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Clin Med 3 - Exam 3 (Women's Health) > Menopause, Infertility, PCOS > Flashcards

Menopause, Infertility, PCOS Flashcards

1
Q

what is the definition of menopause?

A

permanent cessation of menstruation

defined retrospectively after 1 year of amenorrhea without any other pathological cause

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2
Q

what is the range of menopause years?

A

45-55 y/o (mean 51)

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3
Q

what is the biggest factor affecting menopause? others?

A

GENETICS - biggest

others: tobacco use, chemo, radiation, hysterectomy

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4
Q

how does tobacco affect menopause?

A

tobacco use decreases age of menopause by 2 years

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5
Q

what is primary ovarian insufficiency/premature ovarian failure?

A

premature menopause (before the age of 40)

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6
Q

at what age is premature menopause?

A

40 y/o

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7
Q

what are the stages of menopause?

A

(1) peri-menopause (menopausal transition)
(2) menopause
(3) post-menopause

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8
Q

at how many years does peri-menopause (menopausal transition) occur?

A

47 y/o - 4 years before menopause

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9
Q

when is peri-menopause? what’s happening in it?

A

right before menopause occurs

at this stage egg viability declines before there is any measurable hormonal decrease (ex: FSH, LH)

QUALITY OF EGGS GO DOWN

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10
Q

are hormones recommended at peri-menopause?

A

NO!!!

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11
Q

what is peri-menopause a sign of?

A

ovarian decline

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12
Q

what is happening to the menstrual cycle length in peri-menopause?

A

menstrual cycle length increases and then gets shorter closer to menopause

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13
Q

what is the pathophysiology of menopause?

A

decline in quantity and quality of follicles and oocytes

granulosa cells in follicles stop making estrogen and inhibin

loss of inhibin means loss of negative feedback loop to hypothalamus and pituitary -> thus, FSH and LH increase in production by pituitary

ovary can’t respond to FSH

permanent amenorrhea once all follicles are depleted

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14
Q

what does the loss of inhibin in menopause cause? and what does this lead to?

A

causes loss of negative feedback loop to hypothalamus and pituitary -> thus, FSH and LH increase in production by pituitary

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15
Q

menopause is what type of dx?

A

clinical dx

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16
Q

if <40 y/o and have menopause what must be done? why?

A

complete evaluation b/c not normal age for menopause

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17
Q

if 40-45 y/o and have menopause, what must be done? what must be ruled out?

A

evaluation similar to workup of oligo/amenorrhea

other causes of menstrual dysfunction must be ruled out

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18
Q

if >45 y/o and have menopause what is not recommended?

A

diagnostic testing is not recommended

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19
Q

what other considerations/situations do you need to work up for dx of menopause?

A

underlying menstrual disorders (ex: PCOS need FSH work-up)

OCPs (if taking them late in age b/c suppresses HPO axis)

Hysterectomy (won’t be able to tell menopause based on irregular cycle b/c there’s no uterus -> need FSH measurement)

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20
Q

if menopause and had hysterectomy what labs do you need?

A

FSH levels b/c won’t be able to tell menopause based on irregular cycles since no uterus

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21
Q

what is the HALLMARK sx of menopause?

A

hot flashes

-get sudden sensation of heat in upper chest and face and then centralizes throughout the body

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22
Q

other sx’s of menopause?

A

sleep disturbances, mood changes (depressed, anxiety), cognitive changes, vaginal dryness, decreased sexual function/activity, breast pain and tenderness, joint pain and aches

dyspareunia (b/c of vaginal atrophy/dryness)

DECREASE IN BONE DENSITY

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23
Q

why does vaginal dryness occur in menopause?

A

b/c epithelial lining of vagina and urethra are estrogen dependent tissues and in menopause have decline of estrogen

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24
Q

urinary sx’s of menopause?

A

incontinence, urgency, recurrent UTIs

recurrent UTIs can be fixed with estrogen replacement b/c related to estrogen deficiency

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25
Q

what is the MAIN INDICATION for HRT in menopause?

A

hot flashes

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26
Q

PE findings of labia minora in menopause?

A

fusion or resorption

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27
Q

PE findings of vagina in menopause?

A

atrophy and thin mucosa, pale, lack of rugae (becomes smooth), less elasticity and tutor, shorter and narrower

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28
Q

PE findings of cervix in menopause?

A

atrophy, decreases in size, can become stenosis

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29
Q

what happens to the uterus and ovaries in menopause?

A

they shrink

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30
Q

what happens to the breast in menopause?

A

decrease in size

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31
Q

what happens to skin/hair in menopause?

A

thinning of skin with decreased elasticity

loss of pubic and axillary hair

hirsutism due to increased androgen (b/c ovaries still producing androgens)

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32
Q

what are the long-term effects of menopause?

A

dementia, CV disease, osteoporosis

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33
Q

when is the highest loss of bone mass and osteoporosis in menopause?

A

at 1 year before final menstrual period and 2 years after

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34
Q

what do you counsel menopausal pts on?

A

to stop smoking, do weight bearing exercises, Ca and vitamin D supplementation

may give them bisphosphonates to prevent osteoporosis

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35
Q

important lifestyle modifications for menopause management?

A

avoid triggers that cause hot flashes like spicy foods

smoking cessation

exercise, weight loss

lubricants, vaginal dilators or intercourse

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36
Q

who are HRTs indicated for in menopause?

A

women whose sx’s can’t be controlled by lifestyle modifcations

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37
Q

what are HRT’s NOT indicated for? why?

A

NOT indicated for long-term use and prevention of disease

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38
Q

what can long-term use of HRT’s put you at risk for?

A

long-term use can put you at risk for breast cancer, uterine cancer (b/c of unopposed estrogen)

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39
Q

C/I’s for HRT tx for menopause?

A

coronary heart disease, VTE, stroke, TIA, liver disease, gallbladder disease, breast cancer, unexplained vaginal bleeding, endometrial cancer, high triglycerides, thrombophilias

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40
Q

what must be calculated before initiating HRT tx for menopause?

A

calculate risk before initiating tx

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41
Q

after what age does risk outweighs benefits for use of HRTs?

A

after 60 y/0

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42
Q

what is the duration of therapy for HRTs?

A

2-3 year; max is 5 years or don’t use after 60 y/o

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43
Q

when does risk of breast cancer increase when using HRTs?

A

after 4th year of use of HRT

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44
Q

how do you discontinue HRT tx?

A

use a taper

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45
Q

all routes of estrogen administration are what for symptom relief?

A

equally effective for symptom relief

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46
Q

how do you start dose of HRT?

A

start with lower dose and titrate up if needed

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47
Q

lower doses of HRT have fewer effects of what?

A

fewer effects on coagulation and inflammatory markers, possible lower risk of stroke and VTE

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48
Q

what drugs increase estrogen clearance and what will you need to do to the dose HRT with these drugs?

A

anticonvulsants and thyroid meds increase estrogen clearance so will need to increase dose of HRT

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49
Q

what does alcohol do to exogenous estrogen? limit alcohol use to how many drinks/day?

A

alcohol slow metabolism of exogenous estrogen, so if active heavy drinker should cut down to 1-2 drinks/day

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50
Q

what are the HRT medications?

A

oral 17-beta estradiol

transdermal 17-beta estradiol

progesterone (oral micronized)

topical vaginal estrogen replacement

SERMs

OCPs

51
Q

what is the oral estrogen HRT?

A

oral 17-beta estradiol

52
Q

what does oral 17-beta estradiol have a more favorable effect on?

A

lipid profiles (but unknown if long-term benefit)

53
Q

risk of what with oral 17-beta estradiol? higher risk than what other HRT?

A

risk of VTE and stroker (higher risk than transdermal)

54
Q

oral 17-beta estradiol has lower free ___?

A

lower free testosterone

55
Q

transdermal17-beta estradiol has lower risk of what vs oral 17-beta estradiol? therefore which one is used more?

A

lower risk of VTE and stroke

transdermal patch used more

56
Q

what is the progesterone HRT that is FIRST LINE?

A

oral micronized progesterone

57
Q

all women in menopause with a uterus MUST have what added to their estrogen HRT? to prevent what?

A

a progestin added to prevent endometrial hyperplasia

58
Q

what are the side effects of progesterone HRT?

A

mood changes, bloating

59
Q

what helps to relieve the side effects of progesterone HRT?

A

continuous administration

60
Q

if menopausal pt is not tolerating progesterone for HRT, what can you give them that is off-label use?

A

lower dose leveonorgestrel IUD

61
Q

what is the difference in what systemic HRT treats and what topical HRT treats?

A

system HRT treats hot flashes

topical HRT can be used indefinitely but doesn’t treat hot flashes -> only treats local symptoms like atrophy

62
Q

what do topical HRTs (topical vaginal estrogen replacement) treat?

A

vaginal atrophy

63
Q

is progestin needed for topical vaginal estrogen replacement?

A

probably don’t need progestin, but if use vaginal creams you may need progestin b/c higher systemic absorption

64
Q

what are the formulations of topical vaginal estrogen replacement?

A

vaginal ring (string)

vaginal tablet (vagifem)

vaginal cream (Premarin or estrace)

65
Q

what HRT is NOT first line?

A

SERMs - Bazedoxifen

66
Q

when would menopausal pt be put on SERM?

A

if can’t tolerate oral HRT or IUD

have moderate-to-severe hot flashes who have breast tenderness w/estrogen-progestin therapy or women who can’t tolerate any type of progestin therapy b/c of adrs

67
Q

Bazedoxifen (SERM) use in addition to what?

A

estrogen

68
Q

what is Bazedoxifen (SERM) used for the tx of?

A

tx of menopausal vasomotor sx’s and osteoporosis prevention

69
Q

what does Bazedoxifen (SERM) prevent and as a result what is not necessary to administer?

A

Bazedoxifen (SERM) prevents estrogen-induced endometrial hyperplasia so that administering a progestin is NOT necessary

70
Q

what does Bazedoxifen (SERM) increase your risk of?

A

VTEs

71
Q

when can OCPs be used for menopause?

A

used in perimenopausal women who also desire contraception and for women who need control of heavy bleeding

72
Q

if woman is perimenopausal and desires contraception and/or may need control of heavy bleeding, what can you give them?

A

OCPs

73
Q

what is the OCP used for perimenopausal women? used at what age?

A

20mcg ethanol estradiol

used at ages 40-50

74
Q

at what age do you not want to use OCPs for perimenopuase?

A

> 50 b/c high doses of estrogen so increases clot risk

75
Q

OCPs should be avoided in who?

A

obese women d/t risk of VTE as well as hx/o smoking, HTN, or migraine HA’s

76
Q

stop OCPs how?

A

by 1 pill a week (taper) otherwise get abrupt hot flashes

77
Q

what are the most effective non-hormonal therapies for menopause?

A

SSRIs - paroxetine, fluoxetine (Prozac)

78
Q

do the alternative therapies for menopause work? what should women be aware of?

A

NO - women should be area of safety and efficacy of many alternative therapies b/c they are unproven

79
Q

what is infertility based on?

A

based on fecundability - probability of pregnancy with each menstrual cycle

80
Q

what is primary infertility?

A

inability to conceive in a couple who never has been pregnant (man or woman)

81
Q

what is secondary infertility?

A

inability to conceive in a couple with a history of prior pregnancy (man or woman)

82
Q

does age play a role in infertility of men?

A

unclear if age plays any role in men for infertility

83
Q

does age play a role in infertility of women? increased rate of what?

A

YES!!!

increased miscarriage rate with increased age
-damage to eggs -> get chromosomal abnormalities

84
Q

when do you evaluate/refer patients for infertility?

A

under 35 y/o attempts for 12 months

over 35 y/o attempts for 6 months

85
Q

female causes of infertility?

A

tubal obstruction or damage, PID, ovulatory dysfunction, uterine anomalies/adhesions, fibroids, endometriosis, cervical factors, premature ovarian failure

86
Q

male causes of infertility?

A

varicocele, ED, testicular trauma or infection, hypogonadism, oligospermia, azoospermia, cryptorchidism

87
Q

female evaluation work-up for infertility includes?

A

ovarian evaluation, uterine evaluation, labs, genetic testing

88
Q

female PE work-up for infertility includes?

A

BMI, breast exam (galactorrhea), pelvic exam, skin exam (hirsutism, acne), thyroid exam

89
Q

labs to obtain for female infertility work-up?

A

TSH (want to be < 3)

Prolactin

STI testing

Prenatal screening

Genetic testing

90
Q

what is involved in ovarian evaluation for infertility?

A

confirm ovulation and ovarian reserve testing

91
Q

how can you confirm ovulation?

A

use ovulation predictor kit

Can also do progesterone labs during mid-luteal phase -> if >3 then the patient ovulated

92
Q

if progesterone level during mid-luteal phase >3, what does that mean?

A

pt ovulated

93
Q

what is the MOST COMMON ovarian reserve testing for ovarian evaluation for infertility?

A

Day 3 labs - FSH and Estradiol

94
Q

what are the ovarian reserve tests for ovarian evaluation for infertility??

A

Day 3 labs (M/C) - FSH and estradiol

Clomiphene Citrate Challenge Test (CCCT)

Anti-mullerian Hormones (AMH)

Antral Follicle Count (AFC)

95
Q

what labs are in Day 3 ovarian reserve testing?

A

FSH and estradiol

96
Q

what do you want FSH level to be? borderline? abnormal?

A
  • Want <10
  • 10-15 is borderline
  • > 15 abnormal
97
Q

what should the ovaries be doing to FSH?

A

suppressing FSH

98
Q

why check estradiol levels in day 3 labs?

A

to make sure they area actually cycle day 3

also check for any abnormalities

99
Q

what level should anti-mullerian hormone (AMH) for ovarian evaluation in infertility?

A

> 1

100
Q

what is FIRST LINE uterine evaluation for infertility?

A

Hysterosalpingogram

101
Q

what’s good about hysteroscopy for uterine evaluation in infertility?

A

good if only care about uterus, can also treat with it (remove polyps)

102
Q

what analysis for male evaluation in infertility? when collected?

A

semen analysis

-collected 2-7 days after abstinence

103
Q

oligospermia is most frequent cause of what in men? what does it mean?

A

most frequent cause of infertility; low concentration of sperm in ejaculate and may be associated with ejaculatory dysfunction

104
Q

what is azoospermia? results from/

A

complete absence of sperm

results from congenital absence or bilateral obstruction of the vas deference or ejaculatory dcts

105
Q

what is asthenospermia?

A

abnormal sperm motility

106
Q

what is teratospermia?

A

abnormal morphology

107
Q

what is the tx for male infertility?

A

based on underlying pathology

smoking cessation

108
Q

what do all therapies for infertility center on?

A

manipulation of the physiologic HPO axis in 2 ways:

(1) ovulation induction
(2) controlled ovarian stimulation - use gonadotropins

109
Q

most common ovulation induction agents?

A

Clomid -> SERM

Letrozole -> aromatase inhibitors

110
Q

what is the end result of how clomid works?

A

makes higher plasma levels of FSH and LH which stimulate ovarian follicular growth

tricks brain into thinking estrogen is low so secretes a lot of FSH -> follicles grow -> egg

111
Q

whats the FIRST LINE tx for ovulation induction for infertility?

A

Clomid

112
Q

side effects of Clomid?

A

typical menopause sx’s

  • vasomotor symptoms
  • mood swings
  • visual sx’s -> D/C med
113
Q

when do you D/C Clomid?

A

when visual sx’s occur (blurred or double vision)

114
Q

main adr of Clomid?

A

ovarian cancer if used >12 months/cycles

115
Q

what is Preimplantation genetic screening (PGS)? reason to do it?

A

genetic testing for embryo - both parents are chromosomal normal so screen embryos for aneuploidy

recurrent pregnancy loss

116
Q

what is preimplantation genetic dx (PGD)?

A

one or both parents carry a specific known genetic mutation or defect

screens embryos for that defect

117
Q

what is PCOS characterized by?

A

amenorrhea, obesity, hirsutism

118
Q

PCOS is due to?

A

insulin resistance

119
Q

PCOS risk factor for?

A

CVD, obesity, DM

endometrial hyperplasia and endometrial cancer

120
Q

why PCOS at risk for endometrial cancer?

A

b/c of unopposed estrogen exposure

121
Q

dx of PCOS? what criteria?

A

Rotterdam criteria - 2/3 of following:

(1) ovulatory dysfunction (oligo and/or an ovulation)
(2) chemical and/or biochemical signs of hyperandrogenism
(3) polycystic ovaries on US

122
Q

main tx for PCOS if not pursuing pregnancy?

A

OCPs

123
Q

main tx for PCOS if pursuing pregnancy?

A

Letrozole

Clin Med 3 - Exam 3 (Women's Health) (9 decks)

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