Midlife & Aging-Related Body Changes

Question 1

Benefits of Estrogen & Androgens on Vulvovaginal Health

Answer 1

-estrogen:
>maintains blood flow to vulvovaginal tissue
>maintains collagen w/in epithelium
>maintains hyaluronic acid & mucopolysaccharides w/in epithelium
>maintains pH of 4.5 by supporting balance of microbiome
>protects from pathogens
>receptors found throughout vagina, vulva, urethra, & trigone of the bladder
-androgen(s):
>simulate nerve fibers
>maintains healthy epithelium
>receptors are found in all three vaginal layers

Question 2

Effects of Estrogen & Androgen Loss

Answer 2

-Vulva ->thinning of vulvar tissues
-vagina ->thinning of superficial epithelium, loss of elasticity, loss of vaginal ruggae, narrowing of vag canal, poor distention
-decrease glycogen
-decrease in lactobacilli & lactic acid
-higher vag pH, increases lymphocytes & plasma cells
-decrease in physiologic vaginal secretions, increase in pathological vaginal discharge
-urinary tract: urethra moves closer to introitus

Question 3

Body Weight in Menopause

Answer 3

-obesity (BMI >30) in US mostly women
-incr prevalence since 2005
-prevalence of severe obesity (BMI >40) in women nearly double (9.9%) that of men (5.5%) & continues to increase

Question 4

Weight Gain in Menopause

Answer 4

-mostly r/t aging & lifestyle, not meno or HT
-changes in body composition & fat distribution are r/t meno
-meno a/w increase in central adiposity as well as visceral fat & decrease of lean body mass, regardless of age
-obesity in meno a/w metabolic syndrome (MetS), DM type 2, CVD, aortic plaque, hepatic steatosis, breast ca

Question 5

Obesity & VSM

Answer 5

-elevated BMI or adiposity a/w incr severity & frequency of VMS in transition phase
>reverses in postmeno stage
>possibly linked to levels of estradiol
-perimeno & premeno women who are obese have lower levels of estradiol compared w avg women
>postmeno women who are obese have higher levels of estradiol
-no clear study to test effect of weight loss on VMS
-some evidence shows perimeno & premeno women benefit from weight loss w decr VMS

Question 6

Optimization of Body Weight

Answer 6

-healthy diet, incr physical activity, minimize weight gain is appropriate advice for all women —> 150min/wk moderate exercise, 60min/d for wt loss
-small amounts of wt loss (3-10% of body wt) improves many metabolic parameters, including glucose, lipids, BP, fatty liver disease, chronic pain, CVD risk
-sleep disturbance a/w incr cortisol, lower thyrotropin, lower leptin, reduced glucose tolerance, & decreased energy expenditure that contributes to wt gain

Question 7

Tx Options for Obesity

Answer 7

-behavior therapy
-regular exercise
-pharmacotherapy
-bariatric surgery

Question 8

AHA Recs on Diet & Lifestyle

Answer 8

-maintain healthy body wt; use put at lease as many calories taken in
-eat a variety of nutritious foods from all food groups
-eat less nutrient-poor foods
-base eating patterns on these recs:
>diet high in fruits/veggies, whole grains
>high in oily fish
>minimize sugar-sweetened beverages
>decr salt
>don’t smoke tobacco & avoid second-hand smoke & vape
>limit etoh
-pay attention to food eaten outside the home in regard to salt, portion size, & trans fat

Question 9

Skin Changes

Answer 9

-intrinsic: genetics, ethnic differences
-extrinsic: UV exposure, smoking, pollution, poor diet, sleep deprivation, decline in estrogen
-30% decline in skin collagen in the first 5yr after menopause; approximately 2% per year decline over next 20yrs

Question 10

Skin Changes (cont)

Answer 10

-strong correlation btwn skin thickness & collagen content w years since meno than chronological age
-estrogen receptors are present in significant numbers in skin
-decreased estrogen = decr cellular growth factors, ability to repair enzymes, decrease dermal vasculature
-less elasticity, dryness, skin barrier disruption, dermal thinning

Question 11

Recs for Skin Care

Answer 11

-proper UV light protection
-use of sunscreen
-healthy diet & adequate sleep
-smoking elimination
-use of emollients & topical agents
-cosmetic options for skin improvement
>targeted in-office procedures
>peeling agents & laser tx
>filling agents & toxins
>deep dermal & subs repair, radio frequency, US
>collagen stimulators
>modified hyaluronic acids

Question 12

Hair Changes

Answer 12

-incr ration of androgen to estrogen during meno transition may influence changes in some women
-hair growth aberrations have negative effect on body image, self-esteem, QOL, emotional well-being
-female pattern hair loss (FPHL, thinning on crown) & telegenic effluvium (sudden onset of hair shedding) most common causes
-other causes include male pattern hair loss, frontal fibrosis alopecia (FFA), thyroid disease, various cicatricial (scarring alopecias), trichotillomania, alopecia neoplasticism, tinea capitis, alopecia areata

Question 13

Hair Changes (cont)

Answer 13

-exact mechanism of FPHL is unclear; r/t inflammatory process & altered hormone imbalance, & environmental/genetic factors
-hirsutism, coarse facial hairs on chin, upper lip, cheeks affects 5-15% of women & is a/w androgen overproduction or peripheral hypersensitivity, often bc of PCOS
-work up includes H/P, fam hx, ROS
>meds, stress, malignancies, autoimmune disease
>baseline studies CBC, CMP, thyroid function, testo free & total, DHEA, & SHBG, iron, ferritin, zinc
>scalp bx also if indicated

Question 14

Tx for Hair Loss

Answer 14

-goal is to prevent progression
-correct underlying nutritional deficiencies
-no strong evidence that vitamins or supplements support hair regrowth
-topical minoxidil is the only FDA-approved for FPHL
-hormone agents for tx of FPHL have not be evaluated, but used off-label
-adjunctive therapies such as prostaglandin analog/prodrug, OTC ketoconazole shampoo, low-energy laser light have been used w variable response
-off-label use of anti androgens spironalactone or finasteride