Repro pathophys: Aging, Menopause Flashcards
physiology menopause
- follicular decline
- d/t ovulation and *apoptosis of non ovulated follicles, ovarian reserve undetectable by ~50 y/o
- apoptosis of oocytes accelerates ~35 y/o (~25000 starting point at this age) - AMH decline
- AMH is produced by granulosa cells; no follicle = no granulosa cells = no AMH
- undetectably ~5 yr before menopause
- – irregular cycles begin around this time
- AMH levels predictive of ovarian reserve - estradiol (E2) decline
- E2 is produced by dominant follicle; no ovulation/dominant follicle = no estrogen from ovary
- still have estrogen formed at peripheral fat (and other sites) from androgen conversion
- – aromatase inhibitors used in breast cancer treatment inhibit this process = even lower estrogen - FSH increases
- d/t ovarian failure
dx menopause
clinical: cessation of menses for 12 mo at appropriate age (~48-51) or with no other identifiable cause
surgical: d/t bilateral oophorectomy
stages of menopause
- early perimenopause
- middle perimenopause
early perimenopause
- 2-8 yr pre-end of menses
- shorter follicular phase
- higher FSH
sx:
- short-to-normal cycle lengths
- hot flashes
- interrupted sleep
- breast tenderness
- may be asymptomatic (aside from cycle changes)
middle perimenopause
- variable pre-menopause
- unpredictable cycle pattern
- some ovulatory, some anovulatory cycles
- during anovulatory, estrogen rises and falls w/o progesterone
- FSH even higher
sx:: irregular periods - short cycles w/ mixed amenorrhea vasomotor: - hot flashes - interrupted sleep - breast tenderness - dysphoric mood - depression - mild memory problems GU atrophy -- worsens over time - dyspareunia (pain during sex) - atrophic vaginitis - dysuria - urinary urgency/incontinence - may be asymptomatic (aside from cycle changes)
late perimenopause
- first year post-menopause (FMP)
- FSH high
- same sx as middle perimenopause
post menopause
- 1+ yr post-FMP
- sx improve
indications for hormone tx menopause
- osteoporosis/frax risk
- symptomatic menopause
otherwise not indicated
- strokes, blood clots, breast cancer increase (cancels out any benefit related to heart disease or osteoporosis, except when high risk)
- does not improve well-being unless sx
epidemiology menopause sx
more likely, longer in
- smokers
- black
- latina
- high BMI
hot flashes/vasomotor sx mx
- abrupt drop in sex steroids e.g. menopause, GnRH AG/aNTagonists
- pituitary insufficiency e.g. hypophysectomy, primary insufficiency
- can also occur in men experiencing drop in sex steroids e.g. prostate cancer tx
mx:
- estrogen causes inhibition of thermoregulatory center of hypothalamus
- estrogen removal increases serotonin, 5-HT sensitivity in hypothalamus
- others
vasomotor menopause sx primary tx
tx:
- hormone therapy ~80-90%
- oral, transdermal, vaginal
- estrogen + progestin
- progestin essential to prevent uterine cancer if uterus is present (frequency of hyperplasia ~35% otherwise)
- note that there is an increase in breast cancer in estrogen + progestin vs estrogen only, but this is outweighed by risk of uterine cancer in general (obvious exceptions)
- lowest dose for shortest period of time possible
c/i:
- hx breast cancer
- CHD
- VTE/stroke/TIA
- liver disease
- unexplained vaginal bleeding
- endometrial cancer
vasomotor menopause sx alternate tx
- gaba
- SSRIs
- SNRIs
- clonidine
- general healthy lifestyle choices (reduced smoking, drinking, diet, exercise)
complementary: similar to placebo, which is 25-50% reduction
- dong quai
- red clover
- black cohosh
- yam progesterone
- ginseng
- acu
surgical menopause sx tx in transmen
research limited, case studies show incorporation of transdermal estrogen in addition to testosterone did not affect masculinization
as w/ physiologic menopause, may be asymptomatic
vulvar/vaginal atrophy sx, mx
sx:
- burning
- dyspareunia (pain during sex)
- UTI
- itching
*chronic, requires lifelong tx
mx:
- reduced estradiol –> reduction in superficial cells
- increase in parabasal cells
- increased vaginal pH (acid –> base)
vulvar/vaginal atrophy tx
- local estrogen
- note recent RTC show that systemic estrogen not helpful
“non-genital” h&p sexual dysfunction in F
- pt description of problem, OLDCAARTS
- systemic disease ROS
- disabilities
- body image
- stress, fatigue, mood
- intimacy, partner effects
- sexual stimulation
- how partner(s) is/are reacting
- others vs self-stim
- penetration vs toys vs oral, manual
- hx abuse
“genital” h&p sexual dysfunction in F
- gyn sx
- dryness, discharge
- bleeding
- pain
- itching, burning
- STI risk
pelvic exam
- external
- introitus
- internal
- bimanual
sexual dysfunction tx in F
- treat identifiable disorders
- psychological (if applicable, for causes or effects)
- drugs overall unhelpful unless identifiable cause incl gyn condition, systemic, drug side fx
- d/c offending drugs if possible
NOT helpful:
- sildenafil, except +SSRI
- systemic estrogen
- yohimbine
- DHEA
minimal benefit:
- testosterone
- flibanserin
- bremelanotide
- bupropion
nerves involved in sexual response F
autonomic
- *parasympathetic, pelvic splanchnic
- – inferior hypogastric S2,3,4
- some symp, sacral splanchnic
- – lower T and upper L
motor/sensory
- pudendal nerve S2,3,4
drugs associated with reduced libido
SSRIs nicotine chronic alcohol opioids OCPs (mixed data) benzos antipsychotics
health conditions associated with reduced libido
HTN, possibly tx related MS PD pain CKD hypER-T4 hypER-prolactin DM (mixed data) cancer, post-cancer depression anxiety (may also favor increased libido)
RTC show testosterone levels not related but exogenous may increase desire slightly
dysparuneia ddx
superficial:
- vestibulodynia
- vulvodynia
- chronic vulvar dermatoses
- condylomas
- derm
deep:
- endometriosis
- pelvic congestion syx
- interstitial cystitis
- uterine retroversion
- uterine leiomyomas
- adenomyosis
- PID
- pelvic adhesions
- ovarian remnant syx
- IBS
- hx sexual abuse
most significant predictor of sexual activity in older women
available partner
bartholins gland enlargement
ddx abcess vs cyst
rarely: benign or malignant tumor (carcinoma)
- dilation d/t duct obstruction ± infection
- abscess more common than cyst
- common in young pre-menopause and peaks around menopause
- nk risk fx
bartholins gland cyst
clinical:
- unilateral enlargement visible and palpable at 4 or 8 o’clock of vestibule
- 1-3 cm average
- usually painless
tx:
- watch and wait, small asymptomatic
- warm compress
- analgesis
- if larger/symptomatic, I&D or word catheter
- if persistent:
- marsupialization
- excision of entire cyst
- consider biopsy, malignancy (esp in older ppl)
barholins gland abscess
clinical: - soft, painful mass - difficulty walking or sitting - 3-6 cm average fluctuant, warm ± erythema
path:
- usually E. coli
- MRSA, strep also possible
tx:
- I&D
- culture
- word catheter
- abx
- pain
vulvovaginal candidiasis
sx:
- itching
- thick, white, cheesy discharge
exam:
- labial erythema
- edema
- white discharge
- normal ~4.5 pH
- hyphae on wet mount
path:
- usually Candida albicans
tx:
- azoles
- oral: fluconazole 150mg x1
- vaginal: clotri-, mico-, terconazole
don’t fall into trap of presumptive dx
vulvar lichen sclerosus
- derm
- benign but can lead to vulvar neoplasm
sx:
- vulvar itching, pain
- intense, disrupts sleep
- dyspareunia
- ± perianal involvement
exam:
- white, thinned, crinkled epithelium
- labia majora and minora involvement
- ± perianal involvement - hourglass configuration
- loss of skin architecture over time
- ± thickening over time
- majora/minora fusion
- narrowing of introitus
dx:
- vulvar punch biopsy
- exam
mx:
- epithelia thinning ± thickening
- inflammation
- associated w/ low estrogen
- genetics, autoimmunity, local factors, hormonal factors …
epi:
- peaks pre-pubertal and peri/post menopausal
- rising incidence
tx:
- topical steroids BID x 1 month –> 2ce weekly maintenance tx
- minimize irritants
- break itch/scratch cycle
- petrolatum
- yearly f/u one controlled
- watch for malignancy
- hormonal therapy NOT helpful
vulvar contact dermatitis
- irritant or allergic
- allergic more severe, vesicular
sx:
- burning
- stinging
- swelling
- pain
- pruritus
exam:
- erythema
- edema
- thickening
- hypOpigmentation
common irritants:
- scented soaps and detergents
- iodine
- pads
- wipes
- bodily secretions
- spermicides
- deodorants, perfumes
tx:
- remove irritant
- break itch/scratch cycle
- short course topical steroids
- topical petrolatum
- soon soaks
- cold packs
- avoid tight clothing and friction
breaking itch/scratch cycle:
- education
- cutting fingernails
- wearing soft gloves, underwear at night to avoid inadvertent scratching
- topical petrolatum
- pressure vs scratching when itchy
vulvar itching ddx
most common:
- candidiasis
- contact dermatitis
can’t miss:
- lichen sclerosus, risk of carcinoma if untreated
- squamous cell carcinoma
- melanoma
- vulvar biopsy indicated if pigmented lesions, masses, raised, ulcerated, eroded, recurrent
also:
- psoriasis
- atopic dermatitis
- hidrandenitis supperativa
- infection
- lichen simplex chronicus
- lichen planus
tunica albuginea
surrounds corpora cavernosa
provides rigidity for erection
penile fracture
disruption of tunica albuginea
artery of tumescence
cavernous artery
main arterial source to penis
internal pudendal artery
subtunical venous plexus
between tunica albuginea and sinusoids
collapsed during erection to maintain rigidity
nerves of erection
cavernous nerves
S2,3,4 (keep your penis off the floor…) parasympathetics (erection)
T11,12, L1,2 sympathetics (emission)
S2,3,4 sensory/motor (ejaculation)
