menopause

Question 1

menopause beings

Answer 1

no period for 12 months the first day after that year

Question 2

average age of menopause

Answer 2

Menopause is the cessation of menstrual periods occurring at about 51.4 years in normal women

Question 3

impacts of not having estrogen for 30 years

Answer 3

cardiovascular
bone density
sexual function
memory 
dementia

Question 4

late postmenopause takes place

Answer 4

about 5-6 years after menopause begins

Question 5

Perimenopause is defined as

Answer 5

no period for 12 months

Defined as the 2-8 years preceding menopause

and up to 10 years
technically ends one year afte the least mentraul period

ovarian function waxes and wanes

Question 6

what occurs during perimenopasue

Answer 6

less frequent or more frequent bleeding

might get normal ovulary cycles interspersed with regular cycles

irregular menses but still need to be on contraception

Question 7

hormone cycles seen in perimenopause

Answer 7

Fluctuating FSH, estradiol, progesterone

FSH begins to rise, Inhibin B concentrations fall

Progesterone low in luteal phase

Estradiol low (more estrone)

Question 8

CM of peri menopause (early)

Answer 8

changes in bleeding patterns- pretty common

vasomotor symptoms-hot flashes

sleep disturbances-1st complaint

sexual dysfunction

Question 9

CM of peri menopause (late)

Answer 9

genitourinary sxs-later

Vaginal dryness/urogenital atrophy; dyspareunia

sexual dysfunction can also be a problem later

Question 10

as estrogen declines we frequently see these mood changes

Answer 10

depression

Question 11

what are vasomotor sxs associated with peri menopause

Answer 11

most common acute change

vasomotor sxs
75% of women experience hot flashes
sleep disturbance

fatigue irritability, depression and difficulty concentrating

Question 12

Genitourinary symptoms associated with menopause

Answer 12

Vaginal dryness/urogenital atrophy

Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy

Atrophic Vaginitis, Atrophic Urethritis

Recurrent urinary tract infections

Dyspareunia

Question 13

Sexual Dysfunction CM

Answer 13

Decreased vaginal lubrication

Decrease in blood flow to vagina/vulva

Vaginal atrophy, dryness and dyspareunia

Decrease in elasticity of the vaginal wall

? Decreased sensation in the clitoral and vulvar area

Shortening and narrowing of the vaginal vault

Question 14

what predisposes pts to depression

Answer 14

Prior history of depression or PMS is strong predictor

Depression during the perimenopausal years

Question 15

ddx of menopause

Answer 15

pregnancy

premature ovarian failure women <45

thyroid (always check TSH with fatigue or weight changes)

hyperprolactinemia

atypical hot flashes

Question 16

bone pain
weight loss
early satiety with hot flashes or atypical hot flasshes

Answer 16

suspect malignancies

atypical hot flashes only at night and during the day)

Question 17

labs for women under 45 with sxs of menopause

Answer 17

Blood work for HCG, prolactin, TSH, FSH
probably estradiol too (would be low if FSH up )

FSH of 8, 9, 10 = ovary shut down
over 25 probably peri menopause

increasing FSH in the presence of decreasing estradiol is indicative of menopause

Question 18

what would you want to do in a pt over 45 with really heavy bleeding

Answer 18

endometrial biopsy

Question 19

Post Menopausal Bleeding

Answer 19

Bleeding that occurs after 12 months of amenorrhea

never normal and always needs a work up (unless ot is on hormones)

Question 20

HCT bleeding usually looks like

Answer 20

Prolonged (10-14 days) or heavy bleeding associated with hormone replacement

takes about 3 months for women to adjust

Question 21

Unopposed oral estrogen is a bad idea because

Answer 21

Unopposed oral estrogen (without progesterone) in women with a uterus can cause hyperplasia and endometrial carcinoma

if there is a uterus need progesterone!!!!!

Question 22

Major source of estrogen in menopausal women

Answer 22

is conversion of androstendione to estrone

Question 23

Estrone compared to estrogen

Answer 23

Estrone is a less potent estrogen than estradiol

Question 24

what are the effects of estrone on the body

Answer 24

estrone because it is less potent will be accompanied by hot flashes and our typical menopausal symptoms

also can lead to cysts (adnexal mass or pain)

Functional cysts
Hemorrhagic cysts
Diagnosis may be achieved using ultrasound, laparoscopy or laparotomy

Question 25

lifestyle modifications for peri menopausal women

Answer 25

exercise regularly and sleep regularly hydration for regulation of the hypothalamus

Question 26

pH change with menopause

Answer 26

between 3.8 and 4.5 is normal during menopause Vaginal pH 6.0 to 7.5 Increase in pH and vaginal atrophy may impair protection against vaginal and urinary tract infection

Question 27

Inhibin B concentrations fall due to

Answer 27

to a decline in follicle number FSH levels begin to rise

Question 28

what labs would indicate menopause

Answer 28

High FSH and low estradiol values may be suggestive of menopause

Question 29

how topical estrogen is rx

Answer 29

every day for two weeks | to two to three times a week

Question 30

functional vs hemorrhagic cysts

Answer 30

functional cysts do not secrete anything

Question 31

anovulation is the result of

Answer 31

Due to progesterone deficiency

Question 32

other than EMB what else can be done to evaluate DUB in a post menopausal woman

Answer 32

TVS | To look at the endometrial stripe <5mm

Question 33

Vaginal dryness/urogenital atrophy

Answer 33

Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy

Question 34

sxs of atrophic vaginitis

Answer 34

Symptoms can include itching, irritation and dyspareunia (painful intercourse)

Question 35

long term complications

Answer 35

Osteoporosis Cardiovascular disease Dementia

Question 36

Osteoporosis is of significant risk in

Answer 36

more common in women with low estrogen levels

Question 37

cardiovascular disease is seen

Answer 37

seen as early as 2 years post menopause especially in women w/out hormone replacement women at higher risk than men after menopause due to the loss of estrogen

Question 38

when would you need to do a workup for post menopausal tx

Answer 38

if there is any bleeding at all and the pt is not on HRT hx of fibroids maybe do a TUS instead If bleeding for >6 mos on HRT (usually normal in first 3 months) OR on HRT and bleeding Prolonged (10-14 days) or heavy bleeding associated with hormone replacement maybe the fibroid was asleep before and now super heavy bleeding OR on unopposed oral estrogen

Question 39

everyone with a uterus needs to be on this type of HRT

Answer 39

progesterone and estrogen can lead to hyperplasia and endometrial carcinoma

Question 40

why do we workup a pt who is bleeding a lot on HRT

Answer 40

first thing we are worried about is endometrial cancer

Question 41

when can HRT not be considered

Answer 41

over the age of 60 or 10 years post menopause can use vaginal estrogen cardiovascular risk is too high

Question 42

indications for HRT

Answer 42

Osteoporosis prevention and treatment (not first line) Urogenital atrophy Vasomotor symptoms Symptomatic after oophorectomy

Question 43

what is the first line for osteoperosis

Answer 43

bisphosphinates

Question 44

probable benefits of estrogen

Answer 44

``` Improves mood, libido -Decreases skin aging -Decreases incontinence -Reduced osteoarthritis -Prevents cataracts -Prevents macular degeneration Hormone replacement NO LONGER FOR PREVENTION of CAD (Coronary Artery Disease) ```

Question 45

known benefits of HRT

Answer 45

``` Decreases hot flashes Improves bone mineral density (BMD) -Decreases fracture risk Improves sexual function -Improves symptoms of vaginal atrophy -Decreases risk of colon cancer Reduction of benign breast disease Prevention of ovarian cancer and endometrial cancer ```

Question 46

IUD would not work for these sxs of menopause

Answer 46

hot flashes just irregular bleeding would want OCP (enough estrogen to decrease hotflasshes)

Question 47

CI to HRT

Answer 47

```  Hypertension  Atypical breast lesions  Diabetes mellitus  Hx of gall bladder disease or stones  Migraines  Endometriosis  Fibrocystic breast disease  Uterine fibroids  Obesity  Seizures  Past history of deep venous thrombosis or pulmonary embolism ```

Question 48

when can you use OCP as opposed to HRT

Answer 48

OCP until age 51 if no contraindications then you can switch without testing however if you have a woman coming in with sxs and w/out BC probably want to test FSH first if over 25= menopausal and switch to HRT

Question 49

can say with confidence hormone users who develop breast cancer have better outcomes then those not on hormones probably because

Answer 49

more regualr screening

Question 50

if you have a woman with a 10 year CVD rish of 4% when could you use HRT

Answer 50

anywhere from 5-10 years after menopause

Question 51

if you have a woman with a 10 year CVD risk of 6% when could you use HRT

Answer 51

Trandermal only

Question 52

when would you avoid HRT if worried about her cardiovascular risk

Answer 52

if greater than 10%

Question 53

CI to HRT

Answer 53

such as a history of breast cancer, coronary heart disease [CHD], a previous venous thromboembolic event or stroke, or active liver disease

Question 54

what type of progesterone should be used in pts interested in oral HRT

Answer 54

micronized progesterone because it is effective for endometrial hyperplasia, is metabolically neutral, and does not appear to increase the risk of either breast cancer or CHD, although data are limited.

Question 55

HRT should be used for the length of time .

Answer 55

Suggest limiting to 5 years | but can be used for longer if time permits