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Menopause - Exam 2 Flashcards

1
Q

______ phase of the aging process during which a woman passes from reproductive to nonreproductive stage

A

climacteric

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2
Q

______ 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?

A

Menopausal Transition

perimenopause

usually lasts 1-3 years

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3
Q

What is the average age of menopause? What is considered premature menopause?

A

51

age 40 or younger

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4
Q

Most women live at least ____ of lives in postmenopausal state. When do you have the most oocytes? How many oocytes are actually ovulated?

A

⅓

20 weeks gestation

400-500 oocytes are actually ovulated

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5
Q

as ovaries lose oocytes, levels of _____ slowly decrease which results in higher levels of _____

A

inhibin

FSH

aka decreased inhibin from decreased amount of oocytes = higher levels of FSH

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6
Q

**What happens as a result of the aging ovary/ decreased oocyte?

A

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

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7
Q

Why do you see bursts of estradiol in menopause?

A

recruitment of multiple follicles from high FSH

2-3X above normal

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8
Q

What is considered premature ovarian failure? What causes it?

A

Spontaneous cessation of menses before age 40

Often idiopathic:
Genetics, autoimmune disease

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9
Q

What are some predisposing factors for menopause? ** What is the underlined one?

A

**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

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10
Q

What is artificial menopause?

A

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

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11
Q

What is the primary androgen in women? What happens to it in the postmenopausal women?

A

androstenedione

Decreased production

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12
Q

What 3 things does mildly decreased levels of testosterone cause?

A

Androstenedione converted to testosterone

Decreased sex hormone-binding globulin levels

Ovary secretes more testosterone after menopause

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13
Q

_____ is believed to be the cause of virilization symptoms after menopause

A

Ovary secretes more testosterone after menopause

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14
Q

Which form of estrogen decreases the most in postmenopause?

A

greatest decrease in estradiol and no longer has circadian variation of estradiol after menopause

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15
Q

after menopause, where is estradiol mainly secreted from?

A

adrenal glands

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16
Q

_____ 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?

A

estrone

androstenedione -> estrone

heavy women have higher conversion rates

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17
Q

measurement of _______ is helpful to confirm diagnosis of menopause. _____ is NOT helpful

A

estradiol

estrone is NOT helpful

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18
Q

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?

A

corpus luteum

low progesterone overall

adrenal glands

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19
Q

Is it helpful to measure progesterone levels in PM women?

A

NOT helpful!!

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20
Q

What are FSH and LH doing PM?

A

FSH and LH rise substantially
FSH usually higher than LH

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21
Q

Measurement of what 3 hormones can help to dx menopause?

A

Measurement of FSH and LH, along with estradiol

high FSH and LH and low estradiol

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22
Q

**What are the 8 highlighted symptoms of menopause?

A

irregular bleeding

irritability and mood swings

vaginal dryness

decreased libido

hot flashes

hair loss

hirsutism

weight gain

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23
Q

What do you think happens to the female reproductive tract due to the loss of estrogen due to menopause?

A

everything atrophies and dries out!!!

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24
Q

estrogen also helps to maintain epithelium of _____ and _____. So may see _____ PM

A

epithelium of bladder and urethra

atrophy of lower urinary tract epithelium

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25
______ 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”
26
What can happen due to loss of urethral tone?
may see urethral caruncle with dysuria, meatal tenderness, and hematuria
27
What happens to the breast as a result of menopause?
regress in size and flatten
28
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
29
What am I?
early atrophic vaginitis
30
What am I?
late atrophic vaginitis
31
**What is first line tx for atrophic vaginitis?
**ROUTINE Vaginal moisturizers PRN lubricants with sex
32
What is the tx for moderate/severe atrophic vaginitis?
vaginal estrogen therapy
33
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
34
**When would vaginal estrogen NOT be recommended?
May be harmful if pt has hx of breast cancer or takes aromatase inhibitors for breast cancer
35
What would you recommend for a pt who has atrophic vaginitis and vasomotor symptoms?
systemic and vaginal estrogen
36
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
37
What is the MOA for Ospemifene (Osphena)? What is the MC SE?
SERM that mimics estrogen only in the vaginal tissue hot flashes
38
What is the MOA for Prasterone (Vaginal DHEA)?
Converts androstenedione and testosterone locally to estrone and estradiol via suppository instead of cream
39
_____ is the MC and characteristic symptom of menopause
hot flashes
40
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
41
Will hot flashes effect heart rhythm or BP?
NO!!
42
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
43
What is the mainstay of tx for hot flashes?
estrogen! Estrogen/Progestin combo - if pt cannot take estrogen
44
addition of ______ in PM women is associated with higher risk of breast cancer
progestins
45
_____ is used in the tx of hot flashes for women who cannot take estrogens
Progestin alone
46
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
47
**_______ 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
48
**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
49
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
50
_____ and ____ are non-hormonal options for hot flashes and is more effective than placebo
oxybutinin and clonidine
51
Which SSRI is the only FDA indicated one for the tx of hot flashes?
Paroxetine
52
_____ can be used in the tx of hot flashes and has shown to decrease them by 50-80%
gabapentin
53
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
54
______ are the newest drug class of non-hormonal hot flash treatment. What is the major SE?
Neurokinin-3 receptor (NK3R) antagonist Hepatotoxicity
55
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)
56
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
57
What are 2 known benefits of MHT?
reduced menopausal symptoms reduced risk of osteoporosis
58
What are the 5 known risks of MHT?
endometrial cancer breast cancer thromboembolic dz stroke gallbladder disease
59
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**
60
How do you reduce the risk of endometrial cancer in a pt using MHT?
give progesterone alongside estrogen
61
What does combination MHT increase your risk of? What are 2 risk factors?
Breast Cancer early menarche and late menopause
62
Long-term use of estrogens alone associated with____ risk of breast cancer
mild decreased
63
So which hormone is increasing the risk of breast cancer?
progesterone increases risk of breast cancer and estrogen decreases risk of breast cancer
64
When comparing thromboembolic and stroke risk in MHT, is transdermal or oral preferred?
both have lower incidence with transdermal MHT
65
Is gallbladder disease associated with combo or estrogen only MHT?
Greater risk with estrogen-only MHT
66
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
67
** When starting MHT, _______ is first line for vasomotor symptoms. What is considered "standard daily dose" of conjugated estrogen?
transdermal 0.625 mg of PO
68
When should MHT dosing be evaluated?
Increase at 1 month intervals if still symptomatic
69
If pt still has an intact uterus, need to add ______. ______ may have lower risk of breast cancer and CHD
progestin Micronized progesterone
70
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
71
What is the MC SE that you might see with clonidine? Oxybutinin?
decreased BP anticholinergic side-effects: cant see, pee, spit, or shit
72
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
73
What are the 3 CAM alternatives that can be used as MHT alternatives?
Isoflavones/Phytoestrogens: soy, lentils, chickpeas Black Cohosh: natural estrogen
74
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%)
75
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
76
** What is the pt education for estradiol tablet for atrophic vaginitis?
per vagina nightly x 2 weeks, then 2x per week
77
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
78
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)
79
_____ is the most specific mammographic feature of breast cancer!
spiculated focal mass
80
What are 2 types of clustered microcalcification that are more suspicious for cancer?
Linear branching microcalcifications granular (nonlinear/irregular) microcalcifications
81
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
82
What are some NON-suspicious calcification findings?
vascular and skin calcifications rim-like calcifications large coarse calcifications smooth round or oval calcifications
83
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
84
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
85
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%
86
What is the chance of cancer is BI-RADS 5?
Chance of cancer is 95-100%
87

Women's Health (16 decks)

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