SM_211b: Menopause and HRT

Question 1

Menopause is ____

Answer 1

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

Question 2

Menopause at < 40 yo is ___

Answer 2

Menopause at < 40 yo is primary ovarian insufficiency

Question 3

Menopausal transition is ___

Answer 3

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

Question 4

Perimenopause is ____ + ____ + ____

Answer 4

Perimenopause is menopause transition + menopause (moment in time) + first postmenopausal year

Question 5

____ is expected in a post-menopausal female

Answer 5

Elevated serum FSH is expected in a post-menopausal female

Question 6

Women experience a lifelong ___ in ovarian reserve

Answer 6

Women experience a lifelong decrease in ovarian reserve

• Number of eggs decreases over time

Question 7

In menopause, the HPO axis changes in that ____ and ____

Answer 7

In menopause, the HPO axis changes in that inhibin production decreases and estradiol production decreases

Question 8

Describe physiology of the menopause transition

Answer 8

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

Question 9

____ is the key finding in postmenopause

Answer 9

Elevated serum FSH is the key finding in postmenopause

Question 10

Decrease in eggs over lifetime until depletion in postmenopause is reflected by ____

Answer 10

Decrease in eggs over lifetime until depletion in postmenopause is reflected by decreasing anti-mullerian hormone

Question 11

Describe diagnosis of menopause

Answer 11

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

Question 12

____ are a better predictor of postmenopausal stage than serum FSH

Answer 12

Changes in menstrual bleeding patterns are a better predictor of postmenopausal stage than serum FSH

Question 13

Describe vasomotor symptoms of menopause

Answer 13

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

Question 14

____ of women experience hot flashes

Answer 14

60-80% of women experience hot flashes during menopause transition

Question 15

Vasomotor symptoms in menopause occur due to ____

Answer 15

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

Question 16

Describe health problems arising in menopause

Answer 16

Health problems arising in menopause

• Menopausal symptoms: vasomotor symptoms, vulvovaginal atrophy, genitourinary syndrome of menopause
• Depression
• Osteopenia / osteoporosis
• Coronary heart disease

Question 17

Screen for ____ during menopause

Answer 17

Screen for depression during menopause

• 2x increased risk of depression over baseline especially if history of depression
• Risk returns to baseline postmenopause

Question 18

Osteoporosis is ____

Answer 18

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

Question 19

____ is the most prevalent disease to present in the menopause years and is a leading cause of death in women

Answer 19

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

Question 20

Decreased estrogen leads to ____, ____, and ____

Answer 20

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

Question 21

____ initiation of estrogen hormone therapy is associated with less progression of atherosclerosis during perimenopause

Answer 21

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

Question 22

Which patient should receive systemic hormone therapy?

Answer 22

Which patient should receive systemic hormone therapy?

• 55 yo with well-controlled HTN, moderate hot flashes, LMP 3 years ago

Question 23

Describe who should be treated with estrogen hormone therapy

Answer 23

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

Question 24

Describe how to treat menopause symptoms

Answer 24

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

Question 25

If uterus in situ, treat menopause with ____

Answer 25

If uterus in situ, treat menopause with estrogen + progestin

Question 26

If post-hysterectomy, treat menopause with ____

Answer 26

If post-hysterectomy, treat menopause with estrogen alone

Question 27

Describe the types of hormone therapies available for menopause

Answer 27

Hormone therapies available for menopause

• FDA-approved estrogens: oral, transdermal, transvaginal
• FDA-approved progestins: oral, intravaginal, IUD, E + P combos

Question 28

Describe non-estrogen treatment for symptoms of menopause

Answer 28

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

Question 29

____ is the clinically important hormone for treating vasomotor symptoms

Answer 29

Estrogen is the clinically important hormone for treating vasomotor symptoms

• Women with a uterus also need progesterone

Question 30

Post-menopause is characterized by ____

Answer 30

Post-menopause is characterized by vulvovaginal atrophy

Question 31

Genitourinary syndrome of menopause is ____

Answer 31

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

Question 32

Describe treatment of local vulvovaginal symptoms

Answer 32

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)

Question 33

Describe FDA-approved indications for hormone therapy

Answer 33

FDA-approved indications for hormone therapy

• Vasomotor symptoms
• Prevention of bone loss
• Hypoestrogenism: hypogonadism, POI, surgical menopause
• Vulvovaginal atrophy and GSM

Question 34

Treat menopausal clinical depression with ____

Answer 34

Treat menopausal clinical depression with antidepressants

Question 35

Menstrual bone loss can be prevented with ____

Answer 35

Menstrual bone loss can be prevented with hormone therapy

• Bone loss accelerates 2 years before until 3 years after menopause

Question 36

Describe natural history of menopausal symptoms

Answer 36

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

Question 37

What is the most appropriate treatment?

Answer 37

Systemic estrogen alone

Question 38

What is the best option for medical management of her symptoms?

Answer 38

SNRI (venlafaxine)

Question 39

What management option is most appropriate?

Answer 39

Topical estrogen