Case 17 - 55 yo female with post-menopausal bleeding

Question 1

Symptoms of menopause

Answer 1

mostly due to lack of estrogen: hot flashes (vasomotor sx), atrophic vaginitis, urinary sx, sexual dysfxn, mood disturbance

Question 2

Consequences of osteoporosis

Answer 2

increased risk of fractures, especially vertebrae, hips, distal radius and prox humerus
one year mortality rate following hip fracture = 20-25%

Question 3

Osteoporosis risk factors

Answer 3

Fam hx, previous low-impact fracture, smoking, heavy alcohol, corticosteroid use, caucasian, low body weight
FRAX can help calculate risk of fracture

Question 4

Osteoporosis screening recommendations

Answer 4

All women over 65, younger women with equivalent risk to 65 year old woman (9.3% ten year risk of osteoporotic fracture)
No evidence for screening men

Question 5

How is osteoporosis diagnosed?

Answer 5

DEXA scan done, T score less than -2.5 = osteoporosis, T score between -1 and -2.5 = osteopenia.

Question 6

Cancer screening recommendations

Answer 6

• Breast cancer: mammography for women 50-74 every 2 years according to USPTF, some orgs recommend starting at 40
• Colon cancer: screening recommended for 50-75, colonoscopy is preferred, FOBT can be done, positive FOBT needs to be followed up by colonoscopy
• Cervical cancer: every 2 years 21-30, every 3 years after 30, no need after 65, increased paps for those who are immunosuppressed
• Ovaria cancer - no screening recommendation, Ca-125 NOT a good screening test

Question 7

Endometrial cancer risk factors

Answer 7

Unopposed estrogen therapy, tamoxifen, obesity, anovulatory cycles, estrogen secreting neoplasms, early menarche, late menopause, nulliparity

Question 8

Endometrial cancer protective factors

Answer 8

Smoking, OCPs

Question 9

DDx for postmenopausal bleeding

Answer 9

• cervical polyps (r/o in pelvic exam)
• endometrial hyperplasia (simple or atypical)
• endometrial cancer - 4th most common cancer in women, 90% have abnl vaginal bleeding
• proliferative endometrium
• iatrogenic causes - SSRIs, antipsychotics, anticoagulants
• systemic disorders - thyroid, heme, hep, adrenal, pituitary,hypothalamic
• genital tract pathology (vaginal lesions)

Question 10

Postmenopausal bleeding studies

Answer 10

• 1st test for low risk for cancer - transvaginal ultrasound - evaluates thickness of endometrial stripe (>5mm, more work up req’d)
• endometrial biopsy - gold standard for evaluation of abnl bleeding at high risk for endometrial cancer
• CBC, LFTs, TFTs, FSH/LH

Question 11

Osteoporosis prevention

Answer 11

• 800 IU vitamin D daily
• 1200-1500 mg calcium daily
• weight bearing exercise and muscle strengthening
• limit smoking/alcohol

Question 12

Osteoporosis treatment

Answer 12

• bisphosphanates - inhibit bone resorption and reduce bone turnover, decreases risk of fractures
• parathyroid hormone - given subq for those at high risk
• estrogen replacement - indicated only for short term treatment of vasomotor sx
• calcitonin - reduces vertebral fractures (not others)

Question 13

Menopause hormone therapy uses, benefits and concerns

Answer 13

• used only for short-term treatment of vasomotor and atrophic symptoms
• concerns: increased risk of breast cancer, endometrial cancer, CAD, stroke
• systemic and topical versions exist