Menopause/HT/Incontinence Flashcards
(31 cards)
Define menopause
Final menstrual period.
Ovarian event
Median age 52 (40 -58)
Criteria to diagnose menopause
Amenorrhea greater than 12 months or Surgical loss of ovaries or Radiation or chemically induced loss of ovarian function
Hormone changes in menopause
Estrogens: relatively constant level after menopause
1. Estradiol (E2) 10-20 pg/ml
2. Estrone (E1) 30-70 pg/ml mostly peripheral
conversion
Androgens: after several years, levels drop by 50%, and main source is adrenal
Decreased SHBG = increased free testosterone
Ratio of estrogen:androgen=acne, hirsutism
Factors in late menopause
Multiparity Increased BMI (Body Mass Index)
No link found between age of menopause and:
OCP use, socioeconomic status, age of menarche
Factors in early menopause
Smoking: relationship between number of cigarettes smoked and duration of smoking to age of menopause
Genetics: polymorphisms of estrogen receptors
Thin women, vegetarians
Nulliparity
Depression
Epilepsy: especially with high seizure frequency
Toxic chemical exposure
What is premature ovarian failure?
transient or permanent loss of ovarian function leading to amenorrhea before 40 years old
(1% of women)
What happens to estrogen during hormonal transition?
Erratic hormone secretion: (FSH>10 on days 2-5 of cycle may be first sign of reproductive aging)
- Less follicles create less inhibin B and more FSH - More FSH recruits more follicles each month - More follicles stimulate more estradiol - More estradiol= perimenopausal symptoms (bloating, irritability, mastalgia, menorrhagia, growth of fibroids)
Symptoms of peri menopausal transition
Hot flashes, night sweats (VMS)
Menstrual irregularities, PMS worse
Vaginal dryness, libido changes
Unknown relation to estrogen:
Fatigue, nervousness, headaches, insomnia, depression, irritability, joint & muscle pain, dizziness
Grading of vasomotor symptoms
(1) Not present
(2) Mild – Do not interfere with usual activities
(3) Moderate – Interfere somewhat with usual activities
(4) Severe – So bothersome that usual activities cannot be performed
Triggers and other causes of vasomotor symptoms
Triggers: Stress Hot or humid weather, hot drinks Caffeine, alcohol or spicy food Closed or tight spaces Smoking More likely to occur in late afternoon or early evening (circadian rhythm)
Other causes: Thyroid disease Epilepsy Infection Insulinoma, pancreatic tumors Leukemia Autoimmune disorders Carcinoid syndromes Pheochromocytoma
1st line therapies for VMS
Lifestyle changes:
- Regular exercise
- Trigger avoidance
- Paced respiration (50% improvement)
- Relaxation techniques, deep breathing
- Stop smoking
- Dress in thin layers of cotton clothing
- Dietary changes
Pharmaceutical treatments surrounding menopause
PMDD-Sarafem 20-60mg/day
Prescription antidepressants/anti-anxiety medications: Zoloft, Buspar, Paxil, Welbutrin, Prozac, Tranxene, Xanax, Effexor (37.5mg daily x 4 weeks–> Increase to 75mg daily if modest improvement)
Clonidine (alpha 2 agonist) 0.1mg daily
Gabapentin (anti-convulsant) 600 or 900mg daily
First line therapies for sleep (non-pharm):
Diet: no caffeine after 4PM; avoid late evening heavy meals, spicy food and alcohol
Snack with protein & carbohydrate may help
Stop smoking (prolongs sleep onset and decreases sleep duration)
Keep bedroom dark and cool
Keep bedtime the same time every night
Relaxation techniques: hot bath with lavender, hot milk and honey, soft music, massage, meditation, journal-keeping
Regular exercise, but avoid for at least 2 hours before bed
Pharmacological and herbal sleep aids
Hypnotics & sedatives: Sonata (lasts 1-3 hrs, helps with sleep onset), Ambien, Halcion, Dalmane, Valium
*SE of Sedatives: next-day sedation, rebound insomnia
Low dose OCPs, ERT/HRT if vasomotor Sx
Micronized progesterone
Melatonin 3-5mg 1 hour before bedtime
Valerian 530 mg BID
Evaluation of post-menopausal women (H&P components)
History:
- Personal, family history of osteoporosis
- Cancer (breast, ovarian, uterine, colon)
- Hypertension, cardiovascular disease
- Medications, nutritional supplements, botanicals
- Urinary or fecal incontinence
Physical exam:
- Height, weight, BMI, BP
- Thyroid palpation
- Heart and lung auscultation
- Clinical breast exam, axillae
- Abdominal palpation
- Pelvic exam
- Rectal exam?
Screenings
- Cervical cytology & HPV (ASCCP)
- Mammography annually (ACOG)
- Stool for occult blood/colonoscopy
- Lipid profile, TSH q 5 years
- FBS q 3 years
- Hep C at least once
- Bone mineral density
- Smoking, alcohol, exercise
FSH and estradiol levels that strongly indicate menopause
FSH (serial measurements) > 25
Estradiol < 20
Lipid changes with estrogen loss
Increase in total cholesterol, LDL cholesterol, and triglycerides
Decrease in HDL cholesterol
Symptoms of Genitourinary Syndrome of Menopause (GSM)?
Genital symptoms
- Dryness
- Burning
- Irritation
- Impaired function
Urinary Symptoms
- Urgency, Dysuria, Hematuria
- Recurrent UTIs
Sexual Symptoms
- Loss of libido
- Loss of arousal
- Lack of lubrication
- Dyspareunia
- Dysorgasmia
- Pelvic pain
- Bleeding or spotting during intercourse
Treatment of Genitourinary Syndrome of Menopause
Vaginal estrogen
- Creams (Estrace, Premarin)
- Tablets (Vagifem)
- Ring (Estring)
Non-hormonal (SERM), oral
* Ospemifeme (Osphena)
Intravaginal CO2 laser therapy
* MonaLisa Touch
Radiofrequency
* ThermiVa
Vaginal moisturizers and lubricants
+/- vaginal dilator
Vaginal DHEA
Types of incontinence
- Stress: involuntary loss of urine with increased intra-abdominal pressure (cough, sneeze); most common type
- Usually in drops, small amounts - Urge: loss of urine from contraction of the detrusor muscle (smooth muscle of the bladder wall)
- Large volume of urine lost; flood - Mixed: both of the above at the same time
- Overflow: bladder never really empties; overflows
- Extra-urethral: fistula
Stress incontinence management
- Strengthen pelvic floor muscles (Kegels)
42-56% of women report improvement
5 reps of 10 Kegels daily - Losing weight (if obese)
- Estrogen? (role unknown)
- Pseudoephedrine 30mg 1-3x/day
Urge incontinence management
- Anticholinergic drugs (suppresses detrusor contractions)
- Detrol, Ditropan, Urispas (relaxes smooth muscle)
- Tricyclic antidepresants (relax smooth muscles)
- Botox injections
- Behavior modification
ERT: no apparent role
Vaginal estrogen indications
The genitourinary syndrome of menopause (GSM):
- Dryness
- Burning
- Irritation
- Sexual symptoms (decreased lubrication, pain)
- Urinary symptoms (urgency, dysuria, recurrent UTI)
Discuss with oncologist if h/o breast or endometrial cancer
Can be very expensive/cost-prohibitive
