Menopause/Pregnancy Flashcards
Menopause
general
Physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity (decreased estrogen production)
Epidemiology
Average age: 51 years
Typical range: 44–55 years of age (95% of women)
Perimenopause
Transitional period (2-8 years) from reproductive to nonreproductive stage marked by menstrual irregularity and fluctuating hormone levels
Perimenopause FSH
Hormone levels fluctuate significantly in the perimenopausal period
Perimenopause FSH
IncreasedFSH due to
↓ inoocytesdue to progressive degeneration of ovarian follicles that do not ovulate (atresia) →↓ estrogens
What does estrogen do to FSH prior to perimenopause?
Aging oocytes exhibit diminished capacity to secrete inhibin
During the perimenopausal period, women can still become pregnant; often ovulate twice → twin pregnancy
Primaryestrogenswitches fromestradiol toestrone
Estradiol(E2)
Primaryestrogenin premenopausal women
Starts to decrease within 1 year of menopause
Produced inovaries
Estrone(E1)
Primaryestrogenin postmenopausal women
Produced primarily inadipose tissue
perimenopause
clin man
Symptoms are caused by fluctuating hormone levels
Menstrual changes:
Late reproductive years
Menstrual cycles shorten (cycles get closer)
Menopausal transition
Shorter cycles → longer cycles → very irregular/sporadiccycles → final menstrual period
Emotional symptoms:
Mood swings and irritability
Stress andanxiety
Vasomotor symptoms:
Hot flushes
Occur in 50%–90% of women
Usually last 1–5 minutes, but may last up to 45 minutes
Night sweats
Can significantly disruptsleep→chronic fatigue
Symptoms related to sexual function:
Genitourinary syndrome of menopause (GSM):
Vulvovaginalatrophy
Vaginal dryness and itching
Dyspareunia
Postmenopause
Symptoms & Conditions
Bone loss:
Osteoporosis → fragility fractures
Cardiovascular disease:
Lipid profiles worsen (↑cholesterol)
Weight gain
↑ Risk formyocardial infarctionand thromboembolic events
Hair, muscle, andskinchanges:
Hair thins
Skin becomes drier and rougher
↓Leanmassandmuscle tone
↑ Fatmass
Symptoms of GSM:
Dryness/dyspareunia
↑ Risk ofpelvic organ prolapse
Incontinence issues
↑Urinary tract infections(UTIs)
Perimenopause
Dx
Primarily clinical
Pelvic exam
Assess vaginal atrophy in context of sexual complaints
Routine lab evaluation NOT indicated
FSH,LH, andestrogenlevels fluctuate significantly and are not clinically useful in most cases
Exception: if patient is around age of menopause with abnormal bleeding, ↑FSHmay be helpful in clarifying menopausal status
perimenopause
management
Majority of women inperimenopauseand postmenopause do not require treatment
Primary goals
Relief of bothersome symptoms
Ensuring health through appropriate screening
Cervical cytology: up to age 65/every 3 years
Diabetes testing: at age 45/every 3 years
Colonoscopy: at age 45/every 10 years
Mammography: at age 40 or 50/annually
Bone mineral density: at age 65/every 2 years if risk factors present
Hormone Replacement Therapy (HRT)
indications
Controversial – 1990s clinical trials showed greater detrimental effects than beneficial effects
Use lowest dose for shortest duration required to treat symptoms
Candidates for therapy
Patients within 10 years of menopause
Patients< 60–65 years of age
Symptoms severe enough toaffectqualityof life
No contraindications
Hormone replacement therapy (HRT)
estrogen
Effective for treating
Vasomotor symptoms:hot flushes, night sweats →sleepdisturbances
Mood symptoms in perimenopause, but not postmenopause
GSM: vaginal dryness,dyspareunia
Routes of therapy:
Systemic therapy: oral, transdermalpatches, topical gels
Vaginal therapy: creams, vaginal tablets, ring
Estrogen stimulatesendometrium→ progestin required if patient hasuterus
Hormone replacement therapy
Progestin
Progestin
Higher risk of adverse events than estrogen therapy
Required for endometrial protection in patients withuterus
Selectionof route and dosing:
Usually oral
Give cyclically if still menstruating regularly
Give continuously if post-menopausal
Contraindications toHRT
Hormone-sensitivebreast cancer
High-riskendometrial cancer
Unexplained vaginal bleeding
Cardiovascular disease
Venous thromboembolism
Stroke ortransient ischemic attack(TIA)
Acute liver disease
Other management options - Vasomotor symptoms
Selective estrogen receptor modulators(SERMs)
Modulate effects ofestrogen
Ability to bind and activate estrogen receptors but act as either an agonist or antagonist depending on the tissue type
Non-hormonal medications
Selective serotonin reuptake inhibitors(SSRIs):
Paroxetineis the only FDA-approved SSRI
Serotonin-norepinepherine reuptake inhibitors (SNRIs)
Gabapentin
Clonidine
Lifestyle changes
Layered clothing
Maintain lower ambient temperature at home
Avoid alcohol andcaffeine
Stress management
Management options for GSM
Low-dose vaginal estrogen
Most effective treatment
Doses are low enough that progestins arenotrequired for endometrial protection
Vaginal lubricants
Vaginal moisturizers
Regularsexual activity
Pregnancy
General
Time period betweenfertilizationof an oocyte and delivery of a fetus (~40 weeks)
Sequence of events:
Fertilization of the oocyte by a sperm →embryo
Implantation of the earlyembryointo the uterine wall
Fetal and placental differentiation, growth, and development
Concurrent changes occur in the mother’s body to support the developing fetus and prepare for delivery
Labor and delivery of the infant
Puerperium: return of the mother’s body to the prepregnant state
Pregnancy
duration
Counted by completed weeks + completed days of the current week since the LMP
Duration of normal pregnancy:
Full-term pregnancy: 37–42 weeks
Preterm pregnancy: < 37 weeks
Post-term pregnancy: > 42 weeks
Classified into trimesters:
1st trimester: first day of LMP to 13 weeks, 6 days
2nd trimester: 14 weeks, 0 days to 27 weeks, 6 days
3rd trimester: 28 weeks, 0 days to 40 weeks, 6 days
know duration/terms
pregnancy
Labs
Confirmed based on lab tests and obstetric ultrasound imaging
Laboratory testing
β-hCG
Hormone produced early by the developingembryo → presence indicates pregnancy
β-hCG tests may be:
Qualitative: to detect the presence or absence of β-hCG
Urine or serum test
Reliable approximately 2 weeks after fertilization
Quantitative: to determine serum β-hCG levels
More sensitive, reliable 6–10 days afterfertilization
Can be used to track β-hCG levels when there is a concern for an abnormal pregnancy
Levels should roughly double every 24–48 hours during the 1st month
pregnancy
pregnancy
imaging
Imaging
Ultrasound is theobstetric imaging modality of choice to diagnose and date a pregnancy
Purpose of early ultrasounds:
To establish if a viable pregnancy is present
To establish the location of the pregnancy (R/Oectopic pregnancy)
To determine the number of fetuses
Dating
Dating a pregnancy using ultrasound
1st trimester: measuring the crown-rump length of the fetal pole
2nd and 3rd trimesters: calculated using a formula by considering measurements of biparietal diameter, abdominal circumference, and femur length
