week 11-menopause Flashcards
1
Q
natural menopause
A
e permanent cessation of menstruation, determined retrospectively after 12 consecutive months of amenorrhea without any other pathological or physiological cause
2
Q
age of menopause
what changes cause it
A
after the age of 45 years secondary due to primary ovarian failure to produce follicles/sufficient estrogen [typically between 48–55]
- average age of natural menopause: 51 yrs (Canada)
3
Q
easy menopause at what age
A
menstruation cessation before age 45
4
Q
primary ovarian insufficiency/ premature menopause
A
menstruation cessation before age 40, which may be transient, due to genetic abnormalities, metabolic disturbances, pelvic surgery, radiation therapy, chemotherapy or immune disorders
5
Q
induced menopause
A
permanent cessation of menstruation due to surgery, chemotherapy or radiation
6
Q
factors that can influence the age of menopause
A
- genetics
- autoimmune disease - may lead to earlier menopause
- medical procedures (chemotherapy, pelvic radiation, hysterectomy,
oophorectomy) - can lead to earlier menopause - smoking - advances menopause by approx. 2 years
- diet - undernourished women and vegetarians trend to earlier menopause
- body mass index (BMI) - women with greater adipose tissue may delay
menopause; conflicting data
7
Q
perimenopause
A
the year before the final menstrual period through the first year after the final menstrual period
consider females to be in perimenopause if they have not had a period in the previous 3-11 months or if they have experienced changes in menstrual regularity during the past 12 months
~47yoa
8
Q
post menopause
A
the period of time that follows menopause
9
Q
changes in FSH, AMH, AFC (antral follicle count) in post menopause
A
increase FSH, decrease AMH and AFC
10
Q
changes in FSH, AMH, AFC (antral follicle count) in menopause transition
A
decrease AMH and AFC
decrease FSH or varies
11
Q
typical menses when going into menospause
A
usually shorter cycles, sometimes longer or irregular bleeds
12
Q
vasomotor sx in menopasuse
A
hot flashes, night sweats, sleep disturb
13
Q
genitourinary syndrome of menopause and sexual dysfunction
A
urinary incontiennce, decrease libido, vaginal dryness, dyspareunia
14
Q
psychological sx in menopause
A
worsening PMS
depressed, irritable, mood swings, poor memory and concentration
15
Q
somatic sx in menopause
A
headache, dizzy, palpitations, weight gain, joint aches, back pain, dry and itchy skin
16
Q
highest LR+ for perimenopause findings
A
hot flashes
vaginal dryness
high FSH
low inhibin B
17
Q
not useful findings for prediction of perimonpause
A
estradiol - low sensitivity and highly variable
AMH
18
Q
vasomotor sx
A
flashing and perspiration for 1-5 min
19
Q
most common and characteristic sx of menopause transition
A
hot flashes
20
Q
risk factors for vasomotor sx in menopuase
A
early or surgical menopause
african ethnicity
high BMI
smoker
negative affect; anxiety
sedentary lifestyle
use of selective estrogen-receptor modulators (SERMs) or aromatase
inhibitors (AIs)
21
Q
manage vasomotor sx
A
calcium and vitamin D
contraception, non pharmacologic, estrogen/homronal, progesterone,
CHART ON SLIDE 17
22
Q
diagnose menopause based on
A
sx- can be made clinically
STRAW+10
physical exam
FSH labs
23
Q
DDX for amenorrhea
A
- pregnancy (hCG)
- asherman’s syndrome (TVUS, contrast SHG)
- anorexia (clinical interview + physical)
- malignancy (TVUS, MRI)
- pituitary adenoma (prolactin, TSH, MRI)
24
Q
DDX for vasomotor sx
A
- hyperthyroidism (TSH, fT4, fT3)
- diabetes mellitus (FBS, HbA1c)
- malignancy (TVUS, MRI)
- carcinoid syndrome (5-HIAA, CT)
- pheochromocytoma (CT)
- tuberculosis and other chronic infections (CBC+)
25
DDX for abnormal uterine bleeding
- endometrial hyperplasia or cancer (TVUS, Bx)
26
DDX for atrophic vulvovaginitis (GSM)
vulvar and vaginal infections (e.g. trichomoniasis, candidiasis) (swab)
- dermatologic conditions (e.g. contact dermatitis)
- lichen sclerosus, lichen planus (skin exam)
- carcinoma (vaginal, cervical) (pelvic exam)
27
DDX for osteoporosis (back pain)
- gastric ulcer (endoscopy)
- renal colic (xray)
- pyelonephritis (UA, culture)
- pancreatitis (amylase, lipase)
- spondylolisthesis or acute back strain (xray)
- herniated intervertebral disc (xray)
28
if <45 and think have menopause what do you look for in FSH
FSH >40IU/L on 2 occasions 4-6 weeks apart confirms ovarian failure
29
health maintenance screening in menopause
- cardiovascular health (Framingham risk every 3-5 years)
- BP, weight
- osteoporosis risk assessment - height (annually)
- breast exam and cervical cytology - according to screening guidelines
30
menospause and low estrogen state is associated with
- reduced vulvovaginal health - genitourinary syndrome of menopause (GSM)
- reduced sexual health
- reducing bone mineral density (osteopenia/osteoporosis)
- increased cardiovascular disease risk
- reduced cognitive health
- increased risk of poor mental health
- increased breast cancer risk
- reduced dermatologic health
31
genitourinary syndrome of menopause (GSM)
2 main symptoms
other symptoms and signs
vaginal dryness and dyspareunia
- symptoms: vaginal dryness, dyspareunia, poor lubrication, postcoital bleeding, reduced arousal / libido, vulvovaginal irritation, dysuria, urinary urgency, urinary frequency, recurrent UTI
- signs: labia majora resorption, narrowed introitus, absent hymenal tags, tissue erythema or pallor, urethral prolapse, prominent urethral meatus, absent rugae, fragile or fissured tissue, petechial hemorrhages, scant vaginal secretions, poor elasticity
32
risk factors for genitourinary syndrome of menopause (GSM)
- menopause, premature ovarian failure, and other causes of low estrogen (eg. postpartum period, hypothalamic amenorrhea)
- bilateral oophorectomy
- smoking
- alcohol abuse
- decreased sexual frequency or abstinence
- lack of a vaginal birth
- cancer treatments (e.g. pelvic irradiation, chemotherapy,endocrine therapy)
33
genitourinary syndrome of menopause (GSM)
cause and what it leads to
- low estrogen leads to vulvovaginal, urethral, bladder and pelvic floor atrophy
34
day to day impact of vaginal aging questionnaire
see how vaginal symptoms (i.e. dryness, itching) has interfered with walking, clothes, sleeping, sitting, toilet use, if it effects mood, embarrassed, if it effect sexual intercourse and arousal and feeling desirable...
35
findings of pelvic exam in perimenopause
thin and shiny vaginal mucosa, rug are flattened
introital or vaginal narrowing
pH >4.6 = vaginal atrophy
smears (e.g. vaginal maturation index - greater parabasal cells reflects
greater atrophy)
36
Society of Obstetrics and Gynecology Canada (SOGC) for indications of pelvic exam
any women with gyneologic complaints!!!
- includes: vulvar complaints, vaginal discharge, abnormal premenopausal bleeding, postmenopausal bleeding, infertility, pelvic organ prolapse symptoms, urinary incontinence, new and unexplained gastrointestinal symptoms (abdominal pain, increased abdominal size/bloating, and difficulty eating/early satiety), pelvic pain, or dyspareunia
and women over 70 who dont need cervical cytology
any postmenopausal bleeding must be investigated to exclude malignancy
37
postmenopausal bleeding could be
malignancy; so do pelvic exam
38
therapies for genitourinary symptoms of menopauses
1st line: vaginal moisturizer and lubricants
2nd line: low dose vaginal estrogen (unless high risk of breast cancer)
39
pelvic exam of genitourinary symptoms of menopause looks like
erythematous patches, petechiae, erosions pale, smooth, dry vaginal epithelium yellow-green discharge
40
estrogen deficiency on urogenital tissues causes
vulvovaginal atrophy, urinary urgency, dysuria, and recurrent urinary tract infection
41
if do vaginal estrogen for GSM will it effect system?
Clinically significant systemic hormone absorption does not occur with low-dose therapy, so concomitant progestogen therapy is not needed
42
3 components of sexual function
1. the individual’s motivation (aka., desire or libido)
2. endocrinecompetence
3. socioculturalbeliefs
43
menopause impacts on sexual health
low estrogen effects; decreased vaginal expansion, less secretions and vasocongestion etc
decrease sex desire and libido
44
perimenopausal bone health
primary osteoporosis from estrogen deficiency
effects osteoclast activity; bone resorption increased
risk of fracture
45
signs of low bone density
kyphosis, height loss and fractures
46
osteoporosis risk factors
early menopause (before 45)
age > 65
hypogonadism
malabsorption syndrome
systemic glucocorticoids
smoker
low calcium intake
low weight
RA
excessive calcium and alcohol
47
bone mineral density via ____ and look at what structures
DEXA dual-energy xray absorptiometry
lumbar vertebrae (identifies early rapid bone loss) and femoral neck (predicts femoral head fracture)
48
DEXA recommendations
female >65
younger postmenopausal females with risk factors
females with fractures
females with conditions (i.e. RA) or medications associated with low bone mass
49
normal bone mineral density vs osteoporosis
normal: +2.5 and -1
osteoporosis: < -2.5
50
fracture risk assessment tool (FRAX)
10 year fracture risk from age 40-90
i.e. alcohol, smoking, RA, previous fracture, glucocorticoids, weight...
51
how many postmenopausal female experience osteoporosis related fracture
where is most common
40-50%
vertebrae, femoral neck and wrists are most commonly fractured
52
SOGC guidelines for menopause and osteoporosis
-exclude secondary causes
-FRAX for fracture risk
-calcium and vitamin D
-treat if at immediate risk or high risk
-take bisphosphonate drug holiday after 5 years
-thigh or groin pain on antiresorptive therapy
-osteonecrosis of jaw from antiresoprtive therapy
-screen for increased fracture risk if >65 or if postmenopausal and <65
etccccccc
53
perimenopausal dental health
low estrogen effects oral health; buccal epithelium atrophy, decrease saliva and alveolar bone
- dysgeusia (bad taste in the mouth)
- higher incidence of cavities
- tooth loss
54
perimenopausal Cardiovascular health
higher risk for CVD
-low estrogen causes vasoconstriction of vessel wall and increase LDL
increase body weight, diabetes, BP, insulin
55
menopausal hormone therapy for cardiovascular health
give oral estrogens to increase HDL and triglycerides and lower LDL
(estrogens can make hyper coagulable though= increase coronary event risk)
but estrogen therapy can prevent atherogenesis but also can raise CVD risk if already have atherosclerosis
56
CVD risk and menopause
framingham risk score
57
SOGC for CVD risk and menopause
do menopausal hormone therapy (MHT) right after begin menopause= low risk
but if do 10+ years after menopause then increases risk of CVD
increase risk of stroke, venous thrombotic events
MHT not indicated for primary or secondary prevention of CVD
--> do lowest dose of estrogen possible in MHT
58
cognition in menopsaue
memory and cognition decline
sleep issues and mood
estrogen levels are NOT associated with cognition scores
59
risk factors for decreased cerebral perfusion and thinning of gray/white matter include
transient ischemic attacks (TIAs), hyperlipidemia, hypertension, smoking, excess alcohol consumption
60
mental health in menopause
depression risk 3x higher in perimenopausal females
psychosocial factors (i.e. illness, divorce, gaining parents) can contribute to mood
anxiety, irritable
beauty standards
61
sleep and menopause
problems sleeping can lead to depression and cognition
also OSA, VMS (hot flashes, night sweats), nocturia , restless legs syndrome
highest in late perimenopause
62
recommednations for menospause and sleep
aerobic exercise, black cohosh, valerian root
63
breast health in menopause
low estrogen and progesterone can decrease tissue volume and density
screen for breast cancer @ 40-50yoa
64
risk of breast cancer
very high if have genetics, family hx, radiation therpay etc
other risks on around slide 70
65
Canadian Breast Cancer Screening Guidelines
women aged 40–74 without personal or family history of breast
cancer, known BRCA1 or 2 mutation, or prior chest wall radiation
CTFPHC Screening Recommendations:
- no routine clinical breast exams or breast self-exam to screen for breast
cancer in women at any age
- no routine mammography for women aged 40-49;
- the decision to undergo screening is conditional on the relative value a woman places on possible benefits and harms from screening.
- routine screening with mammography every 2-3 years for women aged 50-74
- no screening of low or average-risk women using MRI
66
menopause and breast cancer
systemic menopausal hormone treatment (MHT) has a risk and is contraindicated if have personal history
use non hormonal options
also modify weight, smoking, alcohol, exercise
non pharm: paced breathing, acupuncture, CBT to help manage VMS sx
if have GMS do lubes and moisturizers and vibrators or local vaginal estrogen's
67
dermatologic health in menopause
reduced thickness, sebum gland, elasticity....
not recommended to do estrogen therapy fro skin
hiar changes; androgenic hair loss or telogenen effluvium, coarse terminal facial hairs
68
MHT for
low does if menopausal (8-12 wks to see effect)
of if early (<45) or premature (<40) bc of CVD and osteoporosis; treat until ~50yoa
69
contraindications for MHT
CI:
- undiagnosed vaginal bleeding
- known, suspected or Hx of breast
cancer
- known or suspected estrogen-
dependent neoplasia
- active or prior venous
thromboembolism (VTE)
- active or prior stroke, MI or TIA
- known thrombophilia
- liver dysfunction or disease
- untreated hypertension
- known hypersensitivity to
ingredients of estrogen preparation
- known or suspected pregnancy
cautions:
- dementia
- gallbladder disease
- hypertriglyceridemia
- prior cholestatic jaundice
- hypothyroidism
- fluid retention plus cardiac or renal
dysfunction
- severe hypocalcemia
- prior endometriosis
- hypothyroidism
- elevated breast cancer risk
- hepatic hemangiomas
70
CHC in menopasue?
can do CHC or LNG-IUS in perimenopause
NO CHC in post menopause (its higher dose of estrogen than MHT)
71
when to follow up on MHT
follow up 1-2 months after starting
then evaluate medically annually
72
