as options, especially if the pt does not want to take hormones?
SSRIs
SNRIs
Anticonvulsants: gabapentin, pregabalin
clonidine
oxybutinin
What are the 3 CAM alternatives that can be used as MHT alternatives?
Isoflavones/Phytoestrogens: soy, lentils, chickpeas
Black Cohosh: natural estrogen
What CAM alternatives are NOT recommended due to lack of evidence? Which vitamin is recommended?
evening primrose oil, flaxseed, ginseng, reflexology, acupuncture, magnets
Vit E is recommended!! but with minimal reduction (30%)
For atrophic vaginitis, which preparation is preferred? give some examples
Vaginal preparations preferred over systemic!!
cream or rings but can give a tablet (per vagina) if necessary
** What is the pt education for estradiol tablet for atrophic vaginitis?
per vagina nightly x 2 weeks, then 2x per week
A patient presents with symptoms of atrophic vaginitis. She has an intact uterus and no risk factors for endometrial cancer. What would be the most appropriate therapy?
vaginal estrogen only
The screening mammogram involves what 2 views? What direction do they compress?
craniocaudal (CC), which compresses the breasts from above (horizontally)
mediolateral oblique (MLO), which compresses the breasts from the side (vertically)
_____ is the most specific mammographic feature of breast cancer!
spiculated focal mass
What are 2 types of clustered microcalcification that are more suspicious for cancer?
Linear branching microcalcifications
granular (nonlinear/irregular) microcalcifications
What does architectural distortion mean on a mammogram report?
change in normal lay of breast tissue
5% of noncalcified cancers appear as areas of architectural distortion of dense tissue without an obvious mass
What are some NON-suspicious calcification findings?
vascular and skin calcifications
rim-like calcifications
large coarse calcifications
smooth round or oval calcifications
What is the BI-RADS scale go through? What does each section mean?
BI-RADS 0: Incomplete assessment and need additional info
1: completely negative exam
2: benign findings
3: probably benign findings but likelihood of cancer is less than 2%
4: suspiciously abnormal, consider bx
5: Highly suggestive of malignancy; Appropriate action should be taken
6: Biopsy-proven malignancy; Appropriate action should be taken
What is the f/u recommendation for BI-RADS 3?
diagnostic mammography and/or US at 6 month intervals x 1 year, and annually for an additional 2 years
What are the different subclasses of BI-RADS 4? Give cancer percentages with each
BIRADS 4A - chance of cancer 2-9%
BIRADS 4B - chance of cancer 10-49%
BIRADS 4C - chance of cancer 50-94%
What is the chance of cancer is BI-RADS 5?
Chance of cancer is 95-100%
