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Flashcards in Menopause Deck (36)
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1
Q

Perimenopause

A
  • the ovary function starts to wane and decrease – you get a change in menstrual bleeding patterns
    • Defined as the 2-8 years preceding menopause
    • Ends one year after the last menstrual period
    • Ovarian function waxes and wanes
      • Less frequent ovulation – usually means irregular bleeding
        • If youre continuing to ovulate, YOU CAN STILL GET PREGNANT
      • Normal cycles interspersed w anovulatory cycles
      • Irregular menses, breakthrough bleeding, DUB
      • Fluctuating FSH, estradiol, progesterone
        • FSH begins to rise, Inhibin B concentrations fall
        • Progesterone low in luteal phase – if women do get pregnant in perimenopause, often times the pregnancy does not progress past the first trimester because of the low progesterone
        • Estradiol low
2
Q

declining ovarian function

A
  • Major source of estrogen in menopausal women is conversion of androstendione to estrone
    • Estrone is a less potent estrogen than estradiol
  • Can lead to ovarian disorders including:
    • Functional cysts
    • Hemorrhagic cysts
    • Diagnosis may be achieved using ultrasound, laparoscopy or laparotomy
3
Q

clinical manifestations of menopause

A
  • Change in bleeding patterns
  • Vasomotor symptoms – hot flashes – usually last a couple years after the start of menopause
  • Sleep disturbance – may be related to hot flashes
  • Genitourinary symptoms
    • Vaginal dryness/urogenital atrophy; dyspareunia
    • Urogenital atrophy and dryness usually occurs about 5 years after menopause
  • Sexual dysfunction – may happen depending on the patient and their relationship, may happen later with vaginal dryness
  • Depression – as estrogen declines, depression increases
    • This is also the case with post-partum
  • Long-term issues
    • Osteoporosis – steep decline in bone density
    • Cardiovascular disease – women are at a higher risk post menopause for dying of an MI than men
    • Dementia
4
Q

changes in bleeding pattern

A
  • Anovulatory bleeding/Chronic anovulation
    • Due to progesterone deficiency
    • Long periods of unopposed estrogen exposure can cause anovulatory bleeding
  • Oligomenorrhea lasting 6 months or more
  • Heavy dysfunctional uterine bleeding
    • Endometrial biopsy
    • Transvaginal ultrasound
5
Q

vasomotor symptoms

A
  • Most common acute change
  • Sleep disturbance secondary to hot flashes
    • fatigue, irritability, depression, difficulty concentrating
  • Up to 75% of women
    • Only 20% seek medical attention
  • Self-limited
  • Pathophysiology: unknown
    • Thermoregulatory dysfunction?
6
Q

genitourinary symptoms

A
  • Vaginal dryness/urogenital atrophy
    • Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy
  • Atrophic Vaginitis, Atrophic Urethritis
    • Symptoms can include itching, irritation and dyspareunia
    • May predispose to both stress and urge urinary incontinence
  • Recurrent urinary tract infections
7
Q

genitourinary symptoms

A
  • Findings on exam:
    • Pale, dry vagina
    • Lack of the normal vaginal folds
    • Petechiae on mucosa
    • Vaginal pH 6.0 to 7.5
  • Increased pH and vaginal atrophy may impair protection against vaginal and urinary tract infection
8
Q

sexual dysfunction

A
  • 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
    • Continuing sexual activity may prevent these changes
  • Responsive to estrogen therapy
9
Q

depression

A
  • Prior history of depression or PMS is strong predictor
  • Characterized by frequent mood changes, irritability, nervousness
  • Depression during the perimenopausal years
  • Nonhormonal events contribute
    • aging parents, empty nest
    • chronic illness, physical limitations
10
Q

long-term issues

A
  • Osteoporosis
  • Cardiovascular disease
  • Dementia
11
Q

secondary amenorrhea

A
  • Pregnancy
  • Premature Ovarian Failure (consider <45)
  • Thyroid dysfunction – always check TSH
    • Irregular menses, sweats, mood changes
  • Hyperprolactinemia
  • Atypical hot flashes and night sweats – if hot flashes are happening only at night
    • Medications
    • Malignancies
12
Q

making the menopause diagnosis

A
  • Definition: 12 months of amenorrhea
  • Women over age 45 in the absence of other biological or physiological causes
    • No further diagnostic evaluation for women in this group
  • Women <45 years: Blood work for HCG, prolactin, TSH, FSH
    • Usually FSH goes up and estrogen goes down
    • If you have an FSH over 25, it’s probably menopause or perimenopause
  • Assessment/History
    • menstrual cycle history
    • menopausal symptoms: vasomotor flushes, vaginal dryness
13
Q

post menopausal bleeding

A
  • Bleeding that occurs after 12 months of amenorrhea
  • Not associated with hormone replacement
  • Prolonged (10-14 days) or heavy bleeding associated with hormone replacement
    • This can be a result of an undiagnosed fibroid
  • Bleeding associated with non-phasic hormone replacement after 3-6 months
  • Unopposed oral estrogen (without progesterone) in women with a uterus can cause hyperplasia and endometrial carcinoma
    • IF THEY HAVE A UTERUS, THEY NEED TO BE ON PROGESTERONE
  • All methods of HRT may yield bleeding
    • Breakthrough bleeding ranges 10-40%
  • Most women will bleed the first three months
  • Vaginal administration of estrogen for urogenital symptoms of estrogen deficiency may rarely stimulate the endometrium
  • Patients using HRT who require evaluation:
    • On hormones for 6 months or more and bleeding
    • Bleeding is irregular, prolonged or heavy
    • Patients with intact uterus on unopposed estrogen
  • Evaluation should include:
    • Yearly endometrial biopsies (preferred)
    • Transvaginal ultrasound to check endometrial stripe
14
Q

hormone therapy treatment

A
  • Don’t start hormones (estrogen and progesterone) if they are over 60 or if they are 10 years post menopausal – DON’T EVER EVER EVER DO THIS
15
Q

Indications for HRT

A
  • Vasomotor symptoms (perimenopause, early menopause)
  • Urogenital atrophy (postmenopausal)
  • Symptomatic after oophorectomy – within a short period of time, you can still put them on hormones
  • Osteoporosis prevention and treatment
    • Not recommended as 1st line therapy
16
Q

Beneficial effects of estrogen

A
  • Definite Benefits
    • Decreases hot flashes
    • Improves bone mineral density (BMD)
    • Decreases fracture risk
    • Improves sexual function
    • Improves symptoms of vaginal atrophy
    • Decreases risk of colon cancer
  • Possible Benefits
    • Improves mood, libido
    • Decreases skin aging
    • Decreases incontinence
    • Reduced osteoarthritis
    • Prevents cataracts
    • Prevents macular degeneration
    • Prevents/slows dementia
17
Q

treatment of perimenopausal symptoms

A
  • Advantages of using hormones (OCP or IUD):
    • Prevention of ovarian cancer and endometrial cancer
    • Reduction of benign breast disease
      • 30% reduction fibrocystic disease
      • 60% reduction fibroadenomas
    • Decrease dysmenorrhea, menorrhagia and anemia
    • Improved bone density
    • Control of erratic vasomotor symptoms
    • Stabilization of irregular bleeding
    • women lose 8-10% of bone mass from age 35-50, OCP use counters the premenopausal losses
    • Do not use use OCP if over 35 years old and smoking
    • IUD does not decrease hot flashes
18
Q

transitioning from OCP to HRT for perimenopause

A
  • OCP until age 51 if no contraindications
    • Can switch without testing
  • Check FSH in day 5-7 of pill free week
    • FSH over 25, probably menopausal
    • Switch to HRT
    • No data support risk benefit or cost benefit of this approach
19
Q

world health initiative study

A
  • Large prospective study (2002, JAMA)
  • 16,608 postmenopausal women (50-79 yo)
    • Average age at enrollment = 63 yrs
  • Two arms:
    • Estrogen + Progestin (Prempro 0.625/2.5), n=8506
    • Placebo, n=8102
  • Study designed to investigate long-term benefits and risks of HRT
    • Outcomes measured:
      • Primary : Coronary heart disease (CHD) and invasive breast cancer
      • Secondary : stroke, pulmonary embolism, DVT, endometrial CA, colorectal CA, hip and vertebral fractures and death from other causes
  • HRT arm of the study discontinued after 5.2 years because potential risks outweighed benefits
20
Q

WHI: ERT vs placebo

A
  • WHI 2004 (JAMA)
  • 10,739 postmenopausal women
    • s/p hysterectomy (50-79 yo)
    • Average age @ enrollment = 63.6 yo
  • Two arms:
    • Estrogen (Premarin 0.625 mg), n=5310
    • Placebo, n=5429
  • Outcomes:
    • Primary: CHD and invasive breast cancer
    • Secondary: stroke, pulmonary embolism, DVT, colorectal cancer, hip/vertebral fractures and death from other causes
21
Q

rationale for trials in recently menopausal women

A
  • A cardioprotective effect of HT initiated early in menopause is supported by:
    • Human outcomes data from large observational studies
    • Experimental data showing:
      • Benefits of early (but not late) HT in primates
      • Beneficial effects on CVD risk factors in humans
  • Data subsets from the WHI provide plausible explanations for differences in HT effects with early vs. late initiation
    • New clinical trials of early HT intervention are warranted
22
Q

WHIMS: world health initiative memory study

A
  • Designed to evaluate postmenopausal estrogen and progesterone and its effect on the reduction of the risk of dementia in women over age 65
  • Absolute risk low in both groups (highest in women 75 and older)
    • 45 cases/10,000 women on HRT
    • 22 cases/10,000 women on placebo
  • After four years:
    • Active drug: 45 cases/10,000 women per year
    • Placebo: 22 cases/10,000 women per year
  • Conclusion: HRT and cognitive function, no clinically significant difference
23
Q

WHI and breast cancer

A
  • The risk of breast cancer published by the WHI is smaller than with other risk factors known to be associated with breast cancer
    • The increased risk of breast cancer attributed to being overweight after menopause is a greater risk
  • “We can say with confidence hormone users who develop breast cancer have better outcomes then those not on hormones”.
    • Leon Speroff M.D., Professor Ob/Gyn
  • This may be due to the fact that they have yearly clinical breast exams and mammograms.
24
Q

weighing the risks of HRT

A
  • Distinguish between individual risk vs. public health risk
  • Risk benefit ratio
    • Can this data be extrapolated to other estrogen progesterone regimens, such as lower doses?
    • Can this data be extrapolated to younger healthy perimenopausal women in their 40’s and 50’s?
  • Decision is up to the well informed patient and health-care provider
25
Q

HRT and menopausal symptoms: benefit/risk assessment

A
  • Assessment of risk in newly menopausal women
    • Breast cancer—generally no increased relative risk observed with short-term use
    • CHD—absolute risk is generally low in newly postmenopausal women, dependent on background rate and risk factors
    • Must consider other potential risks: DVT, PE, stroke
  • For many newly menopausal women with moderate to severe symptoms, benefits will outweigh risks
26
Q

HRT guidelines and recommendations

A
  • Indicated to treat symptomatic patients
    • Vasomotor, depression/mood lability, genitourinary syndrome, sleep disturbances
  • Women in their 50’s who are otherwise healthy have very low risks from HRT
  • Women <60yo or within 10 yrs of menopause and without contraindications or other risk factors are appropriate candidates for HRT
  • The benefits of MHT outweigh the risk for healthy, symptomatic women who are within 10 years of menopause or younger than age 60 years and who do not have contraindications to MHT (such as a history of breast cancer, coronary heart disease [CHD], a previous venous thromboembolic event or stroke, or active liver disease).
27
Q

How to prescribe HRT

A
  • Use lowest dose possible to achieve symptom relief
  • Use shortest duration of treatment
    • Suggest limiting to 5 years
  • Recommend transdermal estrogen
    • Lower risk of VTE, CVA
  • For vaginal atrophy use topical estrogen
  • Recommend micronized progesterone
  • Add progestin to estrogen therapy when uterus intact
  • We suggest transdermal 17-beta estradiol for many women starting MHT. The transdermal route is particularly important in women with hypertriglyceridemia or risk factors for thromboembolism. However, the baseline risk of both venous thromboembolism (VTE) and stroke is very low in otherwise healthy, young postmenopausal women. Therefore, if a patient prefers an oral preparation over a transdermal one (cost or personal preference), we consider oral estrogen to be safe. All types and routes of estrogen are equally effective for hot flashes.
  • For women with an intact uterus who choose ET, progestin therapy must be added to prevent endometrial hyperplasia and carcinoma.
  • We suggest micronized progesterone as our first-line progestin 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.
  • We currently suggest not using MHT for the prevention of chronic disease (osteoporosis, CHD, or dementia). However, women who cannot tolerate other options for osteoporosis may be reasonable candidates.
28
Q

conclusions: hormone therapy

A
  • Postmenopausal hormone therapy (HT) should not be initiated or continued for the prevention of cardiovascular disease or other chronic diseases at any age
  • HT has a clinical role in the treatment of moderate to severe hot flashes and other menopausal symptoms
  • The lowest effective dose should be used for the shortest duration necessary
  • Additional research on the benefits and risks of HT initiated early in menopause is warranted
29
Q

integrative approach to menopause treatment

A
  • Preventive health care
  • Lifestyle counseling
  • Nutrition
  • Supplements / Botanicals
  • Mind-body interventions
  • Hormonal therapy
30
Q

keys to making the transition easy: menopause managment strategies

A
  • Prepare your patients
    • Provide up to date information
    • Make your patients aware of routine testing
    • Set realistic goals
  • Inform them of lifestyle and treatment options
    • Newspaper and magazine articles
    • Web sites
    • Television and videos
31
Q

preventative health care

A
  • Pap smear, blood pressure, height
  • Breast cancer screening (CBE, mammogram)
  • Other health screenings as indicated, bone density, blood work
  • Vision, heart disease and diabetes risk assessment
  • Colon cancer screening
  • Vaccinations as indicated
32
Q

Lifestyle changes

A
  • Addressing use of tobacco, alcohol and other substances
  • Obesity and Physical Activity
  • Adequate Sleep
  • Nutrition
  • Sexuality
  • Spiritual Health
33
Q

alternatives to hormone therapy: for prevention of cardiac disease

A
  • Quit smoking
  • Exercise
  • High fiber/Low fat diet
  • Control high blood pressure
  • Manage coexisting medical problems like Diabetes
  • Possibly Aspirin therapy
34
Q

nutrition

A
  • Whole foods whenever possible, complex carbohydrates
  • Fruits/vegetables 5-9 servings
  • Water intake 8 glasses/day
  • Minimize caffeine, alcohol, sugar intake
  • Coldwater fish, 2-3 servings per week
  • Olive oil, soy, flax
35
Q

supplements

A
  • Calcium
  • Magnesium
  • Vitamin D
  • Multivitamins and Antioxidants
  • Omega-3 fatty acids
  • Vitamin E
36
Q

alternatives to hormone therapy: prevention of hot flashes

A
  • Lifestyle changes
    • Avoid hot spicy foods
    • The layered look
    • Lower thermostat
    • Exercise
    • Relaxation, biofeedback