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REPRO > Ovarian failure/menopause > Flashcards

Ovarian failure/menopause Flashcards

1
Q

Natural menopause definition

A

permanent loss of ovarian follicular activity
12 consecutive mo of amenorrhea
no other obvious pathologic/physiologic cause
avg age 51

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2
Q

Perimenopause definition

A

time prior to menopause and 1st year after menopause

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3
Q

Induced menopause definition

A

cessation of menstruation due to surgical removal of ovaries

OR iatrogenic ablation (chemo/radio)

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4
Q

Premature menopause/POI definition

A

menopause occurs >2 SD below mean age
FSH > 30 mIU/mL x 2 at least 1 mo apart
amenorrhea > 4 mo
preceded with a duration of disordered menses

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5
Q

Pathophysiology of menopause

A

depletion of ovarian follicles
reduced inhibin due to low FSH
increased activin - increases with reduced inhibin, tries to increase FSH
high FSH/LH
low Estrogen - dysfunctional granulosa cells
low progesterone
low androgen levels

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6
Q

Menopause symptoms

A 
headaches/hot flashes
teeth loosen, gums recede
nipples become smaller and flatten
breasts droop and flatten
skin becomes drier, develops rougher texture
backaches
risk of CV disease
abdomen loses muscle tone
vaginal dryness, itching, shrinking
stress/urge incontinence
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7
Q

Issues involved in ovarian failure

A 
menstrual changes
vasomotor symptoms
urogenital changes
mood changes
sexual changes
CVD
bone health
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8
Q

Menopause - menstrual changes

A

Cycles initially get shorter before longer
- rapid follicular recruitment
- initially loop cycle: Luteal Out Of Phase follicular event (short)
- then lag cycles (long)
AUB
Depletion in primordial follicles
amenorrhea eventually occurs

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9
Q

LOOP cycle

A

Luteal Out Of Phase follicular event

premature formation of a follicle due to major surge in FSH during luteal phase

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10
Q

Lag cycles

A

Long follicular phase with aberrant folliculogenesis

high E2, low P4

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11
Q

Vasomotor symptoms during menopause

A

Hot flashes/night sweats
sudden onset - begins in chest, may progress to neck/face
often associated with anxiety, palpitations and sweating
can interfere significantly with life
75-80% of women experience them
generally from 6 mo - 5 y, but can last as long as 15 years
can occur in perimenopause

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12
Q

Etiology of vasomotor symptoms during menopause

A 
Estrogen withdrawal 
-->
Dysregulation of firing rate of thermosensitive neurons in preoptic hypothalamus
decreased alpha2 activity
significantly smaller thermoneutral zone
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13
Q

Management of vasomotor symptoms during menopause

A

Lifestyle - cool rooms, regular exercise, stop smoking
HT: estrogen alone or with progestin - lowest dose for shortest duration
Non-hormonal therapy: clonidine alpha 2 agonist
gabapentin
SSRI
Stellate ganglion block
Non-Rx - controversial, vitamin E??

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14
Q

Urogenical consequences of menopause

A

vaginal atrophy
UTI
incontinence
pelvic prolapse

Atrophy of urogenital epithelium and subepithelial tissues
Degeneration of collagen, elastin, sm
decreased blood flow to tissues

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15
Q

Estrogen-sensitive pelvic tissues

A 
receptors found in:
Introitus
vagina
bladder
urethra
pelvic floor musculature
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16
Q

Vaginal atrophy (menopause)

A

DYspareunia
vaginal dryness
itching
irritation

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17
Q

Pathophysiology of vaginal atrophy

A 
thinning of epithelium
less blood flow
vaginal length/diameter shrink
nerve endings exposed
increased trauma
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18
Q

UTI during menopause pathophys

A

mucosa is thinner
glycogen production declines
decreasing level of lactobacilli
reduced lactic acid production

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19
Q

Urinary incontinence during menopause pathophys

A

reduction in mean uretrhal closure pressure
thinning of bladder mucosa and increased irritation
increased likelihood of urinary incontinence

20
Q

Mood changes during menopause

A

some evidence for increased irritability, tearfulness, anxiety, poor concentration
secondary to - ??
- fluctuating E levels (E has positive effects on serotonin activity, upregulation of 5-HT1 receptors, decreased MOA activity)
- sleep disturbance

21
Q

Depression during menopause

A

Risk factors:

  • Hx of depressive disorders
  • poor physical health
  • Life stressors
  • Hx of surgical menopause
  • Long transition
22
Q

Sexual concerns during menopause

A

Lack of E: dyspareunia, decreased vaginal blood flow, altered sesation
Reduction in ovarian testosterone
AUB is problematic
depressive symptoms

23
Q

Managing sexual concerns during menopause

A

Address interpersonal/contextual components
Address biologic factors (AUB, vaginal atrophy, mood/anxiety)
Routine evaluation of hormone - limited value
testosterone therapy by experienced physicians

24
Q

CVD during menopause

A

women who have had oophorectomy: higher age adjusted risk than those with intact ovaries
Adjusting for age, postmenopaulsa women - 2x risk seen in premenopausal
Less favourable lipid profiles
increased insulin resistance
increased likelihood of thrombosis
HT no longer indicated

25
Q

Bones - menopause

A

Higher rates of fracture in postmenopausal women
loss of bone density
preservation of bone mineral density/fewer fractures with HT

26
Q

Tx of osteoporosis in women

A

recommended for:
T-score =3% for risk of hip fracture
- FRAX >=20% for risk of a major osteoporotic fracture (forearm/hip/shoulder/clinical spine fracture) in next 10 years

Raloxifene, bisphosphonates, PTH, denosumab, calcitonin

27
Q

POI - HT

A

premature menopause/ POI - associated with lower risk of breast ca and earlier onset of osteoporosis, CHD
HT recommended for them at least until median age of normal menopause

28
Q

Considerations with HT use - cognition

A

WHI: no improvement in cognitive function
prospective study on women with mild-moderate AD: no effect for 1 yr on disease progression/cognitive function/global outcome

29
Q

HT and breast cancer

A

HT use 1-4 y: no added risk
5 or more: RR 1.35, risk increased by 2.3% per year of use
elevated risk disappeared by 5 y after stopping
greater risk is still family history

30
Q

HT and colon cancer

A

WHI observational

no protective effect on colorectal cancer mortality

31
Q

HT and lung cancer

A

WHI: no significant increase in incidence

significant increase in death from lung ca in women who took EPT

32
Q

HT and ovarian ca

A

current/recent use of MHT - RR 1.37 for serious endometriod ovarian cancer

33
Q

HT and endometrial ca

A

only progestin / continuous combined reduces risk of endomterial ca

34
Q

HT and stroke

A

EPT - no increase in stroke risk or an increased risk (HERS, WHI)
oral route higher RR than transdermal

35
Q

HT and venous thromboembolism

A

no consistently observed procoagulant effect of HT in prospective studies
oral E mor econsistently affects coagulation and fibrinolysis and transdermal

36
Q

HT and CHD

A

CV risks improve on HT in those >70 y (but not symptomatic for menopause)

37
Q

HT conclusions

A

ET does NOT increase risk of CVD in early postmenopausal years, but increases it if begun some time after menopause

38
Q

HT and gallbladder disease

A

increased risk

39
Q

EPT risks

A 
venous thromboembolism
stroke (inconsistent data)
breast ca for use beyond 5 y
ovarian cancer
gallbladder disease
40
Q

EPT benefits

A

QOL
bone density
colon ca

41
Q

ET in women with previous hysterectomy - risks

A

venous thromboembolism
storke (inconsistent)
ovarian ca
gallbladder disease

42
Q

ET in women with previous hysterectomy - benefits

A

QOL

bone density

43
Q

Causes of POI

A 
Accelerated follicle depletion
Primary hypogonadism
Common causes:
Turner
Fragile X
Somatic and X chromosome gene defects
AI ovarian failure
Toxins
44
Q

Polyglandular autoimmune syndrome

A

adrenal, thyroid, pancreatic failure

45
Q

Estrogen supplementation for depression

A

Not effective

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