Week 6 Menopause Breast Osteoporosis Flashcards
define menopause
- Permanent cessation of menstruation and ovulation
- 1 year of amenorrhea
- average age: 52
- premature menopause: before 40 yrs old (get lab work)
natural vs induced menopause
natural: gradual process, see changes in cycle
induced: surgical, ovarian ablation, chemotherapy, radiation
Factors that influence early menopause?
- LSL
- Lower body weight/BMI
- Nulliparity
- Smoking
- Hx of NO use of oral contraceptives
- mother had early menopause
estradiol (E2)
- most potent secreted by dominant follicle and corpus luteum, main estrogen produced during repro years
- but is low in postmenopausal yrs
estrone (E1)
- weakest estrogen, primary circulating estrogen in post menopausal women, children, men
- estrone is made by adipose conversion of androstenedione by adrenals
estriol (E3)
secreted by placenta and synthesized from androgens by fetus during pregnancy
perimenopause
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
early vs late menopause
- 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
what are vasomotor sx’s and how can you reduce them?
who are they common in ? highest prevalence when?
- 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
other vasomotor symptoms?
- 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
GU changes in menopause
- 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
what is vulvovaginal atrophy (VVA)? Treatment?
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
- Vaginal lubricants (for dryness only)
**NO petroleum jelly (vaseline) as can injury tissue and increase risk of BV**
- hormone tx:
- vaginal estrogen
- creams, rings, suppositories
- femring
- DHEA suppositories
- vaginal estrogen
non medical treatments for VMS
- 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
medication treatment for VMS
- 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
The only FDA approved med for hot flashes who high risk for breast cancer or who have had breast cancer is
PAROXETINE
risk factors for menopause
- Hx depression, PP depression, PMS, PMDD
- Surgical menopause (esp < 48 yrs)
what dysfunction is similar to perimenopause?
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
what labs to check to dx menopause?
- NONE! its based on menstrual hx, medical hx, and sx’s
- only consider labs for abnormal uterine bleeding or PREMATURE menopause
menopause differentials
- ****Pregnancy
- Diabetes
- Thyroid disorders
- Depression
- Carcinoma
- HTN, arrhythmias, anemia
- if in perimenopause, continue contraception
can you use hormone replacement therapy as a contraceptive?
NO! not sufficient enough to prevent pregnancy
when is it recommended to transition to hormone therapy?
55 years old, when 90% reach menopause
Hormone Therapy (HT) for intact uterus
use combined estrogen and progesterone (prog needed for endometrial buildup / hyperplasia)
HT for hysterectomy:
estrogen alone (don’t add progesterone bc higher BC risk)
what is hormone therapy most effective in treating?
hot flashes but takes effect in 2-6 weeks but if stop HT, 50% returns
local/topical estrogen HT..
don’t need progestin but monitor endometrial with ultrasound after 6-12 months and annually
which one to choose if systemic therapy or local vaginal therapy needed for HT?
- Hot flashes = systemic dosing
- Vaginal atrophy = local
contraindications to HT
- 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
sequential EPT vs continuous combined EPT
sequential: estrogen daily, add progestin on days 10-14, predictable w/drawal bleeding (educate this side effect)
continuous combined EPT: estrogen and prog daily
when to stop hormone therapy
- Tx shortest duration for sx relief
- Collab w pt
- Review risk benefits and stop after 5 years of therapy
when should HT NOT be prescribed for?
NOT for purposes for chronic disease prevention in postmenopausal women
in breast cancer, starting estrogen therapy before menopause…? after menopause?
before: decrease risk for breast cancer
BUT starting ET 2 yrs after menopause INCREASES the risk
in cardiovascular disease, HT at earlier age vs later age? HT may
- earlier post menopause can have cardioprotective but should not be used for that reason
- later age = increase risk for CAD
- estrogen destabilizes existing plaque
HT dosing
- ***use lowest dose possible to relieve sx’s and for shortest duration, then evaluate every 2-3 years**
when does HT start to work for vasomotor sx’s and when to f/u?
2- 6 weeks
f/u in 6-8 weeks
when’s the most favorable time/age of starting HT postmenopausal?
< 60 yrs old and < 10 yrs of menopause had more favorable outcomes
Osteopenia
- Low bone mass
- T score -1 to -2.5
what is T score?
number of standard deviations that pt’s BMD is greater or less than that for a young adult
osteoporosis
skeletal dz of low bone mass and deterioration of bone microarchitecture = inc risk of fracture
T score: -2.5 or less
risk factors for osteoporosis
- > 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
OP screening recommendations
- All 65+ screen regardless of risk factors
- < 65 screen with risk factors
Osteoporosis diagnosis
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)
what is FRAX score?
- 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!
osteoporosis management
- 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
when to start meds with OP?
- 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
medications for Osteoporosis postmenopausal
- 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)
duration of medication use for OP treatment
- 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****
fibrocystic breast changes and management
- 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
Breast cysts
- 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
- fine needle aspiration
- 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
fibroadenoma breast mass
- 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.
mastalgia: cyclic vs non cyclic
- 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
mastalgia nonpharm management
- 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
mastalgia pharm management
- 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
diagnostics and management for breast lumps
- 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
can diagnostic images show palpable breast masses?
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
Galactorrhea causes
- 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.
labs to check with galactorrhea
-
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!
galactorrhea differentials
- Hyperprolactinemia
- Pituitary prolactin secreting tumors- adenoma
- Medications (COC’s, Antidepressant: MOAIs, SSRIs, methadone)
- Hypothyroidism
- Neurologic disorder
- Stress
what is non-lactational mastitis associated with, risk factors, and treatment?
- 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
lactational mastitis sx’s and management
- present in BF women with fever, pain, swelling in one breast
- management:
- NSAIDS
- cephalospori antibiotic vs topical
anyone with presumed mastitis that does not resolve completely and have residual breast changes need
to be referred to r/o inflammatory breast cancer or other BC’s
risk factors for breast cancer
- 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
breast cancer screening (average risk and high risk)
- 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
assess for breast cancer by:
- 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
are self breast exams recommended?
- 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.
Clinical breast exam useful for ? harmful for?
- 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
what does fine needle aspiration tell u and NOT tell u?
- 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
what is a core needle biopsy
- more invasive, larger gauge needle
- distinguish invasive form noninvasive cancer and to sample non palpable mass
- complications: lung perforation
describe lipoma
soft, contender, may or may not mobile, fatty tissue
cancer breast lump
- hard and painless, irregular borders, fixed/immobile with lymphadenopathy, skin changes
** Also palpate axillary, supraclavicular and cervical lymph nodes
management of breast cysts
- 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
higher density breasts have
- 4-5x more likely to get breast cancer
- more glandular tissue than fatty tissue
when is a breast ultrasound ordered?
- 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
women over 50 yrs old need what supplements for bone mass?
1200 mg calcium and 800-1000 IU vitamin D daily
when does PrEP take into effect?
1 week to build protective levels in anal and rectal tissues and 20 days in vagina and blood
