Metabolic and Menopause

Question 1

What stimulates releaase of FSH and LH from the pituitary?

Answer 1

GnRH from hypothalamus

Question 2

effect of FSH/LH on uterus and ovary

Answer 2

release estrogen and progesterone

Question 3

Progesterone has ____ effect on GnRH release

Answer 3

negative

Question 4

is a syndrome of ovarian dysfunction affecting 6-8% of reproductive age women worldwide. The most common endocrine abnormality of women of reproductive age.

• Its clinical manifestations include: chronic anovulation (oligo/amenorrhea, infertility) and hyperandrogenism (hirsutism, acne, alopecia).

Answer 4

PCOS

Question 5

Define PCOS

what risks are associated with it?

Answer 5

The syndrome is defined by a clustering of signs and features, where no single test is diagnostic.

• PCOS is associated with an increased risk of diabetes and other metabolic abnormalities which may potentially increase the risk of coronary artery disease

Question 6

Clinical Manifestations of PCOS Hyperandrogenism

Answer 6

Hirsutism, acne, alopecia, deepening voice, more muscle, clitoromegaly often peripubetal onset

Question 7

Pathophysciology of PCOS?

Answer 7

 Complex disorder and partially understood

 Gonadotropin secretion disturbance
 Steroidogenesis disorder
 Insulin resistance

Question 8

Explain pathphys of PCOS in relationship to high androgens effect on:

skin:

insulin:

adipose tissue:

Answer 8

Skin: hirsutism, acne, acnothosis nigrans

INuslin: insuiln resistance

Adipose: increase estrone production causing endometiral hyperplasia as well as follicular atresian = anovulation/amneorrhea

Question 9

We get tons of androgen production in PCOS becse the ____ is stimulated by a high LH:FSH ratio from abnormal androgen and estrone feedback

Answer 9

ovary or theca

Question 10

LH stimulstes the ____ cell to make testosterone and androstendione from cholesterol

Answer 10

Theca cell

Question 11

FSH stimulates the ___ cell to make estradiol and DHT from androstendione and testosterone it gets from the Thecal cell

Answer 11

Granulosa cell

Question 12

High levels of ___ and ___ INCREASE thecal cell production of more androstendion and testesterone

Answer 12

IFG and INhibin

also insulin increases prodcution!!!

Question 13

we see ____ in lean and obese women with PCOS compared to otehr women

Answer 13

insulin resistance (thus encourages Thecal cell to make androgens)

Question 14

Dx criteria for PCOS

Answer 14

at least 2 of the 3:

• Oligo- or anovulation
• Clinical and/or biochemical signs of hyperandrogenism

• Polycystic ovaries on imaging
And

• Absence of secondary causes (CAH, androgen-secreting tumors, Cushing’s syndrome)

Question 15

Similarities of PCOS and Metabolic Syndrome Related to Insulin Resistance

Answer 15

• Central obesity
• Hyperinsulinemia
• Low SHBG
• Abnormal lipids (elevated TG, low HDL)
• Higher prevalence of IGT and diabetes.
• Increased risk of non alcoholic steatohepatitis (fatty liver).

Question 16

Dx of PCOS

Answer 16

• Diagnosis of PCOS made based on history, clinical suspicion
• Biochemical evaluation is for excluding less common causes of hirsutism and menstrual irregularities (androgen secreting tumors, CAH, thyroid disease)
• Biochemical testing will often result in “normal” results
• Tests for insulin resistance are not required to make a diagnosis of PCOS

Question 17

Mangement of PCOS; tx complaint and think about long term issues:

• Treatment of symptoms of anovulation :

Answer 17

• regulate menses
• induce ovulation
• endometrial cancer risk reduction

Question 18

• Treatment of obesity and metabolic disorders in women with PCOS includes:

Answer 18

• Obesity management
• Sleep apnea screening
• Diabetes prevention

-Lipid management and cardiovascular disease risk reduction

Question 19

Treat symptoms of hyperandrogenism and screen for anxiety and depresssion

Answer 19

in women with PCOS

Question 20

HOw do OCPS help tx PCOS?

Answer 20

Suppress ovarian androgen secretion by suppression of gonadotropins

Increases SHBG

Decreases free testosterone and free androgen index

Improves hirsutism

Regulates menses and provides adequate progestin to protect endometrial lining (lowers risk for endometrial hyperplasia)

Question 21

• Competitive inhibitor of androgen receptor

• Improves hirsutism, acne and alopecia
• Does not inhibit androgen secretion
• Requires reliable contraception

used to tx PCOS

Answer 21

spironolactone

Question 22

the final menstrual period and is usually confirmed when a woman has missed her period for 12 consecutive months (in the absence of other obvious causes).

• It reflects complete or near complete depletion of ovarian follicles and absence of ovarian estrogen secretion. It marks the permanent end of fertility.

Answer 22

• Menopause

Question 23

Age of menopause and what is it influenced by?

Answer 23

• Average age is 51, but age ranges from 40 to early 60s. (occurs after 55 in 5% and between 40-45 in 5%.
• Age of menopause influenced by genetics, ethnicity, smoking, and reproductive history.

Question 24

It can last 6 years or more and ends 1 year after the final menstrual

period.

Answer 24

Perimenopause/Menopause Transition

Question 25

Interval of amenorrhea \>60 days with elevated FSH during cycle, and start to see VMS

Answer 25

late transition to menopause

Question 26

Pt has amenorrhea, highly variable FSH with VMS

Answer 26

EArly post menopause

Question 27

pt has amnenhorrea, stable FHS, increaseing UG atrophy

Answer 27

Late post menopause

Question 28

Vasomotor symptoms, sleep disturbance and depression are ___ signs of meonopause

Answer 28

GOOD evidence

Question 29

FAir evidence of menopause

Answer 29

cognitive dysnfx, urinary incontinence,sexual dysfunx

Question 30

Consequences of **Estrogen Deficiency** in the Postmenopausal Years

Answer 30

* Increased risk of _osteoporosis_ * Increased risk of _diabetes_ * Increased risk of _CHD and CVD_ * Changes in body composition-_increased fat mass_ • Skin changes

Question 31

early tests where they gave women E+P for postmenopause discontinued bc? What about Estrogen only?

Answer 31

average follow up 5.2 years due to increased breast cancer, CHD, stroke, VTE Estrogen only: increased risk of stroke

Question 32

Observational studies had different results then the WHI: VMS Age at HT initiaion time since menopause BMI:

Answer 32

Yes had VMS initiated at 52 yrs 2 yrs since menopause BMI 24-25

Question 33

* relieves VMS and relieves vaginal atrophy * blocks bone resorption (approved for prevention of osteoporosis) • provides endometrial protection and an alternative to progestogen therapy for women with a uterus who are averse to vaginal bleeding, breast tenderness, or altered mood.

Answer 33

The combination of CEE with the SERM bazedoxifene (BZA)

Question 34

provides endometrial protection and an alternative to progestogen therapy for women with a uterus who are averse to vaginal bleeding, breast tenderness, or altered mood.

Answer 34

Bazedoxifene

Question 35

Current Indications for Menopausal Hormone Therapy (MHT)

Answer 35

Younger symptomatic postmenopausal women less than a decade from final menstrual period and without increased risk for CHD and breast cancer with LOWEST possible dose

Question 36

must be prescribed with systemic ET for uterine protection in women who have a **uterus**

Answer 36

Progestin or the SERM bazedoxifene

Question 37

MHT is not indicated for

Answer 37

prevention of chronic disease (CHD, breast cancer, dementia, etc)

Question 38

For isolated vaginal symptoms, both systemic and vaginal estrogens are effective

Answer 38

VAGINAL ESTROGEN

Question 39

V is preferred for isolated vaginal symptoms-- vaginal dryness, dyspareunia—given its potent local effect and minimal degree of systemic absorption.

Answer 39

vaginal estrogen \*\*\*dont need progestin even if they have uterus if given at LOW does

Question 40

SERM taken orally for atrophic vaginitis and dyspareunia

Answer 40

OSPEMIFENE

Question 41

NOn hormone alternatives for vasomotor symptoms

Answer 41

SSRI/SNRI- paroxetine, venlafaxine, etc Gabapentin Clonidine

Question 42

• has important systemic effects affecting the risk of cardiovascular disease, osteoporosis, and endometrial and breast cancer

Answer 42

Estrogen

Question 43

• is the most effective treatment for vasomotor symptoms

Answer 43

Estrogen

Question 44

is safe for the majority of symptomatic, younger, healthy postmenopausal women for short term use for treatment of vasomotor symptoms and osteoporosis prevention and treatment

Answer 44

Estrogen therapy

Question 45

Unopposed estrogen is contraindicated in women

Answer 45

with a uterus