TEST 5 Flashcards
Define Menopause
the point in time in which there are been cessation of menstruation for at least 12 consecutive months. occurs in response to normal physiologic changes in the hypothalamic-pituitary-ovarian axis. occurs in most women between 48 and 55 . 51 y.o is average age for women in the western world.
Perimenopause : 3 common signs
menstrual bleeding changes, then ceases
vasomotor symptoms: the hot flush
vaginal symptoms: dryness is common Later, changes in architecture d/t lower levels of estrogen
other issues that may arise: sleeping problems, changes in mood or cognition, dyspareunia.
FSH changes
elevated FSH levels are measured to confirmed menopause. When a woman’s FSH blood level is consistently elevated to 30mlU/mL or higher, and she has not had a menstrual period for a year, it is generally accepted that she has reached menopause
Estrogen changes
Estrone (E1) the weakest estrange is the primary estrogen present in postmenstrual women children and men. Estradiol (e2)<–placenta both are small amount
lifestyle management
dietary changes, exercise, vitamins, or supplements, vaginal lubricants and moisturizers, changes in clothing, smoking cessation, stress management techniques, sleep aids, and activities to enhance memory function
dietary changes
aggravates : refined sugar, caffeine, spicy foods, & alcohol
helps: water to augmented insensible loss of fluids through sweating.
exercise
lower activity level= forgetfulness, difficulty sleeping, heart pointing nor racing, stiffness or soreness.
increase activity level = reduced severity of menopausal symptoms such s vasomotor symptoms, depression, and forgetfulness.
also reduce CAD, osteoporosis risks, improves sleep, and assists with maintaining a healthy weight, relieving stress, reducing moodiness, and improving mental function.
vitamin & supplements
Calcium & vitamin D =postmenopausal women to maintain bone strength
vitamin E = small improvement or no change in hot flashes. = reduced risk for developing Alzheimer’s disease
B vitamins- reduce homocysteine level (associated with CAD) ,
increase fluid & veggies
AVOID IRON excess iron have negative effects on cardiovascular system or liver over time.
vaginal lubricants & moisturizers
lubricants (KY, Astroglide, Lubrin, Moist Again) for dryness & sexual activity.
moisturizers: replenish & maintain fluids in vaginal epithelial cell
V. E oil provide relief for dryness w/o interfere w/ condom or diaphragm function & rarely irritates tissues.
***CAUTION: vaseline can injure vaginal tissue and not easily removed.
douching is not effective for moisturizing & will remove normal flora & increase infection risks.
clothing & environment
layered clothes, breathable fabrics such as cotton or linen, or moisture-wicking fabrics =reduce discomfort with hot flash and sweat.
AVOID; turtlenecks, fabrics that do not allow circulation or absorb sweat.
smoking cessation
cause earlier age at menopause, increased rate of bone loss, and increased prevalence of all menopausal symptoms, except vaginal dryness.
stress management
stress increase menopause symptoms.
stress=poor sleep depression or moodiness
manage: exercise, meditation, relaxation techniques deep breathing, yoga, tai chi taking bath, reading having massage, seeking support from friends or activities r/t spirituality or religion.
sleep
sleep disruption r/t hot flashes or other menopausal symptoms.
manage: light blankets, cotton sleepwear, well ventilated room
* *it is also important to educate women that they require less sleep as they age.
mental function
slow decline in mental function is expected with aging.
management: use memory aids noting appointment and date writing list to use for complete tasks work activities or shopping. participating in activity that keep mind engaging
hormonal medications used for contraception in reproductive age women
a. estrogen plus progesterone therapies (combined methods) like combined oral contraceptive pills (COCPs), Nuvaring, Evra patch.
b. progesterone-only therapies like progestogen only pills (POPs), DepoProvera, Implanon, the levonorgestrel-releasing intrauterine system (Mirena)
c. These can be used from menarche through menopause (by appropriate candidates)
hormonal medications used for POSTMENOPAUSAL:
Estrogen only therapies
Estrogen-only therapies for women WITHOUT UTERUS; these regimens are sometimes called unopposed estrogen which would increase the risk of endometrial cancer if post menopausal woman with a uterus used them.
hormonal medications for POSTMENOPAUSAL : estrogen plus progesteron therapy
for women WITH UTERUS; the progesterone is really only for the purpose of endometrial protection
what is the different between contraceptive & hormonal therapy (HT) if they both composed of estrogen and progesterone ?
contraceptives higher dosage than HT (contraceptive does are high to suppress woman’s ovaries almost completely that’s why they work to stop ovulation & prevent pregnancy.
HT doses are little enough to control symptoms like hot flashes or vaginal dryness.
smokers shouldn’t take estrogen -containing contraceptive between 35 or 40 y.o. and menopause but that same woman would be permitted to use hormone therapy after menopause, even if she cont. smoking
HT systemic dosing (oral, transdermal, and ONE PARTICULAR vaginal therapy called FEMRING) is larger than local treatments like vaginal creams or the vaginal ring that contain estrogen called ESTRING
What do perimenopausal women use ?
–>symptomatic time lead up to menopause (which is the final menstrual period/FMP) and for about a year after then FMP
until a women is absolutely menopausal (it’s been one year since her FMP) its still possible for her to get pregnant so she would need CONTRACEPTIVE THERAPY rather than HT
contraceptive therapies are often used during the perimenopause not only to provide contraception to women who still might get pregnant, but also for symptom-relief for issues like hot flashes and irregular bleeding patterns.
Remember that these women are generally between 45 and 55 y.o. and while many women in this age range are healthy and do not smoke and so are candidates for estrogen-containing contraceptive medication; you need to adhere to careful prescribing practices.
Get into the habit of checking Medical Eligibility Criteria for each method along with woman’s age and any other pertinent aspects of her history.
testosterone
circulating levels of testosterone remain relatively CONSTANT in women who are either perimenopausal or postmenopausal, partly d/t the presence of high FSH & LH levels, which stimulate the ovarian stromal tissues to increase their testosterone production
pharmacologic options to management of menopausal symptoms
oral estrogen, transdermal and topical estrogens, oral progestogens, oral combination estrogen-progestogen products, transdermal combination estrogen-progestogen products, antidepressant, anticonvulsants, antihypertensives, estrogen vaginal creams, tablets, and ring. Progestogen gels and IUD (levonorgestrel)
complementary & alternative therapies
Black Cohosh - vasomotor symptoms
chastetree berry- menstrual irregularity
dong quai- gynecologic conditions
evening primrose oil- hot flashes, mastalgia
Ginkgo- memory change
Ginseng- general tonic improved mood, fatigue
Kava- irritability and insomnia
Licorice root- menopause-related symptoms
passion flower- sedative
St. Johns Wort- vasomotor symptoms, irritability, and depression
Valerian root- sedative antianxiety
Wild Yam- Menopausal symptoms
Hormone therapy
encompassing term for ET/EPT
Estrogen-Progesterone Therapy (EPT)
used for women who HAVE NOT HAD HYSTERECTOMY. Progestogen is added for endometrial protection. It is common to have break through bleeding when using a combination of estrogen and progestogen unless used as a continuous regimen on a daily basis.
Estrogen Therapy (ET)
exclusively for client have HAD HYSTERECTOMY, due to the increased risk of endometrial hyperplasia and cancer. Estrogen therapy can be prescribed systemically as an oral tablet or as a transdermal patch. Additionally, ET is available as a local preparation as cream, tablet or rings.
Vaginal atrophy treatment
vaginal estrogens ( ring or creams) which treat only vaginal atrophy. These are NOT systemic or systemic absorption is very small, so even women with an endometrium can use those w/o adding a progestogen for treating symptoms of vaginal atrophy NOT vasomotor symptoms.
systemic estrogen
pills patches creams sprays and one type of vaginal ring, will treat both vasomotor symptoms AND vaginal atrophy, but must be given with a progestogen if she has a uterus.
Combined hormonal contraception
in addition to providing contraception in the perimenopausal years, can help with both vaginal atrophy and vasomotor symptoms, but the doses are larger than the doses for menopausal symptoms alone. But you cannot give combined hormonal contraception (OCPs, contraceptive ring, or contraceptive patch) to smoker over age 35.
absolute contraindication to estrogen
known or suspected cancer of the breast
known or suspected estrogen-dependent neoplasia
hx. uterine or ovarian cancer
hx of coronary artery disease or stroke
hx of biliary tract disorder
undiagnosed, abnormal genital bleeding
hx. of or active thrombophlebitis or thromboembolic disorders
absolute contraindications to progestogen use
active thrombophlebitis or thromboembolic disorders liver dysfunction or disease known or suspected cancer of the breast undiagnosed abnormal vaginal bleeding pregnancy
potential ASE to HT
fluid retention bloating breast tenderness headache mood changes nausea
management of fluid retention
decrease salt intake, maintain adequate water intake; exercise, recommend an herbal diuretic or mild prescription diuretic
management of bloating
change to low dose transdermal estrogen; lower the progesterone dose to level that still protects the uterus, change the progestogen to try micronized progesterone
management of breast tenderness
lower estrogen dose; change the estrogen; decrease salt intake, change the progesterone decrease caffeine and chocolate consumption
management of headaches
change to transdermal estrogen; lower estrogen and/or progesterone dose; change to CC-EPT regimen; ensure adequate water intake, decrease salt, caffeine, and alcohol use.
management of mood changes
lower the progestogen dose; change to CC-EPT regimen; ensure adequate water intake, restrict salt, caffeine, and alcohol consumption
nausea management
take hormones with meals, change the estrogen; change to transdermal estrogen; lower the estrogen or progestogen dose
Osteoporosis
est. 10mil people in U.S
add. 34 mil people have low bone mass that puts them at risk for osteoporosis
20% are men and disease is found in women and men of all age (not just older woman’s disease)
detection & treatment is necessary to prevent fx which are associated with significant morbidity and mortality. it is also imperative that clinicians promote strategies for bone health and osteoporosis prevention to patients throughout the lifespan.
osteoporosis prevention
Adequate intake of Ca+: 1000, 1200 (>50), 1500 (>65)
adequate intake of vitamin D (400-800 iU/day)
weight bearing and resistance exercise
fall prevention
avoid tobacco
moderating alcohol intake
risk factor of osteoporosis (modifiable)
body weight <22-24
Amenorrhea (d/t eating disorder or excessive exercise)
Nulliparity
Low estrogen level (menopause)
lifestyle factors (smoking, excessive alcohol or caffeine intake, sedentary activity level, or inadequate calcium of vit. D intake)
Medications (thyroid hormone, corticosteroids, anticonvulsants, aluminum containing antacids, lithium, methotrexate, gonadotropin releasing hormone, cholesteramine, heparine, warfarin
chronic disease (endocrine disorders, GI disorders, connective tissue diseases, bone disorders, chronic liver disease, cystic fibrosis, sz disorders, hematologic malignancies, prolonged immobility, eating disorders, chronic renal failure, or frailty)
risk factors (non-modificable)
advanced age female gender race (caucasian & asian women at great risk followed by Hispanic and AA women) Personal hx of fx during adulthood family hx of osteoporosis first degree relative w/ hx of fx
history assessment of osteoporosis
do you have regular periods? when was your last period?
Do you know anyone in your family that has/had osteoporosis?
have any of your family members ever had non-traumatic fracture?
do you or have you ever taken glucocortidoids? if so for how long?
have you ever had a fractured or broken bone? if so what where?
do you smoke
do you drink alcohol? if so how many drinks per day?
Do you eat foods rich in calcium and vitamin D? do you take any calcium or vitamin D supplements?
How active are you on your daily bases? Do you work our regularly?
have you ever been dx with rheumatoid arthritis
Do you take any anticonvulsants or methotrexate?
menopause dx
retrospective dx because it is based on the clinical absence of menses for 12 consecutive months.
perimenopause dx
most accurately identified based on variety of factors, including age and symptoms such as hot flashes, irregular menses, and vaginal dryness
pharmacologic management of menopausal symptoms
estrogen : oral, transdermal, and topical preparation progestogen combination estrogen-progestogen products: orals transdermal antidepressant anticonvulsants antidepressant vaginal hormone creams vaginal tablets ring progestogen gel intrauterine device
estrogen products & ASE
oral : cenestin, enjuvia, estrace, femtrace, menest, ortho-Est, premarin
transdermal/topical prep: fempatch, menostar, estraderm, estrogel, elestrin, evamist
ASE: uterine bleeding, breast tenderness, nausea, abdominal bloating, fluid retention in extremities, headache, dizziness, hair loss
progestogen products & ASE
oral: Provera, Prometrium, micronot, Aygestin, megace
ASE: mood changes, possible increase uterine bleeding than if taking ET alone.
combined estrogen-progestogen products & ASE
transdermal: climara combiPatch.
ASE- CS-EPT withdrawal bleeding monthly
CC-EPT breakthrough bleeding is usually more problematic with this regimen.
Venlafaxine (Effexor)
antidepressant (tx vasomotor symptoms)
ASE: N/V, mouth dryness, decreased appetite
fluoxetine (Prozac)
antidepressant (tx vasomotor symptoms)
ASE: asthenia, sweating, nausea, somnolence, anorgasmia, decrease libido
Paroxetine (Paxil)
asthenia, sweating, nausea, somnolence, anorgasmia, decrease libido, weight gain, blurred vision
Gabapentin (Neurontin)
anticonvulsants (tx vasomotor symptoms)
ASE : somnolence, dizziness, ataxia, fatigue, weight gain
**avoid antacids w/in 2 hours of use; taper when discontinuing
clonidine (catapres)
antihypertensives less effective than antidepressant (tx menopause vasomotor symptoms)
ASE: dry mouth, drowsiness, dizziness, weakness, constipation, rash, myalgia, urticaria, insomnia, nausea, agitation, orthostatic, hypotension, impotence, arrhythmias
non-pharmacological for menopause symptoms
natural bioidentical hormones herbals isoflavones progesterone cream acupuncture
bioidentical hormones
Bi-est & Tri-est (contain 80% estriol) require progesterone for endometrial protection
herbals
they are identified as diet supplement not regulated by FDA. they are widely used for menopausal symptom relief.
isoflavones
plants that have both estrogenic and nonestrogenic properties. they have ability to bind weakly with estrogen receptors, especially the beta receptors, and have been extensively studied for reducing hot flashes.
present in food: soys and red clover
evidence based finding: no different in hot flashes reduction but soy is healthy for reducing risk of heart diseases. & interfere with bleeding profiles/interactions with warfarin.
acupuncture
contradictory results
may reduce severity but not frequency of hot flashes.
how is osteoporosis diagnosed
done with bone mineral density (BMD) measurement by dual energy x-ray absorptiometry (DEXA or DXA) - a technique that is used to evaluate central BMD at the spine and hip. BMD are reported as T. Scores and Z scores
medication for prevention and treatment of osteoporosis.
preventions: exercise site specific & news to be continued to maintain bone strength
Bisphosphonates, selective estrogen receptor modulator (SERM) & raloxifene, Teriparatide (PTH)
estrogens, calcitonin
Biphosphonates
1st line tx postmenopausal women with osteoporosis
selective estrogen receptor modulator (SERM) & raloxifene
is most often considered for postmenopausal women with low bone mass or younger postmenopausal women with osteoporosis. prevents bone loss and reduces the risks of vertebral fractures.
Teriparatide (PTH)
is best offered to postmenopausal women with osteoporosis who are at high risk fx. daily SQ injection have shown to stimulate bone formation hand improve bone density. Indicated for no more than 24 months.
estrogen for osteoporosis
treat mod to sever menopause symptoms (vasomotor symptoms) promote bone effects and can be used a few years of early post menopause
calcitonin
no first line drug for post-menopausal osteoporosis tx as its fracture efficacy is not strong and its BMD effects are less than those of other agents. It is an option for women with osteoporosis who are more than 5 years beyond menopause
when medication is indicated/recommend to tx osteoporosis
women with T scores of -2.5 or lower & those with hip or vertebral fx
for women with T scores in osteopenic range (-1.0 to -2.5 ) medication is recommended if they also have fractures of are at high risk for fracture (immobilized, taking glucocorticoids)
who does NAMS recommend drug therapy for tx of osteoporosis
postmenopausal women with a hx of osteoporotic vertebral or hip fx.
postmenopausal women who have T score of -2.5 or worse at either the lumber spine, femoral neck, or total hip region
postmenopausal women with T score from -1.0 to -2.5 AND a 10 year risk of a major osteoporotic fx (spine, hip, shoulder, or wrist) of 20% or 3% risk of having a hip fx. provides should utilize the FRAX calculator for percentages.
HT vaginal products that are systemic dose vs local dose
systemic dose decreases hot flashes will need progestogen
local only dose does not need progestogen won’t help hot flashes.
T scores
identifies the number of standard deviation the pt’s BMD is above or below that for a young adult and a gender-matched norm
- -> osteopenia is present when T score is -1.0 to -2.5
- ->osteoporosis is present when T score is -2.5 or less.
- *severe or established osteoporosis is present when T score is -2.5 or less and fragility fx present
z scores
provides a comparison in BMD for the pt. to an age matched mean and is used for dx. only in children
1000mg/day of calcium recommended for
premensopausal women and postmenopausal women on HT
1200mg/day of calcium recommended for
perimenopausal women and premenopausal women older than 50 y.o
Teriparatide (Forteo)
Parathyroid — for severe osteoporosis sq increase bone absorption
1500mg/day of calcium recommended for
1500mg/day for postmenopausal women not taking HT and women older than 65 years old
Denosumad
Bone metasize remodeling osteoblasts osteoclasts
ASE infection
