Menopause: seibert Flashcards
Describe Menopause:
- what is this event?
- defined as:
is a normal, natural event, defined as the final menstrual period (FMP), confirmed after 1 year of no menstrual bleeding
-Portion of aging process where a woman moves from her reproductive years to her non-reproductive years
Menopause represents the permanent cessation of ______
menses–> resulting from loss of ovarian follicular function, usually due to aging
When is menopause? (average age)
Naturally (spontaneously), average age 51
Can menopause occur prematurely?
YES–> Prematurely from medical intervention (eg, bilateral oophorectomy, chemotherapy)
Menopause can occur any time from impaired ______ function
ovarian
___% of women stop menstruating between 44-55yo
95%
Menopause: sx
Symptoms vary by individual and cultural expectations/life circumstance
Menopause: classic Sx
- Change in menstrual cycle pattern (early)
- Vasomotor symptoms (includes night sweats)
- Vulvovaginal symptoms (dyspareunia)
- Urinary symptoms
Menopause: other Sx sometimes associated w menopause
- Sleep disturbances besides night sweats
- Cognitive concerns (memory, concentration)
- Psychological symptoms (depression, anxiety, moodiness)
Terminology: Perimenopause
=The time around menopause, also called “the menopause transition”
-Menstrual cycle and hormonal changes that occur a few years before and 12 months after the final menstrual period
Induced menopause= cessation of menstruation that follows _____
bilateral oophorectomy (with or without hysterectomy) or chemotherapy, pelvic radiation therapy, or iatrogenic menopause
Premature menopause=
- Any menopause that occurs before age 40
- Can be natural or induced
- Also called premature ovarian failure
- 0.9% of US population
- Reasons for premature ovarian failure are unknown
T/F: Smoking associated with early menopause
true
Postmenopause=
=The years after the FMP resulting from natural (spontaneous) or premature menopause
-With current life expectancy, the postmenopausal years make up about 1/3 of the lifespan of most North American women
Menopause: diagnostic studies (list 2 main ones)
- Estradiol <20 and FSH level 21-100 helpful in establishing diagnosis
- *FSH of greater than 30mIU/ml is highly suggestive of menopause
Changes in both menstrual flow and frequency are common and usually normal:
(describe)
Lighter bleeding Heavier bleeding Duration of bleeding Cycle length Skipped menstrual periods Amenorrhea
Abnormal uterine bleeding (AUB)=
=Heavy menstrual bleeding (avg. blood loss >80 mL), especially with clots
- Menstrual bleeding lasting >7 days or ≥2 days longer than usual
- Intervals <21 days from the onset of one menstrual period to the onset of the next one
- Any spotting or bleeding between periods
- Bleeding after sexual intercourse
- Organic disease can occur – consider endometrial biopsy
Vasomotor symptoms:
-describe “hot flashes”
- Recurrent, transient episodes of flushing accompanied by a sensation of warmth to intense heat on the upper body and face
- Perspiration and cutaneous vasodilation, may also experience palpitations
- As many as 75% of perimenopausal women have hot flashes
Hot flashes: tx?
-Treatment based on symptom severity and a woman’s risks and personal attitudes about menopause and medication
–**Estrogens, Progestins, Clonidine, SSRIs and SNRIs, Black cohosh, Gabapentin
Hot flash physiology illustration
- increased core body temp
- increased skin blood flow
- increased HR
- increased sweating!!
- intense feeling of “heat” with reddening of upper body
- in the end: chills, shivering
Menopause: Vaginal symptoms
- Sx such as vaginal dryness, vulvovaginal irritation/itching, and dyspareunia are experienced by postmenopausal women
- Unlike vasomotor symptoms, which abate over time, ***vaginal atrophy is typically progressive and unlikely to resolve on its own
- +/- dysuria, urge incontinence, pelvic relaxation, atrophic cystitis, and easy bleeding
Vaginal Sx: tx?
lubricants and moisturizers, and local vaginal estrogen
Menopause: Urinary symptoms
hint: atrophy of ?
- Most menopausal women experience varying degree of atrophic changes of vaginal epithelium -> atrophic vaginitis
- Atrophic changes to cervix -> decrease in size and stenosis, reduced secretion of cervical mucus
- Atrophy of uterus, fallopian tubes, and ovaries
- Supporting structures of reproductive organs suffer loss of tone
Estrogen plays role in maintaining epithelium of bladder and _____
urethra
Declining estrogen during menopause may give rise to..
atrophic cystitis, characterized by urinary urgency, frequency, incontinence, and dysuria
Atrophic vaginitis: tx?
**Kegel exercises can reduce more than 50% of cases of stress incontinence when performed regularly
Menopause:
sexual health changes
-decreased ______ generally increases with aging
libido**
Menopause:
sexual health changes
-effects of decreased estrogen?
- Decreased estrogen causes a decline in vaginal lubrication and elasticity
- Decreased testosterone may contribute to a decline in sexual desire and sensation
Decreased libido and vaginal health: tx?
An active sex life,lubricants and moisturizers, and local vaginal estrogen help maintain vaginal health
Don’t forget STI screening!
-why?
- Clinicians should not assume that peri- and postmenopausal women are not at risk for STIs
- **Vaginal atrophy increases the risk for contracting an STI
- *Older women may not be as knowledgeable as younger women about infection risks or steps to take to reduce those risks
Menopause: sleep disturbances
Peri- and postmenopausal women sleep less, have more frequent insomnia, and are more likely to use prescription sleeping aids
Perceived decline in sleep quality may be attributed to:
- General aging effects (eg, nocturnal urination)
- Sleep-related disorders (eg, apnea) or other illness (eg, chronic pain, depression)
- Stress, negative mood
- Ovarian hormone changes (hot flushes and nighttime awakening)
Women with frequent flushes may experience flushes and awakening episodes hourly, which may cause profound sleep disturbance that can lead to:
cognitive and anxiety disorders in some
Sleep disturbances: Decisions on whether and how to treat—with behavioral or drug therapy, or both—depend on:
- Severity of sleep disturbance
- Context of sleep problem (eg, distressing hot flashes or life stress)
- Severity of daytime consequences
Menopause: Cognitive changes
-Midlife women should be counseled that:
memory and concentration problems are probably not related to menopause but rather to normal aging and/or mood, stress, sleep disturbances, or other life circumstances.
Studies show estrogen influences areas of brain important in _____, but recent studies have shown that estrogen alone or in combo with progestin can increase the risk of _____ _____ in women older than 65yo.
memory
-cognitive decline
Menopause: mood disorders
Feelings of upset, loss of control, irritability, fatigue, and blue moods (dysphoria) at midlife may be caused by fluctuating hormone levels that perturb neural systems transiently
Mood disorders:
-who is most vulnerable?
- Women with a history of premenstrual syndrome, significant stress, sexual dysfunction, physical inactivity, or hot flashes are more vulnerable to depressive symptoms
- Studies assessing effects of estrogen on depression and other mood disorders are mixed
The most predictive factor for depression at midlife and beyond is prior history of ______
clinical depression
Mood disorders: tx?
Relaxation and stress reduction techniques, antidepressants, and counseling, or psychotherapy are options to consider in symptom management
Menopause: Skin and Hair Changes
- Skin becomes thinner and less elastic
- Hair loss increases
- Nails become brittle
- Facial hair may increase
Menopause: osteoporosis
- defined as?
- Definitions based on BMD results:
=systemic skeletal disorder characterized by low bone mass and deterioration with an increase risk in fragility and susceptibility to fracture
-Peak bone mass 25-30yo, then bone loss begins and accelerates in women at menopause, can lose up to 20% of bone mass in 5-7 years after menopause
- Definitions based on BMD results:
- -Normal: T-score greater than or equal to –1.0
- -Low bone mass (osteopenia): T-score between –1.0 and –2.5
- -Osteoporosis: T-score less than or equal to –2.5
Osteoporosis risk factors
Advanced age (40-90) Previous fracture (adult life) Parental history of fragility fracture Female sex Current tobacco smoking Weight (low weight) Long-term use of glucocorticoids
National Osteoporosis Foundation recommendations for BMD testing:
- All postmenopausal patients younger than 65yo w/ > or equal to one additional risk factor (other than white, postmenopausal, and female)
- All women age 65yo and older
- Postmenopausal women who present with fractures
- Women considering therapy for osteoporosis if testing would help decision
- Women who have been on HRT for prolonged periods
- Women who have been on treatment to monitor treatment effect
- Women considering discontinuation of treatment
Osteoporosis Treatment
-All individuals at risk for or who have been diagnosed with osteoporosis should be advised to consume adequate calcium (minimum of 1200mg daily) and Vitamin D (800-1,000 IU/d), smoking cessation, avoid excess alcohol, and regular weight bearing exercise.
- Pharm therapy is recommended for:
- -Women who have had vertebral or hip fracture
- -Women with T-scores ≤−2.5 with no risk factors
- -Women with T-scores from −1.0 and below with a 10-year FRAX risk of major osteoporotic fracture of at least 20% or of hip fracture of at least 3%
- –Example - Bisphosphonates
-Alendronate 70 mg tablet po q weekly
Menopause: Cardiovascular disease
- Heart disease affects about 8 million women in US
- Deaths from CHD in women number more than 230,000 per year
-CHD increases with age
Before age of menopause, very few women die from CHD
- After menopause rate of CHD increases 2-3x
- Numerous studies show estrogen and progesterone receptors present in heart and aorta
- HRT should not be prescribed for prevention of CHD, decision to use should be based on benefits of other systems, potential risks, and patient preference
For better cardiovascular health:
-advise Pt to ____
have good cholesterol, blood pressure, blood glucose, BMI, quit smoking, eat healthy and be physically active
Because cancer rates increase with age, screen for the following cancers regularly:
Breast cancer
Colorectal cancer
Cervical cancer
Hormone therapy (HT) FDA approved indications:
prevention of osteoporosis, treatment of vasomotor symptoms, and treatment of vulvovaginal atrophy. HT encompasses both estrogen-alone and estrogen-progestogen therapies.
Estrogen therapy (ET)=
Unopposed estrogen is prescribed both a) systemically for women who do not have a uterus, and b) locally in very low doses for any woman with vaginal symptoms
Estrogen-progestogen therapy (EPT)=
Progestogen is added to ET to protect women with a uterus against endometrial cancer, which can be caused by estrogen alone
Bioidentical hormone therapy (BHT)=
Consists of hormones chemically identical or very similar to those made in the body. Available from two sources: 1) FDA-approved and tested; 2) unapproved and untested from compounding pharmacies
Hormone therapy—what we know today
-HT formulation, route of administration, and timing of initiation produce different effects (e.g. transdermal route may carry lower risk for thrombosis)
Absolute risks for HT include:
- thrombosis, stroke, and cardiovascular events
- HT initiation in older women carries greater risks
- **Breast cancer risk increases with EPT in WHI study
- Consider each woman’s priorities and risk factors prior to initiating HT
Contraindications to (HRT) hormone replacement therapy: (list)
- Undiagnosed vaginal bleeding
- Active DVT or PE or a history of these conditions
- **Arterial thromboembolic disease (MI and stroke)
- Liver disease
- History of endometrial or breast cancer
Alternatives to hormone therapy:
-Nonhormonal prescription drugs (off-label use):
- Antidepressants:
- -SSRIs: fluoxetine, paroxetine, escitalopram
- -SNRIs: venlafaxine and desvenlafaxine
- Insomnia:
- -Eszopiclone - (Lunesta)
- Anticonvulsant:
- -Gabapentin
- Antihypertensive:
- -Clonidine
-Neuropathic pain drug:
Pregabalin
Complementary & Alternative Medicine (list Ex’s)
- Soy isoflavones:(phytoestrogen)
- Traditional Chinese medicine
-Herbs: Black cohosh Cranberry St. John’s wort Valerian- good for anxiety
-Over-the-counter hormones: (dietary supplements)
Melatonin
Lifestyle changes:
- Try relaxation techniques (eg. yoga, meditation)
- Eat a healthy diet
- Get regular exercise
- Avoid hot flash triggers (eg, caffeine, alcohol, spicy food)
- Keep cool:
- -Dress in layers (eg. light clothing)
- -Sleep in cool room (eg. fan, thermoregulating pillow)
- -Consume cold drinks
-Reduce sexual discomfort and increase sensitivity with moisturizers, lubricants, and vibrators
POSTMENOPAUSAL HEALTH:
The menopause transition and the time afterward are important periods for implementing lifestyle and behavioral changes to ensure that each woman:
maximizes her health moving forward.
Lifestyle counseling for midlife women:
-Discontinue unhealthy habits: (list)
Tobacco use
Excess Alcohol
Drug/medication abuse
Lifestyle counseling for midlife women:
-Promote healthy food and exercise:
Limit fat and cholesterol intake
Maintain caloric balance
Consume whole grains, fruits, vegetables, water
Ensure adequate vitamin and mineral intake, especially calcium and vitamin D
Engage in regular physical activity
Lifestyle counseling for midlife women:
-injury prevention ?
-Wear lap/shoulder belts in the car
- Institute fall prevention methods
- Appropriate helmet and other safety equipment
- An adequate number of smoke and carbon monoxide detectors
- Ensure safe storage or removal of firearms
- Set water heater thermostat between 120°F and 130°F or lower
- Train household members to deliver cardiopulmonary resuscitation
Lifestyle counseling for midlife women
-Sexual behavior?
- Institute prevention of sexually transmitted infections
- Avoid high-risk sexual behavior
- Use condoms or female barrier, or both
- Prevent unintended pregnancies with appropriate contraception
