Middle and Older Woman Flashcards
1
Q
Age of Menoapuse
A
Avg is 51
5% after 55
2
Q
Age of Perimenopause
A
Usually in 40s
Lasts about 3.7 years
3
Q
Perimenopausal bleeding
A
- Irregular, unpredictable bleeding is common
- Heavy, unpredictable is common
- If persists despite treatment, investigate cause
4
Q
Medical Issues in Perimenopause
A
- Heavy Bleeding
- Anovulatory cycles can lead to endometrial hyperplasia and endometrial cancer
5
Q
Hormonal Changes in Perimenopause
A
- FSH decreases due to decrease in Inhibin B (fluctuation common)
- AMH - Produced by growing follicles, decreases 5 years before menopause (rarely used, expensive)
- FSH low and Estrogen high is reproductive cycle
6
Q
Causes of AUB
A
- Anovulatory cycles
- Physical abnormalities (polyp)
- Medical (pregnancy, medication, anovulatory due to illness)
- Endometrial hyperplasia
- Adenomyosis
7
Q
Describe Anovulatory bleeding
A
- Normally progesterone takes over sloughing uterine lining
- During menopause no regular ovulation so build up of estrogen –> building up of uterine lining
- When bleeding does occur can be “catastrophic”
8
Q
Endometrial Hyperplasia
A
- Unopposed estrogen –> build up of lining –> Hyperplasia
- Risk factor for cancer
- Do a biopsy if you can’t figure out why pt is bleeding
9
Q
Polyps
A
- Almost always benign
- Bleed easily with sex, running, ect.
- Assess lining of uterus
- Can resolve on its own or D&C
10
Q
Adenomyosis
A
- Boggy uterus
- Endometrial cells embedded in myometrium
- Painful, irregular bleeding and menses
- Seen on US
- May do hysterectomy
11
Q
Fibroids
A
- Almost always benign
- Cause irregular heavy bleeding
- Pain on position
- Become bulky
- Myomectomy or hysterectomy
12
Q
Endometrial Cancer
A
- Fullness on bimanula exam
- US shows growth or complex cyst
13
Q
Gestational trophoblastic disease
A
- Not true pregnancy
- Can be malignancy
- Often bleeding is first sign
- R/O with UPT
14
Q
Atrial venous malformations
A
- Rare
- Irregular attachment of arteries and veins
- Require surgery
15
Q
Coagulopathy
A
von Wilebrand’s Disease
16
Q
Lab tests at Perimenopause
A
- R/o pregnancy
- GC/CT - Cervix may bleed
- CBC/Iron
- TSH
- Prolactin - Galatorrhea, alteration of cycle
- TVUS
- Endometrial bx
17
Q
TVUS Uses
A
-Best for uterine bleeding
-Can avoid biopsy if it looks good
3-6 months of treatment failure
Increased risk of endometiral cancer
Polyps, fibroids, endometrial lining, carcinoma
18
Q
EMB Uses
A
- Hyper plasia
- Endometrial Cancer
- If not diagnostic, sonohysterogram and hysteroscopy
- If US clear but bleeding continues
19
Q
Risk factors for endometrial cancer
A
- Estrogen or Tamoxifen use
- Endometrial hyperplasia
- Obesity
- DM
- Chronic anovulation
- HTN
- Family Hx BC, OC, CC, E/M Ca
20
Q
Endometrial Biopsy Results
A
-Proliferative - Concerning if patient is far past menopause
(can be normal into 50s)
-Complex hyperplasia w/o atypical you repeat 6-12mo
-With atypia is highest risk for endometrial cancer
21
Q
Anovulatory bleeding recommendations
A
- Endometrial evaluation 35 and older
- Under 35 if not able to treat
- Obese women with uncontrolled DM are at risk
22
Q
At risk of endometrial cancer
A
- Mostly postmenopausal
- 25% are premenopausal (mostly obese with uncontrolled DM)
23
Q
AUB recommednations
A
- R/O pregnancy, systemic disease, organic etiology, CA
- Most respond to medication
24
Q
Treatment for benign AUB
A
- NSAIDS (decrease bleeding)
- Tranexamic Acid - Antifibrinolytic agent that reduces bleeding (caution with pt at risk for clot)
- COC if not contraindcated (can continue through menopause)
- Progestin only (Not at risk of pregnancy, or COC CI). Use to stop acute bleeding
- Mirena - Very effective. Slough lining and prevent further bleeding
- GnRH agnoists - Cause amenorrhea, induces menopause. Only 6 months a time, pre-surgery
25
NSAIDS to tx AUB
- 600-800 mg
- MUST take around the clock
- Sporadically can increase bleeding
26
Risks of Combined Hormone Therapy
- Breast Cancer
- CHD
- Stroke
- Pulmonary Embolism
- Risks > benefits of reduced fracture and colorectal cancer
27
Risks of Estrogen only
- STROKE
- Insignificant reduction in breast cancer risk
- Better for younger people
- Patients with a hysterectomy ONLY need Estrogen
28
Uses for HT
-NOT to prevent chronic illness
-Short term for vasomotor sxs
-Healthy arteries respond better then atherosclerotic
>63 worse results
29
Combined HT initiated close to menopause
- Reduced risk of CHD
| - Increased risk of breast cancer
30
Estrogen therapy initiated close to menopause
- No difference based on age of initiation
- Benefit for CHD
- Increased risk of stroke
- Neutral for breast cancer
31
HT at age 70
Higher risk of CHD
32
HT and vasomotor sxs
- Hot flashes, poor sleep, irritability, concentration problems
- Primary indication HT
- Any kind except low dose transdermal estradiol
- Progesterone alone not as effective
33
Duration of HT
>5 years increased risk of breast cancer with Combined HT and CVD for all HT
34
Non Hormonal approaches to Hot flashes
- Lifestyle changes
- Reduce ETOH, smoking, caffeine
- Yoga/Meditation
- SSRI at lower dose
35
Non hormonal approaches to vaginal sxs
- Dryness, atropy, dyspareunia
- Moisturizers, vitamin E, lubricants
- Estrogen creams (local), progesterone not as helpful
- Evaluate all postmenopausal bleeding
36
Urinary Tract Health
- Estradiol ring may help overactive bladder
- Systemic HT may increase kidney stones and stress incontinence
- Estrogen cream to protect meatus from cracking and infection
- NOT systemic - local
37
UTI
- Common, E.Coli
- Check resistance, culture
- Ampicillin no longer first line
- Nitrofurantin x5d
- Macrobid post-coital
38
Osteoporosis
- Aging and decreased estrogen lead to decreased bone strength and increased risk of factor
- Other RF: genetics, thinness, smoking, low Ca+, low Vit D, ethnicity
39
Osteoporosis prevention/Osteopenia tx
```
Vit D 800-1000
Calcium 600 in diet 600 supplement
Walking 2-3 miles
-Healthy weight
-Smoking cessation (reduces estrogen if you smoke)
-Avoid ETOH excess
-Prevent falls
```
40
DEXA (When)
>65 or >50 with risk factors: previous fracture, smoking, FMH, rheumatoid arthritis, ETOH,
41
DEXA (What)
- Total hip, lumbar spine, femoral neck, forearm
- Tscore - compared to 20yo
- Zscore - compared to others her age
42
Cause of Low BMD
- Hyperthyroid
- DM 1
- Ankylosing spondylitits
- RA
43
Cardiovascular disease
- Heart disease #1 cause of death
| - RF: Metabolic syndrome, abd obesity, high triglycerides, low HDL, elevated BP, elevated FBS
44
Lichen Sclerosis sxs and tx
- Itching, severe at night
- Diminished labial architecture
- Etiology unknown (Autoimmune)
- Increase after menopause w/low estrogen
- Tx with high potency steroid
- Risk of vulvar cancer
45
Cardiovascular Triad
Waist circumference, HTN, Hyperglycemia = 3 fold increase in mortality
46
Cardiovascular Assessment
- Measure the waist
- Lipid panel once a year
- BP both arms
- Urine for glucose/protein
- Smoking cessation
- Physical activity
47
Pregnancy and Metabolic Syndrome
- Insulin resistance
- Increased inflammation
- Increase in coagulation factors
- Can cause GD, preeclampsia
- Predisposition to risk later in life
