Week 6- Menopause Flashcards
This is defined as the point in time which there has been a cessation of menstruation for at least 12 consecutive months.
Natural menopause
This occurs following either surgical excision of both ovaries (bilateral oophorectomy) or ovarian function ablation caused by medication, chemo, or radiation.
Induced menopause
Which type of menopause has more severe hot flashes?
Induced
What is premature menopause?
Menopause that occurs before the age of 40.
Normal age range of natural menopause?
40-58 with the average at 52
What are the factors that influence natural menopause?
Lower socioeconomic status Lower body weight Nulliparity Smoking Hx of not using oral contraceptives Cycle lengths of less than 21 days
During menopause the ovaries become resistant to what?
FSH
During menopause the ovaries become more resistant to FSH which causes them to produce less?
Estrogen and androgen
What happens to levels of FSH and LH during menopause?
Increase
What happens to testosterone levels during menopause?
Remain about the same as pre-menopausal levels
What happens to estradiol levels after menopause?
They are lower than in reproductive years
Higher weight/ higher amounts of adipose tissue after menopause =
Higher levels of estrogen
How do you diagnose menopause?
No clinical test to predict or confirm
12 months amenorrhea with other causes ruled out.
What does Asherman’a syndrome cause?
Scar tissue causing amenorrhea
Treatments for vagina dryness during menopause include:
Non-hormonal lubricants
Moisturizers
Mood management during menopause:
Non-hormonal prescription- SSRI/SNRIs
Treatment of sleep disorders during menopause include:
Gabapentin for sleep
Catapres/clonidine
Non-pharm options
If patient had hysterectomy, HT for menopause would include:
Estrogen
If patient has intact uterus need both estrogen and progesterone
Contraindications for estrogen/HT?
- Vagina bleeding (investigate)
- Hx of breast cancer or some form of estrogen dependent cancer
- DVT hx
- MI hx
- CVA hx
- Liver disease
- Pregnancy
How long is it possible to get pregnant after onset of menopausal amenorrhea?
12 months
Women’s health initiative study found:
Estrogen/progesterone therapy was found to be more harmful then beneficial overall
- elevated risk of breast cancer
- elevated risk of CV issues
This is characterized by low bone mass, deterioration of bone tissue, and disruption of bone architecture resulting in reduced bone strength that increases the risk for fracture.
Osteoporosis
What are the 3 types of osteoporosis?
- Primary- associated with aging (estrogen depletion)
- Secondary- response to medication or other disease processes
- Idiopathic- in young adults with no other identified cause
This identifies the number of standard deviations that the patient’s bone mineral density is greater than or less than for a young-adult, gender-matched norm.
T score
This is compared to the bone mineral density of an age, sex, and ethnicity-matched reference population (don’t usually go by this score unless they are young patients).
Z score
Who is screened for osteoporosis?
All women over 65
All women under 65 with risk equivalent to that of a 65-year-old
What is the cornerstone therapy of osteoporosis?
Prevention- exercise and diet
When do you start medication for osteoporosis?
For women with T score of -2.5 sd or less and those with vertebral or hip fractures.
Women with FRAX of 10-year probability of hip fractures greater than 3%, or 20% or greater risk of major osteoporotic fracture.
What is the FRAX tool?
A tool used to assess the patient’s 10 year probability of hip fracture and major osteoporotic fracture (it is an algorithm)
What is the first line medication for osteoporosis?
Biphosphonates- however patients don’t adhere to these
These are nodular masses that are associated with hormonal stimulation (fluctuate with menstrual cycle).
Fibrocystic changes of the breast
Are fibrocystic changes of the breast typically unilateral or bilateral?
Bilateral (bilateral generally means it is normal)
These are fluid filled cysts that are well-delineated, derived from obstructive breast lobules, and are influenced by hormones during menstrual cycle.
Breast cysts
How do you manage simple cysts?
Monitor
How do you manage complex cysts?
Biopsy and rule out malignant diagnoses
These are discrete, smooth, round or oval, nontender and mobile masses. They are usually found in adolescents, unilateral, and commonly resolve spontaneously.
Fibroadenoma
How do you manage fibroadenomas?
Diagnose with ultrasound if needed.
Biopsy if needed.
Then excision if necessary (inconclusive biopsy; becomes enlarged/distorts the breast; age greater than 35; size greater than 2.5 cm)
Unilateral or bilateral masses in breasts should be considered cancer and ruled out?
Unilateral can be indicative of pathology
What makes a mass bad?
If it is red, hardened, or inflamed
This is cyclic breast pain during the luteal phase.
Mastalgia
How do you manage mastalgia?
Well-fitting/supportive bras
NSAIDS
Primrose oil and flaxseed
Adjusting (lowering) estrogen or hormone exposure in contraception
This is milky, clear, or green nipple discharge.
Galactorrhea
Galactorrhea is associated with pregnancy and can persist for months, however, it is also concerning for:
Pituitary adenoma
Renal failure/insufficiency
Thyroid disorder
How do you manage galactorrhea?
Check prolactin level Thyroid hormone levels Creatinine level MRI of pituitary Possibly refer to endo
How do you manage mastitis in non-lactating women?
Antibiotic therapy
Evaluate abscess with ultrasound
Biopsy- if fails to resolve
What are modifiable risk factors for breast cancer?
Exercise Smoke cessation Diet Limiting alcohol Weight management
With this type of biopsy you cannot distinguish between invasive/non-invasive cancer.
Fine needle biopsy
With this type of biopsy you can distinguish between invasive/non-invasive cancer.
Core needle biopsy
According to NAMS, HT should be individualized taking what 3 things into account?
- Her quality of life priorities
- Woman’s health
- Personal risk factors
If you start HT in a woman 50-59 or within 10 years of menopause to treat menopausal symptoms, will it increase risk of CAD?
No
Estrogen/progesterone therapy should be limited to how long and why?
3-5 years
Risk of breast cancer
What is recommended when only vaginal symptoms are present?
Low dose local estrogen therapy
Can you use HT to prevent cognitive changes, Alzheimer’s,
Or CAD?
No
Symptoms of menopause can mask other disorders such as:
Thyroid disorders DM Depression Pregnancy Tumors
When are hot flashes most common and even do they start to subside?
First 2 years and can start to subside in 5 years
What causes a hot flash?
Normal fluctuation of hormones caused by a decrease in estrogen and a surge of LH. Leads to peripheral vascular dilation.
What other symptoms can a women have with hot flashes other than intense heat?
Anxiety
Palpitations
Flushing
What women are more prone to having hot flashes?
African Americans Surgically induced menopause-BSO Younger onset menopause Higher BMI Smokers
What are some physical findings you will see with women in menopause?
Vaginal dryness Thinning of the vagina Decreased or absent rugae folds Micro abrasions Smaller cervix More exam discomfort
During physical exam in a postmenopausal women, what would you do if you felt a large ovary?
Work up for adnexal mass
What GU symptoms can occur if during menopause and after?
Urinary incontinence
Overactive bladder
Frequent uti
Changing of the vaginal pH making it uninhabitable for microbes
What changes during menopause can make a women more at risk for STI and BV?
Thinning of the vagina-leads to microabrasians
Change in vaginal pH
When is it contraindicated to give estrogen therapy for menopause?
Undiagnosed vaginal bleeding Hx of breast cancer Suspected estrogen dependent cancer Hx of DVT, PE, stroke, MI Liver disease Pregnancy
When you start HT when do you follow up?
6-8 weeks
What are some symptoms of estrogen HT?
Nausea
HA
Can start period or spotting 3-6 months
If they are on continuous combined therapy will patient bleed/spot?
No- eventually lining of uterus will thin
You should educate patient that symptom relief will start how long after starting HT?
2-6 weeks
What can you recommend for a woman to change about her diet to help with hot flashes?
Avoid: Hot drinks/meals Spicy food Alcohol Caffeine Chocolate Sweets
What is the one FDA approved med for hyposexual desire for women?
Flibanserin or ADDY- expensive
If your patient is high-risk for breast cancer at what age should they begin MRI and mammogram?
30 -annually
What are symptoms or changes of breast cancer with breast pain?
More likely unilateral
Peau D’orange
Blood nipple discharge
What skin changes are seen with breast cancer?
Dimpling
Retractions
Peau D’orange
You have a patient with a unilateral, nontender breast mass, what might you suspect?
Fibroadenoma
How would a fibroadenoma feel?
Hard, mobile, firm, rubbery, nontender, well circumcised
What ages does fibroadenoma usually occur?
Peak at 20-30
Do fibroadenomas resolve spontaneously?
About 40% do
If you suspected fibroadenoma in a 21-year-old what would you order?
Ultrasound
When do we remove a fibroadenoma?
Greater than 4cm
Growing rapidly
Bothering patient
How would a breast cyst feel?
Tender Unilateral Soft Mobile Mushy
Can an ultrasound diagnose cyst?
Yes
What are some treatment options for cysts?
Needle aspiration
With a simple cyst is biopsy needed?
No
What will an ultrasound tell you about a mass?
If it is solid or has fluid
T or F: fibroadenomas can increase in size during pregnancy or estrogen therapy and regress after menopause?
True
When should women begin to get a mammogram yearly?
45
45-54
How long should breast cancer screening continue?
As long as a women is in good health and is expected to live 10 years or more.
Women should have the choice to start annual breast cancer screening at these ages:
40-44
What is the most important risk factor for breast cancer?
Age
