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Women's Health > Lecture 8: Menopause > Flashcards

Lecture 8: Menopause Flashcards

1
Q

Define climacteric

A

Phase of the aging process during which a woman passes from reproductive to nonreproductive stage.

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2
Q

Define menopausal transition/perimenopause

A

Part of climacteric before menopause occurs when menstrual cycle is irregular and when other climacteric symptoms/complaints may be experienced.

Usually lasts 1-3 yrs

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3
Q

What is the average age for menopause?

A

51 years old

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4
Q

What qualifies as premature menopause?

A

Prior to age 40

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5
Q

When do women have the most oocytes?

A

At birth

Nature’s clock

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6
Q

As levels of inhibin decrease due to loss of oocytes, what rises?

A

FSH

FSH rises as you have less oocytes

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7
Q

What happens to the oocytes responsiveness to gonadotropins over time? (4)

A
  • Less responsive to FSH and LH
  • Irregular response
  • Irregular length of follucular phase
  • Irregular menstrual cycles

Less responsive and irregular

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8
Q

Why do we see bursts of estradiol in physiologic menopause?

A

Recruitment of multiple oocytes

Primary estrogen prior to menopause

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9
Q

What is the MCC of premature ovarian failure/premature menopause?

A

Idiopathic

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10
Q

What is the primary predisposing factor to menopause?

A

Smoking

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11
Q

Why might we cause artificial menopause on purpose? (4)

A
  • Endometrial cancer
  • Endometriosis
  • ER+ breast cancer
  • Ovarian cancer predisposition

All estrogen related

Cancer, cancer, cancer, endometriosis

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12
Q

What is the primary androgen in women that is decreased in production in menopause?

A

Androstenedione

Has a DI, same like estraDIol which is low in menopause.

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13
Q

What happens to testosterone levels in menopause?

A

They appear decreased lab-wise, but the ovaries are making more after menopause.

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14
Q

Which estrogen decreases the greatest in menopause?

A

Estradiol

Often measured to also confirm menopause

It is the primary estrogen prior to menopause.

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15
Q

Should we check progesterone levels in postmenopausal women?

A

NO

No clinical use.

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16
Q

What hormone measurements can help confirm menopause? (3)

A
  • Estradiol
  • FSH
  • LH

FSH and LH go up, estradiol should be low in menopause.

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17
Q

What are the MC S/S seen in menopause? (8)

A
  1. Irregular bleeding
  2. Irritability and mood swings
  3. Vaginal dryness
  4. Decreased libido
  5. Hot flashes
  6. Hair loss
  7. Hirsutism
  8. Wt gain

Menopause causes HAVOCS

  • Hot flashes
  • Atrophy of the Vagina
  • Osteoporosis
  • CAD
  • Sleep Disturbances
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18
Q

What is the major growth factor of the female reproductive tract?

A

Estrogen

Estrogen Enhances

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19
Q

As estrogen decreases, what can happen to urinary and mammary epithelium as well? (4)

A
  • Atrophic cystitis: urgency, frequency, incontinence and dysuria
  • Uretheral curuncle as urethral tone is lost
  • GU syndrome of menopause
  • Mammary: regress in size and flatten
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20
Q

What is characteristic of atrophic vaginitis? (5)

A
  • Burning
  • Soreness
  • Dyspareunia
  • Dryness
  • Thin watery or serous discharge
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21
Q

What happens to vaginal pH in atrophic vaginitis?

A

Increases

Becoming basic

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22
Q

How is atrophic vaginitis diagnosed?

A

Clinically

Can do pap smears to help

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23
Q

Image of normal, early, and late atrophic vaginitis

A
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24
Q

How is atrophic vaginitis treated initially? (2)

A
  • Vaginal moisturizers: replens, vagisil, K-Y liquibeads
  • Lubricants with sexual activity

Moisturize daily, lubricants only with sex

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25
What is the pharmacologic treatment for mod-severe atrophic vaginitis?
**Vaginal estrogen** therapy
26
What are the 3 benefits of vaginal estrogen therapy?
1. **Restored vaginal pH** and microflora 2. **Increased vaginal secretions** and **thickened vaginal epithelium** 3. Diminished overactive bladder symptoms and **fewer UTIs**
27
In what situation might vaginal estrogen therapy be detrimental to health?
If someone is on **aromatase inhibitors for breast cancer** | Estrogen and aromatase inhibitors do not work well together ## Footnote Think anastrazole
28
What is the newer alternative treatment to **atrophic vaginitis**? (1)
Ospemifene (Osphena): **selective estrogen receptor modulator (SERM)** | Only mimics estrogen on vaginal receptors
29
What is the MC SE of ospemifene?
Hot flashes
30
What are the **alternative therapies for atrophic vaginitis** besides ospemifene? (3)
* **Prasterone** (Vaginal DHEA) suppository (caution in ppl with ER+ women) * Testosterone cream * Pelvic PT
31
What is the most common and characteristic symptom of menopause?
Hot flashes | 75% of all women or bilateral oophorectomies
32
How long do hot flashes last?
**4 minutes on average** | seconds to around 10 mins ## Footnote **Lasting hours would be SUS**
33
How frequent are hot flashes?
Anywhere from 1-2 per hour to 1-2 per week
34
How are hot flashes typically described?
1. **HA-like pressure** 2. Physiologic **flush** with pressure increase 3. **Sweating** that is prominently over the head, neck, upper chest, and back | **heat or burning in the Face neck and chest**
35
What changes are specifically not seen in hot flashes? (2 vitals)
* No change in heart rhythm * No change in BP
36
What 3 things do hot flashes tend to contribute to/lead to?
1. Night sweats 2. Insomnia 3. Cognitive/psychiatric symptoms
37
What ethnicity tends to report hot flashes more frequently?
AA women
38
What is the mainstay of tx for hot flashes?
Estrogens
39
If a woman cannot take estrogen, what is the other hormone can they take for their hot flashes?
Progestin | Depot or norethindrone acetate
40
What are the **hormonal alternatives to estrogen for hot flashes**? (3)
* Progestin * **Tibolone**: synthetic steroid to mimic estrogen, progesterone, and androgens * **Bioidentical hormones**: expensive af * **SERMs + estrogen**
41
What are the non-hormonal alternatives for treating hot flashes? (6)
* SSRIs: paxil, citalopram/escitalopram * SNRIs: venlafaxine/desvenlafaxine * Black cohosh/phytoestrogens * Gabapentin * Clonidine * CAM (alternative medicine)
42
In what situation should paxil be avoided in hot flash treatment?
Pt is already on tamoxifen for breast cancer | Tam and pax do not get along.
43
What are the 2 emerging therapies for hot flashes?
* Oxybutynin * Neurokinin-3 receptor antagonist (hypothalamus binding)
44
What are the 2 biggest known **benefits** of MHT/HRT?
* Reduced menopausal symptoms * Reduced risk of osteoporosis (from estrogen!) | **For GU symptoms only, vaginal estrogen is as good as other routes.**
45
What are the 5 primary known risks of MHT?
1. **Endometrial cancer** 2. Breast cancer (**only if using combo MHT**) 3. **Thromboembolic** dz (combo and estrogen are highest risk) 4. **Stroke** (combo and estrogen are highest risk) 5. **Gallbladder** dz (estrogen)
46
How is endometrial cancer risk mitigated in MHT tx?
Must **add progesterone** to estrogen therapy
47
What are the 4 Fs of gallbladder dz?
1. **Female:** Gallbladder disease, particularly gallstones, is more common in women than in men. 2. **Fat**: A high-fat diet can contribute to the development of gallstones, which are a major cause of gallbladder disease. 3. **Forty:** Gallbladder disease is more common in individuals over the age of 40, although it can occur at any age. 4. **Fertile:** Pregnancy and estrogen use (such as in hormone replacement therapy or birth control pills) are factors that can increase the risk of gallbladder disease. ## Footnote A Fat, Fertile, Forty year old Female
48
How can MHT affect lipids? (2)
* Can lower LDL and increase HDL * Can increase TGs
49
What are the contraindications to MHT? (7)
1. **Breast cx** 2. Estrogen-dependent cx 3. DVT/PE (known or hx) 4. Arterial thromboembolic dz (active or within 1 yr) 5. Liver dz 6. HSR to components of MHT 7. Pregnancy (known or suspected) | CIA PRISM ## Footnote C: Current or history of Certain types of cancer (e.g., breast cancer, endometrial cancer) I: Irregular vaginal bleeding (without known cause) A: Active or history of Arterial disease (e.g., stroke, heart attack, blood clots) P: Pregnancy (MHT is not for use during pregnancy) R: Recent liver disease (or severe liver dysfunction) I: Individual history of blood clots (deep vein thrombosis, pulmonary embolism) S: Severe migraines with aura M: Migraine headaches (generally with aura)
50
In what conditions should we be **cautionary** in implementing MHT? (8)
* Gallbladder dz (4 Fs) * Hypertriglyceridemia (increases TGs) * Prior cholestatic jaundice * Hypothyroidism * Fluid retention/cardiac/renal dysfunction * Severe hypocalcemia * **Prior endometriosis** * Hepatic hemangiomas
51
For a patient with **predominantly vasomotor S/S in menopause**, what medication route is preferred?
**Transdermal**
52
What is the "standard daily dose" of MHT?
0.625mg of PO conjugated estrogen
53
How long do you wait to increase MHT?
1 month intervals
54
When are we required to add progestin for MHT?
**If the patient still has a uterus** | MPA (most studied), micronized (might be better) ## Footnote MPA = medoxyprogesterone acetate **Look for any Q with hx of hysterectomy**
55
What is the standard recommendation of MHT duration?
**Do not use more than 5 years** and taper down later.
56
Describe regimen 1 of MHT (3)
* Estrogen days 1-25 * Progesterone 5-10 mg days 14-25 * No hormones from day 26 to end of month | Lighter, more painless monthly period.
57
Describe regimen 2 of MHT (2)
* **Daily** estrogen and progestin * Will **eventually produce atrophic endometrium** | Initial bleeding or spotting is common ## Footnote Easier to do, but more symptomatic?
58
Which MHT form is primarily aimed at **minimizing the risk of breast cx and endometrial cx**?
SERM + estrogen | Bazedoxifine + conjugated estrogen
59
What foods are phytoestrogens/isoflavones?
* Soy * Lentils * Chickpeas | Risky
60
What two alternative therapies are barely better than placebo in MHT?
* Black cohosh * Vit E
61
What two MHT therapies have the highest efficacy in reducing hot flash severity? (besides estrogens)
* MPA 400 * Megestrol | After 4 weeks
62
What are the 3 vaginal preparations for atrophic vaginitis?
* Cream (CE or estradiol) * Rings (estradiol) * Tablet (estradiol) | Rings tend to have more reliable absorption than cream.

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