1.3 Menopause Flashcards Preview

Woman's Health > 1.3 Menopause > Flashcards

Flashcards in 1.3 Menopause Deck (34)
Loading flashcards...
1
Q

What does date of menopause mean?

A

Corresponds to the woman’s final menstrual period (only known with certainty after 12 consecutive months of amenorrhoea)
• Normally occurs between 45 – 55 years of age

2
Q

What does post menopause mean?

A

Phase of a woman’s reproductive life beginning at the date of the final menstrual period:
• Associated with long-term loss of protective oestrogen effect on urogenital & cardiovascular systems, and bone

3
Q

What does menopausal transition mean?

A

Phase extending from the onset of menopausal symptoms to the final menstrual period (highly variable; average 3 years)

4
Q

What does peri menopause mean?

A

Phase extending from the onset of menopausal symptoms to 1 year after the final menstrual period:
• Associated with symptoms of variable severity (vasomotor, menstrual, psychological, sexual) → usually self-limiting but may persist in some women

5
Q

What is premature ovarian failure?

A

Menopause occurring before 40 years of age (premature ovarian insufficiency) → different management from patients with later physiological menopause

6
Q

What is early menopause?

A

Menopause occurring between 40 – 45 years of age → managed in a similar way to patients with POF

7
Q

what are the hormonal changes associated with menopause?

A

In the post-menopausal phase, the gonadotrophins are high (FSH > 30 IU/dL), with low oestradiol (< 40 pg/mL) and undetectable progesterone, AMH, inhibin

8
Q

why does inhibin decrease in menopause?

A

Normally produced by the ovarian granulosa cells → decline in number of ovarian follicles in early menopause transition → reduced inhibin B

9
Q

why does anti mullerian hormone (AMH) decrease in menopause?

A

Glycoprotein produced by antral (secondary) follicles → not directly involved in feedback mechanisms:
• Levels are high at menarche then decline thereafter as the number of ovarian follicles declines with age

10
Q

Why does FSH increase in menopause?

A

Normally inhibited by inhibin B (negative feedback) → low inhibin B fails to suppress FSH → higher FSH in the early follicular phase of the menstrual cycle in the 2 years leading up to final menstrual period
• Persistently elevated during the post-menopause

11
Q

Why does oestrodial decrease in menopause?

A

Normally produced by ovarian granulosa cells (in response to FSH) → levels fall in the 2 years leading up to final menstrual period (with some fluctuation):
• Persistently declining during the post-menopause

12
Q

Why does progesterone decrease in menopause?

A

Falls steadily throughout menopause transition (due to reduced progesterone production by the corpus luteum and increased frequency of anovulation)

13
Q

What oestrogens dominate pre- menopause?

A

Mainly 17β-oestradiol (E2) → 95% derived from the ovaries (from CYP450 metabolism of oestrone and testosterone)
• Levels vary with the menstrual cycle

14
Q

What oestrogens dominate post - menopause?

A
Mainly oestrone (E1) → derived from hepatic E2 metabolism and adipose peripheral conversion of androstenedione
• ~1/3 biological potency of E2
15
Q

where is testosterone produced in the body?

A

Pre-menopausal: 50% produced via peripheral conversion of androstenedione (25% in the ovaries; 25% in adrenal cortex):
• Testosterone aromatised to oestradiol intracellularly

16
Q

Why does testosterone decrease during menopause?

A

oss of ovarian follicular function knocks out 25% of peripherally produced testosterone (which is quite difficult for the body to compensate using the adrenal cortex) → levels decline (but not as much as oestradiol → 95% from ovaries)

17
Q

how is androstenedione affected during menopause?

A

post-menopausal ovary still contributes 20% to the circulating androstenedione levels → loss of ovarian function is also compensated by increased adrenal synthesis (even in POF) → levels remain largely unchanged

18
Q

how is Dehydroepiandro-sterone sulfate (DHEAS) affected during menopause?

A

Pre-menopausal: produced almost exclusively by the adrenal cortex → levels tend to decline with age (both sexes; women > men due to relative oestrogen deprivation)

Menopause: ovaries do not contribute much to DHEAS synthesis in the first place → levels remain largely unchanged from before menopause (only age-related decline)

19
Q

What is the criteria for diagnosis of menopause in woman > 45 years old

A

Clinical diagnosis: history of menopausal symptoms (see below) + secondary amenorrhoea for ≥ 12 consecutive months
• Menopause transition: based on menopausal symptoms + menstrual irregularity

20
Q

What is the criteria for diagnosis of menopause in woman < 45 years old

A

Lab testing (if suspected primary ovarian failure or early menopause) → 2 FSH samples taken 4 – 6 weeks apart (raised > 40 pmol/L)

21
Q

Hot flushes are the earliest and most characteristic symptom of oestrogen deficiency:
• Relative (not absolute) decline in oestradiol → dysfunction of _______________ (maintains core temperature)
• Frequency: affects ~75% of women (may be less frequent in Asian women) → generally resolves in < 5 years (persists in 25% of women)
• Risk factors: ______, __________
• Clinical features: subjective sensation of intense warmth of the upper body (lasting 3 – 10 minutes) of variable frequency and intensity (occasional/daily/hourly)

A

brainstem thermoregulatory nucleus;

cigarette smoking, obesity

22
Q

Urogenital symptoms are correlated with _____________ :
• Oestrogen receptors in the urogenital system and pelvic region (vagina, vulva, pelvic floor, endopelvic fascia, urethra, bladder trigone) decline with menopause transition → may become restored with oestrogen treatment
• Symptoms are often chronic (rarely resolve spontaneously) → progress if untreated

What are the symptoms?

A

low oestrogen levels;

Genital: Vaginal dryness, burning, irritation
Pain during intercourse (dyspareunia) → due to vaginal thinning, decreased distensibility, reduced secretions

Urinary: Urgency, dysuria
Recurrent UTIs → due to thinning of vaginal epithelium, change in vaginal pH, reduced secretions

23
Q

What are the short term effects of menopause

A
  • Hot flushes
  • Urinary urgency & frequency, Vaginal dryness, Dyspareunia
  • Menstrual irregularity (due to anovulatory cycles)
  • Low mood, Memory loss, Insomnia
  • Decreased libido, Dyspareunia
24
Q

What are the effects of menopause o \n bone?

menopause causes bone disorders like osteoporosis:
• Bone density peaks in the __________ and remains constant until perimenopause → rapid decline in late perimenopause and early post-menopause (due to accelerated bone resorption) → loss of 2% (in the spine) and 1% (in the hip)
• Mechanism is unclear → bone cells express oestrogen receptors → oestrogen deficiency appears to stimulate osteoclast formation and activity → resorption

Osteoporosis: important long term consequence of menopause, 1/3 of women have it by 50 years of age –> age adjusted rates of hip fracture ↑ 5 fold since 1960s)

  • Decreased bone density –> increased risk of osteoporotic fractures
  • Risk factors: low _____________________
  • Generally asymptomatic until a fracture occurs (‘silent’)
A

20s – 30s;

BMI , lifestyle (smoking, alcohol), diet , genetics , co existing diseases

25
Q

what is the benefit of weight management?

A

Target is to maintain a normal BMI (not too high/low):
• High BMI: more severe hot flushes, increased CVD risk
• Low BMI: increased osteoporosis risk

26
Q

what is the benefit of exercise?

A

Relieves hot flushes, reduces CVD & osteoporosis risk

27
Q

what is the benefit of smoking cessation?

A

Relieves hot flushes, reduces CVD & osteoporosis risk

28
Q

what is the benefit of avoidance of alcohol & caffeine?

A

Relieves hot flushes

29
Q

what is the benefit of adequate calcium & vitamin d intake?

A

Reduces risk of osteoporosis

30
Q

what is the benefit of phytoestrogens?

A

Relieves hot flushes (some evidence → plant-based oestrogens)
• Isoflavones: soya beans, chickpeas, clover
• Lignans: flax seeds, bran

31
Q

what is the indication of combined (oestrogen + progesterone) therapy?

A

All women > 45 years of age considering HRT as treatment (due to risk of endometrial hyperplasia and cancer in oestrogen-only preparations) → combined HRT not associated with adverse endometrial effects
• Progesterone is mandatory for > 10 days/month

32
Q

what ist he indication of only oestrogen therapy?

A

Women who have had a hysterectomy (no risk of endometrial cancer)

33
Q

what are the benefits of HRT?

A
  • Short-term relief of symptoms of oestrogen deficiency (e.g. vasomotor, low mood, low libido, vaginal dryness) → prolongs euhormonal state of mid-life phase to maintain the endocrine autonomous equilibrium
  • Long-term benefit on bone density (if oestrogen deficiency is the only cause of bone complications) → helps to prevent osteoporosis
  • Improves the quality of life (psychological + physical) in the long run

*HRT prescribed to women < 60 years of age has favourable benefit/risk profile → older women often also have age-related co-morbidities of the CVS and bone, so they may not necessarily respond well to HRT (+ additional risks of HRT like cancer, increased CVS risk)

34
Q

What are the risks of HRT?

A

In all women: increased risk of breast cancer and ATEs/VTEs

• In older women > 60 years of age: increased risk of CVD