SM_211b: Menopause and HRT Flashcards
Menopause is ____
Menopause is the final menstrual period in a women resulting from ovarian ageing / loss of ovarian follicles
- Officially diagnosed after 12 months of amenorrhea
- Average age is 52
Menopause at < 40 yo is ___
Menopause at < 40 yo is primary ovarian insufficiency
Menopausal transition is ___
Menopausal transition is the time of waning ovarian function leading up to the final menstrual period
- Signs: menstrual cycle change, vasomotor symptoms, sleep disturbance, mood changes, vaginal dryness / dyspareunia
- Average age: 47.5
- Time period averages 4 years
Perimenopause is ____ + ____ + ____
Perimenopause is menopause transition + menopause (moment in time) + first postmenopausal year
____ is expected in a post-menopausal female
Elevated serum FSH is expected in a post-menopausal female
Women experience a lifelong ___ in ovarian reserve
Women experience a lifelong decrease in ovarian reserve
- Number of eggs decreases over time
In menopause, the HPO axis changes in that ____ and ____
In menopause, the HPO axis changes in that inhibin production decreases and estradiol production decreases
Describe physiology of the menopause transition
Physiology of the menopause transition
- Follicle depletion
- Decreased inhibin B
- Increase in FSH but with fluctations
- Initial increase in Estradiol
- Decrease in anti-mullerian hormone
- Unremitting follicle depletion with E2 decline
- Permanent amenorrhea
____ is the key finding in postmenopause
Elevated serum FSH is the key finding in postmenopause
Decrease in eggs over lifetime until depletion in postmenopause is reflected by ____
Decrease in eggs over lifetime until depletion in postmenopause is reflected by decreasing anti-mullerian hormone
Describe diagnosis of menopause
Menopause diagnosis
- Age 40-45 with irregular menstrual cycles: exclude pregnancy (hCG), hyperprolactinemia and thyroid dysfunction
- FSH level is too variable to rely on during the transition
- Not clinically necessary but unclear if can measure the blood levels of these hormones: FSH > 25, E2: low, AMH: low
____ are a better predictor of postmenopausal stage than serum FSH
Changes in menstrual bleeding patterns are a better predictor of postmenopausal stage than serum FSH
Describe vasomotor symptoms of menopause
Vasomotor symptoms of menopause
- Recurrent transient episodes of flushing
- Sensation of heat that begins in upper body, face / neck, and spreads throughout
- Increased HR, palpitations, and / or anxiety
- Sweating, often followed by chills
- 60-80% of women
____ of women experience hot flashes
60-80% of women experience hot flashes during menopause transition
Vasomotor symptoms in menopause occur due to ____
Vasomotor symptoms in menopause occur due to a narrowed thermoneutral zone in the hypothalamus
- Genetic polymorphisms of estrogen metabolism and receptors
- Reduced reproductive hormones play an integral role and the thermoregulatory process
- Inherent thermoregulatory process within the individual
Describe health problems arising in menopause
Health problems arising in menopause
- Menopausal symptoms: vasomotor symptoms, vulvovaginal atrophy, genitourinary syndrome of menopause
- Depression
- Osteopenia / osteoporosis
- Coronary heart disease
Screen for ____ during menopause
Screen for depression during menopause
- 2x increased risk of depression over baseline especially if history of depression
- Risk returns to baseline postmenopause
Osteoporosis is ____
Osteoporosis is low bone mass and architectural deterioration of bone tissue leading to enhanced bone fragility and increase in fracture risk
- Can treat with estrogen replacement
- High mortality with hip fracture
- DEXA T score ≤ 2.5 is osteoporosis
____ is the most prevalent disease to present in the menopause years and is a leading cause of death in women
Coronary heart disease is the most prevalent disease to present in the menopause years and is a leading cause of death in women
- Declining estrogen levels after menopause are associated with a sharp increase in CHD risk
Decreased estrogen leads to ____, ____, and ____
Decreased estrogen leads to increased total cholesterol / LDL / triglycerides, vasoconstriction, and insulin resistance
- Women with premature menopause have earlier onset CHD
- Surgical menopause without estrogen treatment leads to higher CHD mortality than hormone users
____ initiation of estrogen hormone therapy is associated with less progression of atherosclerosis during perimenopause
Early initiation of estrogen hormone therapy is associated with less progression of atherosclerosis during perimenopause
- However current guidelines say estrogen hormone therapy should not be used for CHD prevention
Which patient should receive systemic hormone therapy?
Which patient should receive systemic hormone therapy?
- 55 yo with well-controlled HTN, moderate hot flashes, LMP 3 years ago
Describe who should be treated with estrogen hormone therapy
Who should be treated with estrogen hormone therapy
- Women without contraindications: breast cancer, CHD, previous VTE, active liver disease, unexplained vaginal bleeding
- Women with moderate to severe vasomotor symptoms affecting quality of life
- Initiate therapy in perimenopausal women if: < 10 years from final menstrual period and/or < 60 years of age
Describe how to treat menopause symptoms
Treating menopause symptoms
- Conservative measures: lowering room temperature, using fans, dressing in layers, avoiding triggers
- Systemic estrogen: most successful therapy (widens thermoneutral zone), use lowest dose for symptom relief if menopausal, and use for shortest duration
- Menstruating women need pregnancy protection: higher dose such as birth control pills
If uterus in situ, treat menopause with ____
If uterus in situ, treat menopause with estrogen + progestin
If post-hysterectomy, treat menopause with ____
If post-hysterectomy, treat menopause with estrogen alone
Describe the types of hormone therapies available for menopause
Hormone therapies available for menopause
- FDA-approved estrogens: oral, transdermal, transvaginal
- FDA-approved progestins: oral, intravaginal, IUD, E + P combos
Describe non-estrogen treatment for symptoms of menopause
Non-estrogen treatment for symptoms of menopause
- SSRIs: paroxetine, escitalopram (avoid in breast cancer patients on tamoxifen)
- SNRIs: venlafaxin, gabapentin, clonidine, complementary meds generally equal to placebo
____ is the clinically important hormone for treating vasomotor symptoms
Estrogen is the clinically important hormone for treating vasomotor symptoms
- Women with a uterus also need progesterone
Post-menopause is characterized by ____
Post-menopause is characterized by vulvovaginal atrophy
Genitourinary syndrome of menopause is ____
Genitourinary syndrome of menopause is genital, sexual, and urinary symptoms related to estrogen decline
- Genital dryness, burning, irritation
- Discomfort or pain with intercourse
- Urgent need to urinate, dysuria, or recurrent UTIs
Describe treatment of local vulvovaginal symptoms
Treatment of local vulvovaginal symptoms
- Non-estrogen treatments: regular sexual activity, lubricants, moisturizers, dilators
- Topical estrogen: premarin or estrace (cream), vagifem (vaginal tablet), estring (ring)
- Ospemifene (SERM)
Describe FDA-approved indications for hormone therapy
FDA-approved indications for hormone therapy
- Vasomotor symptoms
- Prevention of bone loss
- Hypoestrogenism: hypogonadism, POI, surgical menopause
- Vulvovaginal atrophy and GSM
Treat menopausal clinical depression with ____
Treat menopausal clinical depression with antidepressants
Menstrual bone loss can be prevented with ____
Menstrual bone loss can be prevented with hormone therapy
- Bone loss accelerates 2 years before until 3 years after menopause
Describe natural history of menopausal symptoms
Natural history of menopausal symptoms
- Systemic vasomotor symptoms resolve over time in most women (mean duration of 10 years)
- Local vulvovaginal symptoms do not resolve without treatment and may be progressive
What is the most appropriate treatment?
Systemic estrogen alone
What is the best option for medical management of her symptoms?
SNRI (venlafaxine)
What management option is most appropriate?
Topical estrogen
