perimenopausal and menopausal

Question 1

What is Menopause?

Answer 1

DEFINITION:

Aging process  cessation of ovarian estrogen source  cessation of menses.

Question 2

Menopause-Effects estrogen target organs:

Answer 2

Ovary, endometrium, vaginal epithelium, vulva, bladder & urethra, uterus, breasts, hepatic metabolism, lipoprotein metabolism, & bone metabolism, cardiovascular system.
Latest research  brain?, colon?

Question 3

Menopause US Demographics

Answer 3

2000:
@ 42.19 million woman over age 50
@ 33.21 million women are over 55.

By 2020  # of women over 55 expected to be 45.2 million.

Question 4

Age of menopause and onset

Answer 4

Average age of menopause  48 – 55
Median age for onset of menopause
transition  47.5

Today  woman who reaches 54 can expect to reach age of 84.3.
Women can expect to live approximately one-third of their lives without ovarian function.

Question 5

Menopause Diagnosis

Answer 5

DIAGNOSIS
6 - 12 months of amenorrhea in women over 45.

Elevated levels of FSH & LH → conclusive of ovarian failure.

Question 6

Perimenopause

Answer 6

25 year continuum from age 35-60 with three distinct phases:
Climacteric.
Menopause
Postmenopause

Question 7

Perimenopause Climacteric Phase

Answer 7

(“premenopause” “transitional phase”):
Phase in aging process → woman passes from reproductive to nonreproductive state.

8-10 years prior to onset of menopause:
Menstrual cycle likely to be irregular.
Other climacteric symptoms may occur.

Question 8

Perimenopause 2nd phase menopause

Answer 8

The final menstruation → terminates reproductive capability.

Diagnosis made only in retrospect.

Question 9

Perimenopause 3rd phase menopause

Answer 9

Phase of life after menopause has occurred,

Question 10

Premature menopause/premature ovarian failure

Answer 10

Cessation of menses before age 40.

Question 11

Surgical menopause

Answer 11

Abrupt onset of menopause/menopausal symptoms after removal of ovaries.

Question 12

Menopause “Aging”

Answer 12

natural progression of changes in structure & function that occur with the passage of time in the absence of known disease.

Question 13

Aging of the Menstrual Cycle:

Answer 13

Aging of the female reproductive system begins at birth & proceeds as a continuum.
Menopause is a natural biological process  not an estrogen deficiency disease.

Question 14

Menopause

Fetal Development

Answer 14

6-7 million eggs in a 20 week female fetus; 80% lost by birth.

Question 15

Menopause

Puberty Onset

Answer 15

300,000 eggs.

With each menses: for every follicle which ovulates, close to 1000 follicles will pursue abortive growth patterns.

Question 16

Menopause

Age 38-42

Answer 16

Number of follicles are decreased & less responsive to FSH  less estrogen is produced.

Decreased estrogen no longer proliferates endometrium to yield menses & menopause occurs.

Question 17

menopause

Bleeding Pattern Changes

Answer 17

Changes in hormones during climacteric starts onset of menopause transition begins → changes in either frequency, flow or both in a woman who previously experienced regular cycles.

Average woman can expect menstrual irregularity for @ 4 years prior to actual menopause.

10% women experience a perimenopause of less than 6 months duration or sudden amenorrhea.

Question 18

Menopause
Hormones after Menopause
Estrogen

Answer 18

Two types:
Estradiol
Secreted by the ovary.  
Major deficiency in menopause.
Estrone	
After menopause  major circulating estrogen.

Question 19

Menopause

Estrone

Answer 19

A less potent estrogen → secreted by ovary before menopause.
After menopause:
Minor source: adrenal gland
Major source: Comes from the conversion of androgens which occurs in fat, muscle, liver, bone marrow, brain, fibroblasts, & hair roots.
Amount of fat tissue is the major determining factor of estrogen levels.
Obesity  creates increased amounts of estrogen.
Puts women at higher risk for endometrial cancer

Question 20

Menopause

Progesterone

Answer 20

Remains about 30% of follicular phase levels.

Appears to be secreted by the adrenal gland.

Question 21

Menopause

Testosterone

Answer 21

Continues to be secreted by ovary & only minimally lower than premenopausal women.

Two different perspectives:
Coupled with decreased estrogen may partially explain the defeminization, hirsutism & virilism occasionally seen in older women.
Contribute to women’s sex drive, muscle strength, & energy level  improves quality of life.

Question 22

Menopause

Gonadotropins

Answer 22

Levels rise → absence of negative feedback system.
Luteinizing Hormone (LH)  3X premenopausal level.
Follicle Stimulating Hormone (FSH)  10-15X premenopausal levels.

Question 23

Physiologic Changes of Menopause

Answer 23

Estrogen causes the growth of the female reproductive tract → decreased estrogen causes a regression of all reproductive organs.

Changes also occur in estrogen-target organs.

Question 24

Menopause

Urogenital Tract

Answer 24

Labia Majora & Minora:
Become less prominent.
Vulva skin becomes extremely thin.
Loss of pubic hair. (variable)
Changes make women more prone to vulvar irritation & disease.

Question 25

Menopause

Vagina

Answer 25

Shortens & narrows.
Walls thin & dry with ↓ vascularity & elasticity.
Rugae progressively flatten as epithelium thins → capillary bed shines through as diffuse or patchy reddening.
Changes make women more prone to:
“Atrophic Vaginitis” → bacteria easily invade thinning epithelium.
Vaginal bleeding from minimal trauma with douching, sex.
Dyspareunia.

Question 26

menopause

cervix

Answer 26

Shrinks & atrophies.

Cervical canal decreases in size.

Question 27

menopause

Uterus

Answer 27

Becomes atrophied.
Decreases in size.
Uterine myomas & foci of endometriosis shrink.
Changes make women more prone to:
Increased risk of uterine prolapse due to decreased uterine support.

Question 28

Menopause

Ovaries

Answer 28

Begin to decrease in size after age 30 → rate accelerates after age 60.
Becomes atrophic mass of fibrous tissue.
Palpating ovaries on bimanual exam  becomes increasingly difficult.
If ovaries are palpated → must r/o ovarian neoplasm.

Question 29

Menopause

Bladder & Urethra

Answer 29

Atrophy causes a change in bladder mucosa & urethral tone.

Changes make women more prone to:
“Atrophic Cystitis” – urinary frequency,
urgency, & incontinence.

Question 30

Menopause

Vasomotor

Answer 30

Symptoms:
Hot flashes/flushes.
“flash”– symptoms leading to the “flush”
“power surges” or “hot flashes”?
Night sweats.
Symptoms not life-threatening → can impair the quality of life.

Question 31

Menopause

Hot flashes

Answer 31

Most frequent physical complaint:
Affects 80% of all women.
30% classify symptoms as “severe”.

Can happen for a few months up to several years before & after the last menstrual period.

Symptoms last:
1-2 years – most women.
25-50% women - longer then 5 years.

Question 32

Menopause
Hot flashes
symptoms

Answer 32

Symptoms:
Sudden onset of reddening of skin over head, neck, & chest.
Feeling of intense body heat.
Sometimes concludes with profuse perspiration.
Appear to be more frequent & more severe at night & at times of stress.

Duration: few seconds  several minutes →
hour+ (rare).

Frequency: rare  recurrent q 10 - 30 minutes

Question 33

Menopause

Etiology of hot flashes

Answer 33

Exact cause is unknown  has to do with presence of estrogen & then its withdrawal.

Believed to be related to estrogen deficiency’s effect on hypothalamus.
Area of GnRH neurons as well as thermoregulatory centers.

Recent research  hot flashes may be induced by an imbalance of the endogenous B-endorphins.

Question 34

Menopause
Musculoskeletal
System

Answer 34

Symptoms:
Backache.
Osteoporosis.

Reduction in the quantity of bone structure  mechanical fragility  compression and fracture.

Question 35

Effects of 
Osteoporosis
on 
Musculoskeletal
System
Most Common Fx

Answer 35

Most common fractures:
Spinal compression fracture:
Vertebral crush fractures (T-8 to L-3)
Most common site of fracture.
Most often occur in 1st decade after menopause.
Decrease in height, dowager’s hump, increased pain.
Average white postmenopausal woman can expect to shrink 2 1/2 inches.

Question 36

Effects of 
Osteoporosis
on 
Musculoskeletal
System Wrist

Answer 36

Colles fracture:

Distal forearm & wrist

Question 37

Effects of 
Osteoporosis
on 
Musculoskeletal
System 
Hip

Answer 37

Head of femur (hip) fracture:
Most likely to occur later in life → consequence of both aging & long term effects of lower estrogen levels.
20/1000 women age 45 – 85 → 80% associated with osteoporosis.

Question 38

Effects of 
Osteoporosis
on 
Musculoskeletal
System 
Hip

Answer 38

With hip fracture → increased morbidity due to complications:
Prior to availability of hip replacement surgery:
Leads to death within 4 months in 12-20% of women.
1/2 of the surviving women need nursing home placement.
Statistics for morbidity improving with advent of total hip replacement.

Question 39

Menopause

Bone Loss

Answer 39

Loss of mineral content occurs in all aging individuals, but there are major risk factors:
Age.
Initial bone density.
Menopause
Bioavailability of calcium
Family history.
History of fractures earlier in life.
History of eating disorder.

Question 40

Bone Loss Sporadic risk factors

Answer 40

Race ( risk for blacks).
Smoking  risk.
Alcohol use  risk.
Thin stature  risk.
Medical illnesses  risk.
Weight-bearing exercise  risk.

Question 41

Bone Loss Relationship with estrogen

Answer 41

Unknown.
Possibly has effect on parathyroid function  parathyroid gland involved in bone synthesis.
Accelerated rate of bone loss after estrogen levels decrease, slows with time, & levels out after approximately 10 years.

Not all postmenopausal women develop osteoporosis  many as-yet undetermined factors may play a role.

Question 42

Menopause

Cardiovascular System and Estrogen

Answer 42

Protective effect against CV disease in women.

Incidence of CV events rise rapidly after menopause.

10 years after the ovaries stop producing estrogen
→ incidence of CV disease in women approaches that observed in men.

Question 43

Major deleterious changes in CV system associated with menopause involves alterations in

Answer 43

Vasoreactivity – shift from vasodilatation to vasoconstriction.
Coagulation – increased fibrinogen levels & increased platelet aggregation.
Lipid profile
Increased level of low-density (LDL) cholesterol & lipoprotein.
Increased aortic cholesterol accumulation.

Question 44

CV disease facts

Answer 44

Single greatest killer of postmenopausal women.
Affects more than 65% of women over age 65.
About 50% of all women will die from CVD.

By the time a woman seeks medical attention, she is usually sicker than her male counterpart.

In spite of this information  women remain less afraid of CVD than breast or uterine cancer.

Question 45

Important Studies - CV disease

Answer 45

Heart & Estrogen Replacement Study (HERS)
Postmenopausal women with significant CV disease were given estrogen/progestin HRT  found that HRT did not provide a protective effect for older women.

Question 46

Important Studies CV disease

Answer 46

HERSII → part of WHI
Began in fall 1997 → scheduled to be completed in 2005.
Women given estrogen/progestin therapy.
May 2002, study was halted → 26% increase in breast cancer among study group.
Concluded → postmenopausal hormone therapy should not be used for the sole purpose of reducing risk for coronary heart disease in women with CV disease.

Question 47

Menopause

Breast

Answer 47

↓ estrogen - symptoms:
Reduced size.
Softer consistency.
Drooping.

Question 48

Menopause

Endocrine System

Answer 48

Symptoms:
Decreased estrogen.
Decreased progesterone.
Increased FSH & LH.

Question 49

Menopause

GI System

Answer 49

Symptoms:
Decreased BMR.
Easy to gain weight; more difficult to lose it

Question 50

Menopause

Skin & Mucous Membranes

Answer 50

Questionable relationship with estrogen deficiency.
Epidermis thins with age in both sexes.
Estrogen may affect water retention in the skin.

Question 51

Menopause

Sexuality

Answer 51

Decreased estrogen has 2 effects:
Estrogen-sensitive neuroreceptors located throughout the nervous system.
Decreased estrogen affects nerve impulse transmission  slower response to stimuli.

Decreased estrogen influences peripheral blood flow response to sensory stimulations.
Affects the timing & degree of vasocongestive response during sexual activity.

Question 52

Menopause

General Sexual Problems

Answer 52

Delayed or absent vaginal lubrication.
Decreased congestion in the outer third of the vagina.
Fewer & occasionally painful uterine contractions with orgasm.

Question 53

Menopause

Cognitive Functioning

Answer 53

Does estrogen plays a major role in the prevention of Alzheimer’s Disease?
Estrogen receptors located throughout the brain.
Hypothesis  estrogen helps support the growth, survival & repair of nerve cells  protecting them from being injured by toxic substances.
Estrogen favorably alters the limbic system which is involved in long-term memory storage & promotes the transmission of brain signals.
Estrogen may also protect against plaque formation in the CNS.

Question 54

Menopause and Alzheimer’s Disease

Answer 54

Preliminary studies showed estrogen might be helpful in preventing Alzheimer’s Disease  slowing its rate or progression or improving cognitive functioning in women with the disease.

Question 55

Menopause

WHI Memory Study (WHIMS)

Answer 55

Initiated to evaluate the effects of combination HT on cognitive impairment & dementia in postmenopausal women 65 and older.
WHIMS participants received either estrogen alone or estrogen/progestin combination.
Study terminated in 2002 → estrogen-progestin group had twice the incidence of dementia as the placebo group.
Investigators recommended that combination estrogen/progestin therapy not be used to promote cognitive functioning in postmenopausal women.

Question 56

Menopause

Mood

Answer 56

Estrogen does influence human female behavior  enhances mood, psychological function, & specific aspects of cognitive function.
Menopause has been associated with psychological problems, particularly depression.
Studies repute this → depression more likely related to social & personal circumstances.

Question 57

“Menopausal Syndrome”

Answer 57

Symptoms:
Fatigue, headaches, insomnia, depression, irritability, joint & muscle pain, dizziness, palpitations.
Area not well studied due to the “subjectivity” of complaints.
Symptoms
“domino effect” from the other symptoms of menopause?
Not generally felt to be estrogen related.

Question 58

Developmental Tasks of Menopause:

Answer 58

Emancipating adolescent children.
Achieving a peak in one’s career.
Maintaining relationships with aging parents (who may be coming more dependent).
Developing new satisfactions in relationship with spouse.
Developing satisfaction from use of leisure time.
Becoming grandparents.
Preparing for retirement.
Adjusting to physiological aspects of aging.
Husband’s progression through midlife crisis.