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Well Women (UPenn) > Menopause/HT/Incontinence > Flashcards

Menopause/HT/Incontinence Flashcards

1
Q

Define menopause

A

Final menstrual period.

Ovarian event

Median age 52 (40 -58)

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2
Q

Criteria to diagnose menopause

A 
Amenorrhea greater than 12 months
or
Surgical loss of ovaries
or
Radiation or chemically induced loss of ovarian function
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3
Q

Hormone changes in menopause

A

Estrogens: relatively constant level after menopause
1. Estradiol (E2) 10-20 pg/ml
2. Estrone (E1) 30-70 pg/ml mostly peripheral
conversion
Androgens: after several years, levels drop by 50%, and main source is adrenal
Decreased SHBG = increased free testosterone
Ratio of estrogen:androgen=acne, hirsutism

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4
Q

Factors in late menopause

A 
Multiparity
Increased BMI (Body Mass Index)

No link found between age of menopause and:
OCP use, socioeconomic status, age of menarche

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5
Q

Factors in early menopause

A

Smoking: relationship between number of cigarettes smoked and duration of smoking to age of menopause

Genetics: polymorphisms of estrogen receptors
Thin women, vegetarians

Nulliparity

Depression

Epilepsy: especially with high seizure frequency

Toxic chemical exposure

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6
Q

What is premature ovarian failure?

A

transient or permanent loss of ovarian function leading to amenorrhea before 40 years old
(1% of women)

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7
Q

What happens to estrogen during hormonal transition?

A

Erratic hormone secretion: (FSH>10 on days 2-5 of cycle may be first sign of reproductive aging)

- Less follicles create less inhibin B and more FSH
- More FSH recruits more follicles each month
- More follicles stimulate more estradiol    - More estradiol= perimenopausal symptoms (bloating, irritability, mastalgia, menorrhagia, growth of fibroids)
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8
Q

Symptoms of peri menopausal transition

A

Hot flashes, night sweats (VMS)
Menstrual irregularities, PMS worse
Vaginal dryness, libido changes

Unknown relation to estrogen:
Fatigue, nervousness, headaches, insomnia, depression, irritability, joint & muscle pain, dizziness

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9
Q

Grading of vasomotor symptoms

A

(1) Not present
(2) Mild – Do not interfere with usual activities
(3) Moderate – Interfere somewhat with usual activities
(4) Severe – So bothersome that usual activities cannot be performed

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10
Q

Triggers and other causes of vasomotor symptoms

A 
Triggers:
Stress 
Hot or humid weather, hot drinks
Caffeine, alcohol or spicy food
Closed or tight spaces
Smoking 
More likely to occur in late afternoon or early evening (circadian rhythm)
Other causes:
Thyroid disease
Epilepsy
Infection
Insulinoma, pancreatic tumors
Leukemia
Autoimmune disorders
Carcinoid syndromes
Pheochromocytoma
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11
Q

1st line therapies for VMS

A

Lifestyle changes:

  • Regular exercise
  • Trigger avoidance
  • Paced respiration (50% improvement)
  • Relaxation techniques, deep breathing
  • Stop smoking
  • Dress in thin layers of cotton clothing
  • Dietary changes
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12
Q

Pharmaceutical treatments surrounding menopause

A

PMDD-Sarafem 20-60mg/day

Prescription antidepressants/anti-anxiety medications: Zoloft, Buspar, Paxil, Welbutrin, Prozac, Tranxene, Xanax, Effexor (37.5mg daily x 4 weeks–> Increase to 75mg daily if modest improvement)

Clonidine (alpha 2 agonist) 0.1mg daily

Gabapentin (anti-convulsant) 600 or 900mg daily

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13
Q

First line therapies for sleep (non-pharm):

A

Diet: no caffeine after 4PM; avoid late evening heavy meals, spicy food and alcohol
Snack with protein & carbohydrate may help

Stop smoking (prolongs sleep onset and decreases sleep duration)

Keep bedroom dark and cool
Keep bedtime the same time every night

Relaxation techniques: hot bath with lavender, hot milk and honey, soft music, massage, meditation, journal-keeping

Regular exercise, but avoid for at least 2 hours before bed

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14
Q

Pharmacological and herbal sleep aids

A

Hypnotics & sedatives: Sonata (lasts 1-3 hrs, helps with sleep onset), Ambien, Halcion, Dalmane, Valium
*SE of Sedatives: next-day sedation, rebound insomnia

Low dose OCPs, ERT/HRT if vasomotor Sx

Micronized progesterone

Melatonin 3-5mg 1 hour before bedtime

Valerian 530 mg BID

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15
Q

Evaluation of post-menopausal women (H&P components)

A

History:

  • Personal, family history of osteoporosis
  • Cancer (breast, ovarian, uterine, colon)
  • Hypertension, cardiovascular disease
  • Medications, nutritional supplements, botanicals
  • Urinary or fecal incontinence

Physical exam:

  • Height, weight, BMI, BP
  • Thyroid palpation
  • Heart and lung auscultation
  • Clinical breast exam, axillae
  • Abdominal palpation
  • Pelvic exam
  • Rectal exam?
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16
Q

Screenings

A
  • Cervical cytology & HPV (ASCCP)
  • Mammography annually (ACOG)
  • Stool for occult blood/colonoscopy
  • Lipid profile, TSH q 5 years
  • FBS q 3 years
  • Hep C at least once
  • Bone mineral density
  • Smoking, alcohol, exercise
17
Q

FSH and estradiol levels that strongly indicate menopause

A

FSH (serial measurements) > 25

Estradiol < 20

18
Q

Lipid changes with estrogen loss

A

Increase in total cholesterol, LDL cholesterol, and triglycerides
Decrease in HDL cholesterol

19
Q

Symptoms of Genitourinary Syndrome of Menopause (GSM)?

A

Genital symptoms

  • Dryness
  • Burning
  • Irritation
  • Impaired function

Urinary Symptoms

  • Urgency, Dysuria, Hematuria
  • Recurrent UTIs

Sexual Symptoms

  • Loss of libido
  • Loss of arousal
  • Lack of lubrication
  • Dyspareunia
  • Dysorgasmia
  • Pelvic pain
  • Bleeding or spotting during intercourse
20
Q

Treatment of Genitourinary Syndrome of Menopause

A

Vaginal estrogen

  • Creams (Estrace, Premarin)
  • Tablets (Vagifem)
  • Ring (Estring)

Non-hormonal (SERM), oral
* Ospemifeme (Osphena)

Intravaginal CO2 laser therapy
* MonaLisa Touch

Radiofrequency
* ThermiVa

Vaginal moisturizers and lubricants

+/- vaginal dilator

Vaginal DHEA

21
Q

Types of incontinence

A
  • Stress: involuntary loss of urine with increased intra-abdominal pressure (cough, sneeze); most common type
    - Usually in drops, small amounts
  • Urge: loss of urine from contraction of the detrusor muscle (smooth muscle of the bladder wall)
    - Large volume of urine lost; flood
  • Mixed: both of the above at the same time
  • Overflow: bladder never really empties; overflows
  • Extra-urethral: fistula
22
Q

Stress incontinence management

A
  1. Strengthen pelvic floor muscles (Kegels)
    42-56% of women report improvement
    5 reps of 10 Kegels daily
  2. Losing weight (if obese)
  3. Estrogen? (role unknown)
  4. Pseudoephedrine 30mg 1-3x/day
23
Q

Urge incontinence management

A
  1. Anticholinergic drugs (suppresses detrusor contractions)
  2. Detrol, Ditropan, Urispas (relaxes smooth muscle)
  3. Tricyclic antidepresants (relax smooth muscles)
  4. Botox injections
  5. Behavior modification

ERT: no apparent role

24
Q

Vaginal estrogen indications

A

The genitourinary syndrome of menopause (GSM):

  • Dryness
  • Burning
  • Irritation
  • Sexual symptoms (decreased lubrication, pain)
  • Urinary symptoms (urgency, dysuria, recurrent UTI)

Discuss with oncologist if h/o breast or endometrial cancer

Can be very expensive/cost-prohibitive

25
Q

Vaginal estrogen formulations/doses

A

Tablet: Vagifem estradiol 10 mcg daily for 2 weeks then twice weekly

Cream: Estrace (estradiol), Premarin (conjugated estrogen) 0.5g daily for 2 weeks then twice weekly

Ring: Estring (estradiol) q. 3 months 7.5 mcg estradiol released per day

  • Small amount systemic absorption
  • Progestin still not needed
26
Q

Systemic hormone replacement indications

A
  1. Vasomotor symptoms
  2. Prevention of bone loss
  3. Premature hypoestrogenism (surgical menopause / POI)
  4. Genitourinary symptoms
27
Q

Contraindications of systemic hormone therapy

A
  • Unexplained vaginal bleeding
  • Severe active liver disease
  • Prior estrogen-sensitive breast or endometrial cancer
  • Coronary heart disease
  • Stroke
  • Dementia
  • Personal history or high risk of thromboembolic disease

Note: NOT the same as MEC

28
Q

Systemic hormone therapy Rx guidelines

A
  • Start with medium/low dose and may titrate PRN
  • Prefer transdermal estrogen (< VTE occurrence)
  • Oral or intrauterine progestin if needed (protective against endometrial cancer)
  • Cyclic vs. continuous? Consider regimen adherence

***Many options: combipatches vs solo patches, IUDs as LNG delivery option, pills of CEE or E2, topical emulsion/transdermal spray

29
Q

What is bioidentical hormone therapy?

A
  • Synonym for custom-compounded hormone formulations
  • May include estrogen, progestin, testosterone, DHEA
  • 17β-estradiol (Estrace) and micronized progestin (Prometrium) are chemically identical to endogenous hormones
  • ACOG/NAMS recommend FDA regimens only since hormone levels vary so much through the day no way to appropriately personalize
30
Q

Uro- genital tissue receptors are dependent on endogenous estrogen levels to maintain normal physiology. What happens when estrogen is low?

A

Loss of prolubricative and proelastic function → predisposed to irritation and sexual trauma.
* diminished collagen, elastin, and hyaluronic acid
content; thinned epithelium; impaired smooth
muscle proliferation; denser connective tissue
arrangement; and loss of vascularity

Reduction of Lactobacillus→ alkaline pH of 5.0 → impaired viability of healthy vaginal flora → overgrowth of gram- negative rod fecal flora including group B streptococci, staphylococci, coliforms, and diphtheroids → vaginal infection and UTI and inflammation

The bladder and urethra also become atrophic → urinary incontinence and frequency

31
Q

Vaginal Moisturizers

A

use 2-3x per weeks because they last 2-3 days

Replense - almost as effective as Estrace for vaginal dryness

Luvena - 2 enzymes: 1 anti-candida, 1 antibacterial

Hyalogen - attracts 60x its weight in water

Well Women (UPenn) (17 decks)

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