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531 > Week 6 Menopause Breast Osteoporosis > Flashcards

Week 6 Menopause Breast Osteoporosis Flashcards

1
Q

define menopause

A
  • Permanent cessation of menstruation and ovulation
  • 1 year of amenorrhea
  • average age: 52
  • premature menopause: before 40 yrs old (get lab work)
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2
Q

natural vs induced menopause

A

natural: gradual process, see changes in cycle
induced: surgical, ovarian ablation, chemotherapy, radiation

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3
Q

Factors that influence early menopause?

A
  • LSL
  • Lower body weight/BMI
  • Nulliparity
  • Smoking
  • Hx of NO use of oral contraceptives
  • mother had early menopause
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4
Q

estradiol (E2)

A
  • most potent secreted by dominant follicle and corpus luteum, main estrogen produced during repro years
  • but is low in postmenopausal yrs
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4
Q

estrone (E1)

A
  • weakest estrogen, primary circulating estrogen in post menopausal women, children, men
  • estrone is made by adipose conversion of androstenedione by adrenals
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5
Q

estriol (E3)

A

secreted by placenta and synthesized from androgens by fetus during pregnancy

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6
Q

perimenopause

A

time when women begin to experience cycle irregularities and other menopause-related sx’s (hot flashes, bag dryness) and ends when dx of menopause made after 12 months amenorrhea

keep using back up contraception bc unexpected ovulation

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7
Q

early vs late menopause

A
  • early menopause: cycle irregularities of 7 days or greater
  • late menopause: women 45+ with periods of amenorrhea for 60 days or more
  • FSH levels rise in both
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8
Q

what are vasomotor sx’s and how can you reduce them?

who are they common in ? highest prevalence when?

A
  • From declining estrogen levels
  • **controlling chronic health issues like diabetes, obesity, hypothyroidism HTN, etc can reduce sx’s
  • Flushing, sweating, heat sensation
  • palpitations/anxiety, chills
  • Common in and more severe in:
    • African women
    • Smokers
    • > 27 BMI
      • ^ adipose = ^ androgen to estrogen
    • Menopause at younger age
    • Surgical menopause esp during 1st year
  • Younger age menopause and higher BMI = more vasomotor sx’s
  • Hot flashes highest prevalence: 1st year
    • 50% for 4-5 years
    • 25% > 5 years
    • 10% > 15 years
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9
Q

other vasomotor symptoms?

A
  • Poor quality sleep
    • Insomnia or prolonged time need to fall asleep
  • weight gain
  • vaginal dryness
  • incontinence
  • psychological
    • dizziness, anxiety, poor memory, mood swings, less interest in sexual activity
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10
Q

GU changes in menopause

A
  • Atrophy: vaginal cervical epithelium that is thin, dry, and pale
  • Microabrasians
  • Absent rugae
  • Cervix decreases in size, less mucus (painful sex)
  • Smooth shiny pale appearance (sparse capillary bed, atrophy of epithelium)
  • Ovaries small, impalpable
  • Small - moderate fibroids are sensitive and shrink after menopause
  • Urinary incontinence and overactive bladder
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11
Q

what is vulvovaginal atrophy (VVA)? Treatment?

A

Declining estrogen levels in 90% women in late post menopause

  • decreased rural folds of walls, pale mucosa, loss of elasticity, dryness
  • Nonhormonal tx’s:
    • Vaginal lubricants (for dryness only)
      • Water based
      • Silicone based
        • KY jelly
      • Oil based
        • coconut oil, olive oil
      • pH balanced

**NO petroleum jelly (vaseline) as can injury tissue and increase risk of BV**

  • hormone tx:
    • vaginal estrogen
      • creams, rings, suppositories
      • femring
      • DHEA suppositories
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12
Q

non medical treatments for VMS

A
  • Phytoestrogens- Soy Isoflavones , Red Clover
  • Herbal supplements-
    • Black Cohosh, St John’s Wort
  • Clothing/environment
    • Layers, fan, cool room
  • Lifestyle changes
    • smoking cessation, exercise, healthy BMI, stress reduction
  • Dietary changes
    • avoid or reduce trigger foods: hot drinks, caffeine, ETOH, chocolate, spicy foods
  • Yoga/meditation
  • Acupuncture
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13
Q

medication treatment for VMS

A
  • Mood disorders: first line = SSRI
    • Venlafaxine (Effexor)
    • Fluoxetine (Prozac)
    • Paroxetine (Paxil)
    • SE: less libido
  • Hot flashes:
    • Antihypertensive: clonidine (Catapress) patches
  • Anticonvulsant: Not FDA approved but hot flashes ok
    • gabapentin (Neurontin)
  • no antihistamines = too drying
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13
Q

The only FDA approved med for hot flashes who high risk for breast cancer or who have had breast cancer is

A

PAROXETINE

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14
Q

risk factors for menopause

A
  • Hx depression, PP depression, PMS, PMDD
  • Surgical menopause (esp < 48 yrs)
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15
Q

what dysfunction is similar to perimenopause?

A

thyroid dysfunction

  • Similar sx’s to perimenopause:
    • Changes in menstrual patterns
    • Fatigue
    • Mood changes
    • Sleep difficulties
    • Heat intolerance
    • Palpitations
  • Consider screening for thyroid dz
  • screen for thyroid dz
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16
Q

what labs to check to dx menopause?

A
  • NONE! its based on menstrual hx, medical hx, and sx’s
  • only consider labs for abnormal uterine bleeding or PREMATURE menopause
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17
Q

menopause differentials

A
  • ****Pregnancy
  • Diabetes
  • Thyroid disorders
  • Depression
  • Carcinoma
  • HTN, arrhythmias, anemia
  • if in perimenopause, continue contraception
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18
Q

can you use hormone replacement therapy as a contraceptive?

A

NO! not sufficient enough to prevent pregnancy

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18
Q

when is it recommended to transition to hormone therapy?

A

55 years old, when 90% reach menopause

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19
Q

Hormone Therapy (HT) for intact uterus

A

use combined estrogen and progesterone (prog needed for endometrial buildup / hyperplasia)

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20
Q

HT for hysterectomy:

A

estrogen alone (don’t add progesterone bc higher BC risk)

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21
Q

what is hormone therapy most effective in treating?

A

hot flashes but takes effect in 2-6 weeks but if stop HT, 50% returns

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21
Q

local/topical estrogen HT..

A

don’t need progestin but monitor endometrial with ultrasound after 6-12 months and annually

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22
Q

which one to choose if systemic therapy or local vaginal therapy needed for HT?

A
  • Hot flashes = systemic dosing
  • Vaginal atrophy = local
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23
Q

contraindications to HT

A
  • Undiagnosing vaginal bleeding
  • Known or suspected hx of breast cancer, suspected estrogen dependent cancer
  • Hx of DVT, pulmonary embolism, CVA, or MI [thromboembolic disorder]
  • CVD / MI
  • Active liver disease
  • Pregnancy
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24
Q

sequential EPT vs continuous combined EPT

A

sequential: estrogen daily, add progestin on days 10-14, predictable w/drawal bleeding (educate this side effect)

continuous combined EPT: estrogen and prog daily

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24
Q

when to stop hormone therapy

A
  • Tx shortest duration for sx relief
  • Collab w pt
  • Review risk benefits and stop after 5 years of therapy
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25
Q

when should HT NOT be prescribed for?

A

NOT for purposes for chronic disease prevention in postmenopausal women

26
Q

in breast cancer, starting estrogen therapy before menopause…? after menopause?

A

before: decrease risk for breast cancer

BUT starting ET 2 yrs after menopause INCREASES the risk

27
Q

in cardiovascular disease, HT at earlier age vs later age? HT may

A
  • earlier post menopause can have cardioprotective but should not be used for that reason
  • later age = increase risk for CAD
    • estrogen destabilizes existing plaque
28
Q

HT dosing

A
  • ***use lowest dose possible to relieve sx’s and for shortest duration, then evaluate every 2-3 years**
29
Q

when does HT start to work for vasomotor sx’s and when to f/u?

A

2- 6 weeks

f/u in 6-8 weeks

30
Q

when’s the most favorable time/age of starting HT postmenopausal?

A

< 60 yrs old and < 10 yrs of menopause had more favorable outcomes

31
Q

Osteopenia

A
  • Low bone mass
  • T score -1 to -2.5
32
Q

what is T score?

A

number of standard deviations that pt’s BMD is greater or less than that for a young adult

33
Q

osteoporosis

A

skeletal dz of low bone mass and deterioration of bone microarchitecture = inc risk of fracture

T score: -2.5 or less

34
Q

risk factors for osteoporosis

A
  • > 65 yrs
  • Hx fracture w/o trauma as adult
  • Fam hx OP
  • Female
  • Late menarche > 15 or early menopause < 45
  • Smoking
  • BMI < 19 or < 127 lb
  • Nulliparity
  • Eating disorder, exercise induced amenorrhea
  • Chronic steroid use (> 3-6 months use)
  • Inadequate vitamin D or Ca
  • Falling risk
    • Weakness, envi haz, poor vision, impaired cog
  • Chronic illness
    • Arthritis, hyperparathyroidism, impaired absorption, autoimmune, heavy alcohol use
  • Meds
    • Anticonvulsant
    • Steroids
    • Anticoagulants
    • Dep-provera
    • tamoxifen
    • SSRI, PPI
35
Q

OP screening recommendations

A
  • All 65+ screen regardless of risk factors
  • < 65 screen with risk factors
35
Q

Osteoporosis diagnosis

A

DEXA scans

  • T score
  • Compares mean peak bone mineral density of normal young and same sex population
  • Standard deviation that a person’s bone mineral density differs from the mean
  • Take femoral neck and lumbar spine and total hip measurements = lowest value is diagnostic category
    • Normal: -1 to 0+
    • Osteopenia: -2.5 to -1 SD
    • Osteoporosis: < -2.5 SD
  • Z score (for premenopausal women, children, men < 50 yrs)
36
Q

what is FRAX score?

A
  • Fracture risk assessment tool for osteoPENIA
    • identifies who should start medication therapy
    • calculates 10 year probability for hip fracture and 10 year probability for any major osteoporotic fracture
    • If hip fracture probability is > 3% or if risk for any major osteoporotic fracture is > 20%, recommend meds!
37
Q

osteoporosis management

A
  • Prevention!
  • Weight bearing and resistance exercise
    • Dancing, stair climbing, tai chi, walking, jogging
    • Improve strength, agility
  • Fall prevention
  • Smoking cessation
  • Mod alcohol (< 2 drinks per day)
  • Diet
38
Q

when to start meds with OP?

A
  • Osteoporosis: T score < -2.5
  • Osteopenia: hx of fragility fracture of hip or spine
  • FRAX score: T-score between -1.0 to -2.5 osteopenia at the femoral neck, total hip or lumbar spine who have a 10-year risk of ≥ 3% at the hip or ≥ 20% for a major osteoporotic fracture
39
Q

medications for Osteoporosis postmenopausal

A
  • 1st line: Bisphosphonates
  • Alendronate (Fosamax):
    • prevention: 5mg daily or 35 mg weekly
    • tx: 10 mg daily; 70 weekly
  • Oral:
    • esophagitis: don’t eat/drink or lie down for 30 minutes
    • take 1st thing in morning + 8 oz water
    • take 2 hrs before antacids/ Calcium
  • Risedronate (Actonel)
  • Zoledronic acid (reclast)
  • Ibandronate (boniva)
  • Calcitonin
    • for tx: 200 spray or 100 subq inj
  • selective estrogen receptor modulator (SERM)
    • Raloxifene (Evista)
    • worsen hot flashes/clots
  • parathyroid hormone
    • teriparatide (Forteo)
  • Denosumab (Prolia)
40
Q

duration of medication use for OP treatment

A
  • Stop Bisphosphonates after 5 years if:
    • no Fracture HX or low risk for fracture
    • hip BMD is greater than -2.5:
    • Consider drug Holiday and reassess in 2-3 years
  • Continue over 5 years if:
    • HX of fracture before or during treatment
    • BMD is -2.5 or less or high risk for fracture
  • ***Reassess every 2 yr -3 yrs****
41
Q

fibrocystic breast changes and management

A
  • from hormonal simulation & fluctuate with menstrual cycle
  • Diffuse tender and swollen nodular masses prior to menses
  • UNCOMMON in postmenopausal women
  • Asx or pain or tenderness
  • “bag of beans”
  • Fibrous tissue firm or rubbery but not rock hard
  • Management
    • Aspiration of larger, painful cysts
    • OC decreases changes
    • No a/s of breast cancer
42
Q

Breast cysts

A
  • tender, mobile, size changes with menstrual cycle
  • cyst filled & inflammation
  • 35 - 50 yrs olds
  • Diagnosis
    • fine needle aspiration
      • drain cyst
    • Repeat US in 2-4 months
  • Simple cysts: symptomatic relief
  • complex cysts/ solid masses: biopsy
    • US in 2-4 months to see changes
    • abscess, hematoma, cancer, or fat necrosis or a galactocele
  • If < 30 yrs, order US
  • > 30, US and mammo
  • US differentiate b/t solid and fluid filled cysts
42
Q

fibroadenoma breast mass

A
  • smooth, round/oval, non-tender, movable, rubbery; stoma without fat
  • most common in adolescents/young women (20-30 yrs)
  • 40% resolve spontaneously
  • Dx: biopsy
  • If pathology indicates fibroadenoma, excision is not necessary its enlarged or distorts the breast.
    • Complex fibroadenomas have a higher risk of proliferative breast changes and breast cancer.
  • Excisional biopsy if:
    • > 35 years old
    • NOT movable, a poorly circumscribed mass, biopsy is inconclusive, or the size is greater than 2.5 cm
    • can increase in size during pregnancy or estrogen therapy, and they generally regress after menopause.
43
Q

mastalgia: cyclic vs non cyclic

A
  • Cyclical mastalgia/breast pain:
    • During luteal phase, resolves with the onset of menses bilaterally
    • age 30 to 50
    • sharp, shooting, full, tender, or deep aching and throbbing pain.
    • normal; more common than non cyclic
  • Non-cyclic mastalgia/breastpain:
    • not related to menstrual cycle
    • unilateral, localized pain
    • burning, or sharp pain.
    • a/s mastitis, cysts, tumors, previous breast surgery, meds
44
Q

mastalgia nonpharm management

A
  • First line: reassurance
  • Well-fitting, supportive bra
  • topical or oral non-steroidal medications.
  • Primrose oil or flax seed
    • 3 months for benefit
  • Caffeine restriction failed to help
45
Q

mastalgia pharm management

A
  • significant SE’s and release after stopping meds
  • Danocrine/Danazol
    • FDA approved
    • SE: depression, acne, hirsutism, hot flashes, menstrual irregularities, amenorrhea, weight gain, and nausea.
    • interferes with oral contraceptive effectiveness
  • Bromocriptine (Parlodel)
  • Tamoxifen
    • least side effects but NOT FDA app for mastalgia
46
Q

diagnostics and management for breast lumps

A
  • Mammogram and/or ultrasound
    • Ultrasound: distinguish if mass is cyst or solid
    • Mammogram: detects non palpable abnormalities and microcalcifications
  • Management:
    • < 30 yrs: order U/S alone
    • > 30: order mammogram AND ultrasound
47
Q

can diagnostic images show palpable breast masses?

A

Palpable breast masses may NOT be visible on diagnostic images and cannot rule out malignancy so need a surgical referral for biopsy to determine benign vs malignant

48
Q

Galactorrhea causes

A
  • milky nipple discharge not pregnant or lactated in the last 12 months.
  • causes:
    • breast manipulation
    • Nipple stimulation
    • Antidepressants, anxiolytics, anti-hypertensives, anti-psychotics, h2 blockers, contraceptives, opiates, amphetamines, anesthetics, cannabis, Danazol, INH, metoclopromide, ranitidine, sumatriptan, and valproic acid, thyroid disorder, pituitary adenoma, renal insufficiency, and renal failure.
49
Q

labs to check with galactorrhea

A
  • Prolactin level in morning
    • If elevated = check thyroid hormones and creatinine level
  • MRI pituitary (sella turcica)
  • Pregnancy test
  • Mammogram if 30 yrs +
  • NO cytology testing and ductogram painful and rare to use
  • Unilateral, serious, bloody discharge spontaneously = cancer, esp with breast mass in those > 40 yrs
    • Referr!
50
Q

galactorrhea differentials

A
  • Hyperprolactinemia
  • Pituitary prolactin secreting tumors- adenoma
  • Medications (COC’s, Antidepressant: MOAIs, SSRIs, methadone)
  • Hypothyroidism
  • Neurologic disorder
  • Stress
51
Q

what is non-lactational mastitis associated with, risk factors, and treatment?

A
  • a/s diabetes and immune compromise
  • risk factors:
    • Smoking
    • nipple rings
  • bacteria enter from the skin = periductal inflammation and abscess formation.
  • Treatment
    • Clindamycin or Flagyl AND cefazolin or nafcillin
    • if recurs/doesn’t resolve = biopsy
  • Palpation = elicits pain, so they should be confirmed with ultrasonography.
  • Repeated aspiration preferred over I&D
52
Q

lactational mastitis sx’s and management

A
  • present in BF women with fever, pain, swelling in one breast
  • management:
    • NSAIDS
    • cephalospori antibiotic vs topical
53
Q

anyone with presumed mastitis that does not resolve completely and have residual breast changes need

A

to be referred to r/o inflammatory breast cancer or other BC’s

54
Q

risk factors for breast cancer

A
  • Biggest risk factor: AGE
  • Caucasian highest rate
    • African American highest rate of death
    • Jewish
  • Personal hx/family hx of invasive breast cancer, ductal or lobular cancer or atypia
  • Especially 1st degree relatives
  • BRCA1 & BRCA2
  • Family hx of ovarian or colorectal cancer
  • BMI- overweight & obese
  • Physical inactivity
  • Alcohol intake: one or more per day
  • Nulliparity
  • First full-term pregnancy after age 30
  • E+P HT after menopause
  • Menopause at 55 years+
  • Menarche before age 12
  • Dense breast tissue on Mammogram
  • High dose radiation to chest esp during puberty or childhood
55
Q

breast cancer screening (average risk and high risk)

A
  • ages 40-49 = optional; informed decision making with provider
  • ages 50 - 74 = every 2 years
  • ages 75 and older = no evidence for screening mammography; optional
  • *if high risk = screen in early 40’s mammogram AND MRI annually
    • high risks: hx CA, family hx breast ca, BRCA1 or 2, dense breast, radiation to chest 10-30 yrs old
  • DON’T screen average risk women before 40 yrs old
56
Q

assess for breast cancer by:

A
  • change in appearance of the breast
  • changes to menstrual cycle;
  • skin changes
  • new nipple inversion;
  • nipple discharge, bilateral or unilateral
  • look at color, timing, and frequency of breast pain (cyclical or not cyclical)
  • Masses - location, size, any change in size over time, or tenderness associated with menstrual cycle
57
Q

are self breast exams recommended?

A
  • No. counsel benefits and limitations and potential harm (false positive) of breast self-examination.
  • Breast awareness instead
    • report any changes in how their breasts feel or look rather than performing self-breast examinations regularly
  • Clinical breast exams controversial but still part of the breast cancer screening
  • Differentiating a breast mass from normal tissue or a dominant mask or thickening is difficult on physical examination. Among palpable breast masses, 25% are simple cysts.
58
Q

Clinical breast exam useful for ? harmful for?

A
  • It may be useful to determine whether a mass is discrete or just a thickening of breast tissue.
  • can have false positive findings = anxiety and additional visits, unwarranted imaging and biopsies
59
Q

what does fine needle aspiration tell u and NOT tell u?

A
  • fine needle aspiration
    • diagnostic & therapeutic (drain & collapse cyst)
    • least invasive bx method
    • does NOT tell invasive or non invasive cancer, just if its solid or cystic
  • repeat u/s in 2-4 months
60
Q

what is a core needle biopsy

A
  • more invasive, larger gauge needle
  • distinguish invasive form noninvasive cancer and to sample non palpable mass
  • complications: lung perforation
61
Q

describe lipoma

A

soft, contender, may or may not mobile, fatty tissue

62
Q

cancer breast lump

A
  • hard and painless, irregular borders, fixed/immobile with lymphadenopathy, skin changes

** Also palpate axillary, supraclavicular and cervical lymph nodes

63
Q

management of breast cysts

A
  • based on sx’s, sometimes need I&D
  • asymptomatic simple cyst = no intervention
  • large, painful cyst = aspiration
  • complicated cysts = bx to r/o atypia/malignancy
64
Q

higher density breasts have

A
  • 4-5x more likely to get breast cancer
  • more glandular tissue than fatty tissue
65
Q

when is a breast ultrasound ordered?

A
  • NOT routinely for breast cancer
  • cystic or solid and help with fine needle aspiration for imaging
    • NOT tell malignant or benign
  • if < 30 years old , feel a lump, order ultrasound
  • if > 30 years old, feel lump: order US and mammogram
66
Q

women over 50 yrs old need what supplements for bone mass?

A

1200 mg calcium and 800-1000 IU vitamin D daily

67
Q

when does PrEP take into effect?

A

1 week to build protective levels in anal and rectal tissues and 20 days in vagina and blood

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