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MENOPAUSE Flashcards

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1
Q

natural menopause

A

the permanent cessation of menses

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2
Q

natural menopause is defined after ___________ of no menses

A

Defined retrospectively after 12 months of no menses without any other explanation

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3
Q

median age of menopause

A

51

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4
Q

with menopause = will have an elevated FSH level, however

A

Elevated FSH not needed for dx in woman over 45 ( Dx based on hx and symptoms)

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5
Q

LH acts on ____________ to release __________

A

theca cells to release progesterone

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6
Q

FSH acts on __________ to release ___________

A

granulosa cells to release estradiol

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7
Q

Natural menopause represents the depletion of _________________ and is therefore manifested by low ____________, high ___________, and _________________________

A

ovarian follicles

low estrogen
high FSH
loss of natural reproductive ability

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8
Q

in menopause, the ovaries continue to make

A

testosterone

Estrone (E1) is converted from androstenedione in fat cells

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9
Q

surgical menopause

A

the removal of both ovaries before natural menopause

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10
Q

premature ovarian insufficiency

A

menopause before age 40

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11
Q

perimenopause

A
  • “menopausal transition” of about 4 years, beginning around age 47
  • have wide fluctuations of estrogen, hot flashes, decreased ovulation & irregular menses
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12
Q

MENOPAUSE IS INFLUENCED BY

A

⦁ Genetics

⦁ Smoking (smokers have an earlier menopause than non-smokers)

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13
Q

MENOPAUSE IS NOT INFLUENCED BY

A 
⦁	Age of menarche (age of first period)
⦁	Number of pregnancies
⦁	Use of oral contraceptives
⦁	Race
⦁	SES
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14
Q

SIGNS/SYMPTOMS OF MENOPAUSE

A
  • hot flashes
  • night sweats
  • mood changes
  • memory changes
  • hair / skin / nail changes
  • osteoporosis
  • urogenital atrophy
  • sleep disturbances independent of night sweats
  • lipid changes
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15
Q

HOT FLASHES / NIGHT SWEATS

can last ___________
May be accompanied by ____________

incidence varies widely; may be more influenced by _________ than by __________

A

2-4 minutes

palpitations

may be more influenced by BMI than race/ethnicity

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16
Q

hot flashes / night sweats represent thermoregulatory dysfunction at hypothalamus

A

Symptomatic women trigger mechanisms to dissipate heat at a lower core body temperature with inappropriate peripheral vasodilation

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17
Q

duration of hot flashes / night sweats

A

⦁ median duration = 7.4 years, with 4.5 of those years after the final menstrual period

⦁ 8-9% may have hot flashes more than 20 years after menopause

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18
Q

HAIR SKIN NAIL CHANGES

decreased skin __________ & ___________

increased _________________

A

decreased skin thickness & elasticity

increased facial hair - related to decreased SHBG (due to low estrogen) causing increased free testosterone

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19
Q

osteoporosis occurs because

A

estrogen receptors are present in osteoblasts

(decreased estrogen –> decreased osteoblast function)

⦁ bone density decreases 1-2% / year vs 0.5% / year in perimenopause

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20
Q

LIPID CHANGES IN MENOPAUSE

  • increased ____________ & decreased __________
A

decreased HDL (good)

increased LDL (bad)

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21
Q

UROGENITAL ATROPHY

A

Vaginal dryness contributes to dyspareunia

Atrophic urethritis causing dysuria and frequency

Vulvar and vaginal tissues more easily irritated

Loss of pelvic organ support and increased prolapse

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22
Q

DIAGNOSIS OF MENOPAUSE

A

o Women > 45
⦁ diagnosis by menstrual history - with or without menopausal symptoms
⦁ no reliable way to predict the final period

o Women 40-45
⦁ diagnosis by menstrual history, but also need labs to rule out other explanations for menstrual changes
⦁ TSH, prolactin, and hCG

o Women with hysterectomy / endometrial ablation
⦁ assess menopausal symptoms
⦁ FSH

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23
Q

DIAGNOSIS OF MENOPAUSE IN WOMEN > 45

A

can diagnose based on menstrual history
with or without menopausal symptoms

there is no reliable way to predict the final period

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24
Q

DIAGNOSIS OF MENOPAUSE IN WOMEN 40-45

A

diagnosis by menstrual history, but also need labs to rule out other explanations for menstrual changes

labs: TSH, prolactin, and hCG

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25
what labs are needed to diagnose menopause in women aged 40-45
TSH Prolactin hCG
26
DIAGNOSIS OF MENOPAUSE IN WOMEN WHO HAVE HAD A HYSTERECTOMY / ENDOMETRIAL ABLATION
Assess menopausal symptoms | Get FSH
27
HORMONE REPLACEMENT THERAPY IS NOW CALLED
MENOPAUSE HORMONE THERAPY
28
MENOPAUSE HORMONE THERAPY includes the replacement of
⦁ Estrogen ⦁ Progesterone ⦁ Testosterone
29
THE BENEFITS OF ESTROGEN
1) control of vasomotor symptoms (VMS) (hot flashes / night sweats) 2) relief from urogenital atrophy symptoms 3) maintain bone density (decreased hip fractures)
30
the many options to initiating drug therapy for menopause
- Regimens containing estrogen with or without the addition of a progestin - Nonhormonal options such as SSRIs & Gabapentin - Estrogen agonist / antagonist agents & tissue selective estrogen complexes
31
tamoxifen is an
estrogen agonist
32
drug therapy depends on whether they still have a uterus or not if they still have a uterus = _______ if no uterus = __________
still have a uterus = need both estrogen & progesterone; can’t just give estrogen → sets them up for endometrial cancer no uterus = just estrogen
33
giving just estrogen to a menopausal women with a uterus = sets her up for
endometrial cancer
34
alternatives to estrogen = SSRIs & SNRIs
Venlafaxine (withdrawal symptoms)* Paroxetine (Brisdelle) FDA approved lower dose 7.5 mg Fluoxetine (Prozac) Some recommendations for citalopram/escitalpram
35
issue with venlafaxine =
withdrawal symptoms SNRI
36
other alternatives to estrogen other than SSRIs and SNRIs
- Gabapentin - Cetirizine (Zyrtec) - Clonidine
37
clonidine SE
dry mouth constipation dizziness
38
integrative modalities with inconsistent studies
``` Soy (isoflavones) Black cohosh Acupuncture Weight loss Mind-body therapies Cognitive behavioral therapy Hypnosis Vitamin E ```
39
RISK OF CVD WITH ESTROGEN
- The risk of CVD (cardiovascular disease) appears to be influenced by age of exposure to estrogen (usually cardioprotective when young) ⦁ no excess risk, and possible cardioprotection with use immediately after menopause. Jen says studies show about 4 years out, should start to d/c estrogen and switch to alternative ⦁ risk of CVD was only when using estrogen 10 years out of menopause; can use estrogen during that time period, however, if pt then has a heart attack, she is now at increased risk of CVD from the estrogen
40
risk of breast cancer
with estrogen + progesterone not with just estrogen therapy
41
rather than progestins like medroxyprogesterone acetate, ________________ is preferred
micronized progestin (natural)
42
why is micronized progestin preferred over medroxyprogesterone acetate?
Associated with lower risk of thromboembolism, stroke and elevated triglycerides Has not been associated with increased risk of breast cancer or CVD
43
the slight decrease in testosterone production that accompanies menopause can cause a
significant decrease or complete loss of libido in some women ⦁ testoserone can be added in doses of 1.25 - 2.5 mg methyltestosterone ⦁ wouldn't ever give testosterone alone; ass add on therapy - usually for decreased libido, but also see an increase in energy as well - the ovarian androgen production (testosterone) decreases at menopause --> can lead to decreased sexual function in postmenopausal women - can use testosterone replacement (usually 1 or 2% cream)
44
SE OF TESTOSTERONE
⦁ Acne & Hirsutism ⦁ Decreased HDL ⦁ Testosterone is aromatized to estrogen**
45
goal of free testosterone level
5-10
46
why do free testosterone levels need to be checked
because of decreased SHBG (sex hormone binding globulin) due to decreased estrogen, leads to increased free testosterone levels
47
how often to check free testosterone levels
every 6 weeks until stable, then every 6 months
48
with testosterone therapy, there is some concern about long-term _____________ effects
CV
49
If symptoms of urogenital atrophy are the only reason to use estrogen, is it recommended to use local estrogen or systemic estrogen?
local estrogen
50
- if systemic symptoms, will usually need a systemic approach - oral hormones or non-hormonal therapy (SSRIs/SNRIs / Gabapentin / Clonodine)
⦁ Nothing works as well as estrogen for vasomotor symptoms but consider other approaches first
51
give synthetic progestin or natural progesterone if the uterus is present?
natural progesterone (micronized)
52
A woman with a uterus using estrogen NEEDS ___________________ to protect the endometrium from unopposed estrogen, which increases the risk of hyperplasia & cancer
A PROGESTIN
53
unopposed estrogen increases the risk of
endometrial cancer | hyperplasia & cancer
54
how does estrogen cause a risk of clotting?
increases plasma fibrinogen and the activity of coagulation factors, especially factors VII and X; antithrombin III, the inhibitor of coagulation, is usually decreased
55
why is transdermal estrogen safer than oral
Less stimulation of clotting proteins by avoiding the first pass effect thru the liver = lower risk of VTE and stroke
56
forms of estrogen
- pills - transdermal ⦁ patches ⦁ gels / lotions / mist - Intravaginal ⦁ creams ⦁ tablet ⦁ ring
57
if ONLY treating vaginal dryness/atrophy =
may use topical estrogen cream The woman inserts 2-3 grams with a syringe into the vagina usually 2-3 x a week (at night, so gravity doesn't make it come out during the day)
58
should you be concerned about endometrial hyperplasia in women with a uterus using topical estrogen?
no, not enough is absorbed systemically to worry about endometrial hyperplasia
59
if someone with a uterus is being put on estrogen, now have to give progesterone too: Progesterone forms =
⦁ Medroxyprogesterone acetate ⦁ Micronized oral progesterone ⦁ Levonorgestrel - releasing IUD (mirena) - not FDA approved in US for this purpose of endometrial protection, but is still used sometimes
60
in terms of progesterone forms, there is less cancer risk associated with ___________ than with ____________
Less cancer (breast cancer) is associated with micronized oral progesterone than with medroxyprogesterone acetate
61
the benefit to risk ratio is FAVORABLE for hormone therapy for women who are:
1) within 10 years of menopause onset or 2) less than 60
62
WOMEN WHO SHOULD NOT BE GIVEN HRT
``` ⦁ hx of breast cancer ⦁ hx of endometrial cancer ⦁ coronary heart disease ⦁ previous thromboembolic event ⦁ stroke ⦁ acute liver disease ⦁ uncontrolled HTN ⦁ or at high risk of complications ```
63
endometrial hyperplasia or cancer can occur within ________ months of starting unopposed estrogen
6
64
who needs an endometrial biopsy
- before starting HRT in women with irregular bleeding - for any woman on continuous therapy who spots or bleeds after 6 months - bleeding or spotting after a year of amenorrhea in women not on hormones

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