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Menopause – Flashcard

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Basic Overview
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-> Menopause occurs with the cessation of estrogen production -> Estrogen depletion leads to a constellation of symptoms that can significantly impact quality of life ->Management of these symptoms can be difficult with estrogen being the best therapy with concerns regarding long term risks ->Osteoporosis is the most important sequelae of long term estrogen deprivation.
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Menopause
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12 months of amenorrhea after the final menstrual period. If reflects ovarian follicle depletion and absence of ovarian estrogen production
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Perimenopause
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Period immediately before and after menopause. Starts with variation of menstrual cycle and ends at start of menopause.
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Postmenopause
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Postmenopause – the first five years after the final period. Have ongoing symptoms and accelerated bone loss.
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Progression
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Median age is 50 – 52 years of age Anovulation becomes more prevalent during perimenopause Ovary becomes more resistant to FSH FSH increases in order to maintain estrogen at steady state. Eventually follicles are depleted, and estrogen production ceases
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Symptoms
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Short term -Vasomotor -Atrophic changes -Psychophysiological Long Term -Osteoporosis -Cardiovascular
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Vasomotor
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The physiology is not clear -Related to estrogen withdrawl at level of hypothalamus -Hot flushes (head, neck, chest, intense body heat)
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Atrophic
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-Thinning and inflammation of vaginal mucosa secondary to lack of estrogen -Can lead to secondary symptoms like bleeding and dysparunia -Can also develop burning with urination -Urgency
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Psychophysiologic
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Unclear wether this is a lone entity or associated with vasomotor symptoms (sleep deprivation) -Depression, irritibility, memory, anxiety
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Osteoporosis
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This occurs due to down regulation of osteoclasts and osteoblasts -The most important complication associated with fractures
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Cardiovascular
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This is controversial!! -May benefit lipids, atherosclerosis, vasodilation -May increase stroke and MI
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Management
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Symptom control and reduce risk of osteoporosis!!! Modalities: -HRT (very effective but symptoms need to be debilitating as it causes a small increase in risk similar to being obese) -HRT can be given orally (premarin), transdermally (patch or gel with theoretical benefit), or locally (reduces systemic effect as suppository, ring, cream) -HRT patients should be given progestin if they have a uterus -HRT Contraindications (Unexplained vaginal bleeding, acute liver disease, thrombus, known or suspected breast Ca, pregnancy) -effexor, clonidine -Life style + vitamin D
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Osteoporosis
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Related to depletion of estrogen which can cause bone loss and increase risk of fracture Can screen using bone density (DEXA – dual energy absorbitometry) Measure hip and spine Change by as little as one standard deviation can lead to 3X increase risk of fracture Measured as T score (standard deviation) -> Lifestyle management is a great way to manage it -> Estrogen (not recommended for prevention), SERMS, bisphosphonates and calcitonin are good ways to
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Postmenopausal Bleeding Keys
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Postmenopausal bleeding is very common problem (11%). The largest concern is excluding uterine cancer. Early diagnosis and management can lead to survival rates of up to 95%. Diagnostic modalities include ultrasound, endometrial biopsy and dilation and curettage. Remember biopsy, biopsy, biopsy as tissue sampling is the gold standard.
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PMB Definition
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Any uterine bleeding in a menopausal woman other than expected cyclical bleeding in women on HRT
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PMB Incidence
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Estimated as high as 10 -15% Higher in first year after one year of amenorrhea Falls significantly after third year
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Etiology
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Think anatomically -Vulva -Vagina -Cervix -Uterus -Fallopian Tube
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Vulvar Sources
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Atrophy Dystrophies Infectious causes Vulvovaginitis carcinoma
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Vaginal Sources
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Atrophy Vaginal carcinoma Vulvovaginitis Infectious Trauma
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Cervical Sources
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Polyps Ectropion Dysplasia Carcinoma
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Uterine Causes
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Atrophy 59% -Hypoestrgenism causes atrophy -lack of fluid leads to friction… Polyps, fibroids 12% -benign endometrial or myometrial growths that have inflammatory processes going on around the growth -inflammation makes it friable which can subsequently bleed -fibroid in postmenopausal women = sarcoma!! Endometrial cancer 10% -fibroids in older women -always have it on the differential -Adenocarcinoma is the most common kind -First sign is often bleeding -Investigate with U/S (90% sensitive), Endometrial biopsy (95% sensitive), Dilation and curettage via hysteroscopy (95% sensitive) -Management includes avoiding unopposed estrogen and removing the tumor as soon as possible Hormonal effect 7% -Any woman can develop bleeding depending on how the hormones are taken so you can inform her Other (pyometra, hematometra) 2%
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Menopause occurs Between ages 50-55. when is the average age?
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Average age is 51 years
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What is considered “premature” Menopause?
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< 40 years
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What is considered ealry menopause?
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between the age 40-45
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What is considered late menopause?
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After age 55
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What could cause “premature” Menopause?
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1) Karyotype abnormalities (Turner’s XO) 2) Autoimmune disorders 3) Iatrogenic – Surgery—Bilateral Salpingo-oophorectomy (BSO) – Chemotherapy – Radiation (XRT)
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Describe the process of Ovarian Senescence
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1) Begins with approximately 1.5 million eggs 2) Menarche: 400,000 eggs 3) 400 menstrual cycles 4) No eggs = no physiologic response to gonadotropins (FSH/LH)
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Transition Stage -2
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Variable cycle lengths and greater than a 7 day difference of the cycles
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Transition Stage -1
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> or equal to 2 skipped cycles and a period of amenorrhea for 60 days
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Menopause- 0
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Menopause (No menstural cycle for 12 months)
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Post Menopause Stage +1
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First 5 years after final period
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Post Menopause Stage +2
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From first 5 years until death
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What are the symptoms of perimenopause?
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1) Irregular menses 2) Endometrial hyperplasia 3) Mood/emotional changes 4) Hot flashes (flushes) 5) Night sweats
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What causes perimenopause?
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1) Ovary function waxes & wanes – Irregular ovulation o Contraception required until amenorrhea X 1 yr – Fluctuating hormone production o Estrogen/Progesterone ultimately cease o Ovary still produces small amounts of androgens during menopause
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In perimenopause there are Anovulatory cycles. What does this cause?
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1) Leads to irregular menses 2) Increased estrogen due to prolonged follicular phase – Exacerbated by obesity – Endometrial stimulation can lead to endometrial hyperplasia or cancer 3) Ultimately no more eggs–no more ovarian estrogen!
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How is Menopause diagnosed?
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1) No menses x 1 yr 2) Serum FSH not necessary – levels will vary throughout perimenopause
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During menopause, what is Androstenedione precursor in the adrenal gland converted to?
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ESTRONE in peripheral fat (which is less potent than estadiol which is produced by the ovaries prior to menopause)
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What are the consequences of menopause?
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1) Vasomotor symptoms (which causes the hot flashes)/Mood symptoms 2) Vulvovaginal atrophy 3) Osteoporosis (The vast majority of bone loss is during the perimenopause period and the year after menopause) 4) Increased risk of CAD/CVA (?) 5) Increased risk of colon cancer (?) 6) Imapired balance (increased risk of colles fractures)
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What is the treatment of vasomotor symptoms?
What is the treatment of vasomotor symptoms?
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1) Lifestyle 2) HRT (Hormone Replacement Therapy)–> The MAIN reason for HRT is to prevent hot flashes
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What are the indications for Hormone Replacement Therapy (HRT)Estrogen Replacement Therapy (ERT)?
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1) Vasomotor sx 2) Vulvovaginal atrophy 3) Osteoporosis (*In women that also have vasomotor sx)
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What are the ciontraindications for Hormone Replacement Therapy (HRT)Estrogen Replacement Therapy (ERT)?
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1) Pregnancy 2) AUB 3) Estrogen-sensitive CA (i.e. Breast cancer) 4) Thromboembolic disease or CVA 5) Liver disease 6) Coronary Artery Disease
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What would I use for a women in menopause that still has a uterus and why?
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Hormone Replacement Therapy (HRT)because administering estrogen alone would cause estrogen to go unopposed and potentially cause endometrial hyperplasia/cancer
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What would I use for a women in menopause that does not have a uterus and why?
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Estrogen Replacement Therapy (ERT) – no risk of hyperplasia/cancer if all the plumming is gone
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This is the First PROSPECTIVE RANDOMIZED CONTROLLED trial evaluating estrogen therapy Sponsored by the National Institutes of Health (NIH) Women ages 50-79 scheduled to be completed in 2005
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Women’s Health Initiative (WHI)
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Based on WHI, what is the mosot effective “the bomb” for treating vasomotor symptoms?
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HRT most effective treatment for vasomotor sx (use the smallest does for the shortest period of time)
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What does ACOG say about how to administer HRT?
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1. If HRT, then smallest dose for shortest time (preferably < 4 years) 2. Long-term rx should be stopped in asymptomatic pts (taper helps decrease rebound sxs)
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What are alternatives to HRT?
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1) SSRIs (consider adding while HRT taper) – Venlafaxine (Effexor) 75-150mg po bid – Paroxetine (Paxil) 20mg po qd – Fluoxetine (Prozac) 20mg po qd – Sertraline (Zoloft) 50mg po qd 2) Gabapentin (Neurontin) 300-900mg po qd 3) Clonidine (Catapres) 0.05-2mg po qhs/patch
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Do herbals have significant data for treatment of menopausal symptoms?
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NO
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What are the herbals that are used?
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1) Phytoestrogens 2) Soy isoflavones 3) Red clover isoflavones 4) Black cohosh 5) Dong Quai 6) Evening primrose oil 7) Bellergal-S 10) Wild yam and progesterone creams
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What are the Vulvovaginal symptoms associated with menopause?
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1) Dyspareunia 2) Atrophic vaginitis 3) Urinary symptoms – Frequency/dysuria – Incontinence – Frequent UTIs
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What causes the vulvovaginal symptoms associated with menopause?
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Lack of estrogen results in vaginal atrophy with an alkaline pH
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What is the best treatment for vulvovaginal symptoms?
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Vaginal estrogen as cream, suppository or ring
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Can Oral estrogen/transdermal estrogen be used for the treatment of vulvovaginal symptoms?
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Yes, but topical is better
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This is the Deterioration of trabecular bone tissue leading to decreased bone mass, fragility, and increased fracture risk
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Osteoporosis
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How does the World Health Organization (WHO) define osteoporosis?
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1) Bone mineral density (BMD) >2.5 standard deviations (SD) below the mean is osteoporosis 2) Bone mineral density (BMD) >1.0 but <2.5 SD below the mean is osteopenia
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When does bone grow?
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From birth until age 35
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How long is bone mass preserved?
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Until Menopause
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When is there rapid bone loss?
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In the first few years
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Women live longer so what does this mean?
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1) 40% of women >50yo will fracture due to osteoporosis! – 2-3x higher than men 2) Vertebral fx 15 yr prior to hip—sentinel event Hip fx 20% mortality 1st yr
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What are the three most common fracture locations in order of frequency?
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1) Vertebrae (Anterior) -MOST COMMON (90% will fracture again in 12 months) 2) Hip 3) Distal radius
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What are the Clinical Risk Factors for Osteoporotic Fracture (independent of BMD)
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1) **Advancing age 2) **Previous history of fragility fracture as adult 3) History of fragility fracture in 1st degree relative 4) Low body weight (<127lb) 5) Current smoking 6) Glucocorticoid therapy 7) Excessive use of alcohol 8) Rheumatoid arthritis
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How is a patient screened for osteoporosis?
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Dual-energy x-ray absorptiometry (DEXA)
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What does the Dual-energy x-ray absorptiometry (DEXA) measure?
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Spine/Hip
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Who should undergo a Dual-energy x-ray absorptiometry (DEXA)?
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1) 50 year-olds with 1 or more risk factors (besides menopause) – Advancing age – Previous history of fragility fracture as adult – History of fragility fracture in 1st degree relative – Low body weight (<127lb) – Current smoking – Glucocorticoid therapy – Excessive use of alcohol – Rheumatoid arthritis 2) All 65 year-olds
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What are the two scores that come from a DEXA scan?
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1) T score 2) Z score
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What does the T score measure?
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It compares Bone Mineral Density to “normal” young adult
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What does the Z score measure?
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It compare Bone Mineral Density with same age and weight
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Can a patient be diagnosed with osteoporosis without a DEXA scan?
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Yes. Fragility fracture regardless of BMD
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What are the 2 indications for a DEXA scan?
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2 indications for DEXA scan include 1) Screening 2) Monitoring drug therapy
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Accordinf to DEXA Scan, Osteopenic =
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Not severe enough to be called ostreoporosis Bone mineral density (BMD) >1.0 but <2.5 SD
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Osteoporosis =
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>2.5 standard deviations (SD) below the mean is osteoporosis
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How can my patient prevent osteoporosis?
How can my patient prevent osteoporosis?
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1) Nutrition – Calcium 1000-1500mg po daily – Vitamin D at least 800 IU po daily 2) Weight bearing exercise (also promotes balance) – 20-30 minutes 3x/wk 3) Avoid: Tobacco and ETOH
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What are two ways to prevent fractures?
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1) Reduce Falls Risk 2) Treat Osteoporosis
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What can my patient reduce fall risk?
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1) Vision assessment 2) Lighting 3) Clean, well-marked stairs and floors 4) Footwear 5) Hip pads
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What are ways to prevent osteoporosis?
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1) Menopausal women T-score >-2.5 SD 2) Menopausal women T-score -2.0 to -2.5 SD (osteopenic) plus 1 additional risk factor for fracture
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What are the drugs to treat osteoporosis?
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1) Hormone Replacement Therapy (HRT) 2) Estrogen Replacement Therapy (ERT) 3) SERMs 4) Bisphosphonates 5) PTH-Parathyroid Hormone 6) Calcitonin
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This drug to treat osteoporosis is described as the following: 1) Agonist at bone 2) Antagonist at breast/endometrium 3) Worsens vasomotor symptoms (Because they act like estrogen) 4) Prevents vertebral fractures 5) Lack of data for hip fractures 6) Inhibit bone resorption
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Selective Estrogen Receptor Modulators(SERM)
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What is an example of Selective Estrogen Receptor Modulators(SERM)?
What is an example of Selective Estrogen Receptor Modulators(SERM)?
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Raloxifene (Evista)
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What is the treatment of choice for osteoporosis?
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Bisphosphonates
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What are the indications for Bisphosphonates?
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1) Osteoporosis prevention – Osteopenia + Risk factor 2) Osteoporosis treatment Treatment of choice
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What are the contraindications for Bisphosphonates?
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1) Esophageal dysmotility 2) Inability to be upright x 30min 3) Hypersenstitivity 4) Hypocalcemia
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Do Bisphosphonates build bone?
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Yes
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What are the complications of Bisphosphonates?
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1) Erosive esophagitis 2) Jaw Osteonecrosis
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Because of the risk of erosive esophagitis with Bisphosphonates, what must be done?
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Esophagitis—must administer medication in the AM, with water only, and remain upright for 30 minutes afterward.
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What are the second line therapies for osteoporosis?
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1) Parathyroid hormone (PTH) 2) Calcitonin
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This drug is described as the following: 1) Stimulates both osteoblasts & osteoclasts – Blasts>>Clasts resulting in improved bone mass 2) Convenient q28 day auto-injector 3) Only requires 18-24 months of therapy 4) Expensive
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Parathyroid hormone (PTH)
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Parathyroid hormone (PTH) seems an unlikely candidate for the treatment of osteoporosis because of its well-described deleterious effect on bone. So why does it work?
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Intermittent administration of recombinant human PTH (both full-length 1-84 or fragment 1-34) stimulates bone formation more than resorption.
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This drug is described as the following: 1) Inhibits osteoclasts 2) Unique indication as the most effective for osteoporosis fracture pain (vertebral) 3) Nasal spray 200 IU daily in alternate nostrils 4) Expensive
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Calcitonin – Not much effect on BMD – Doesn’t decrease fracture risk
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How is osteoporosis monitored?
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1) Repeat DEXA scans every 2 years 2) Bone metabolism markers at 6 months – Serum CTX (carboxy-terminal collagen crosslinks) – Urinary NTX (cross-linked N-telopeptides)
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T or F. 15% of women continue to lose BMD despite therapy
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True
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How is perimenopause defined?
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2-8yrs preceding menopause
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Inhibin B concentrations increase or decrease due a decline in follicle number? What happens to FSH values?
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Inhibin decreases and FSH increases
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High _____ and low ______ values are suggestive of menopause but not confirmatory
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High FSH and Low Estrogen
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Why does the probability of having dizygotic twins peak around 37?
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b/c during perimenopause follicles develop more rapidly in response to increased FSH
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At what age does fertility begin to decline?
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Age 29
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What is the major source of estrogen in menopausal women?
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the conversion of androstendione to estrone (estrone is a less potent estrogen than estuarial)
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Endometrial hyperplasia can be a prerequisite to what?
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endometrial cancer
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What testing technique needs to be performed if you suspect endometrial hyperplasia?
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Endometrial biopsy
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What diagnostic study is used to measure the thickness of the endometrium?
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transvaginal US (normal <5mm)
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What is vaginal dryness/atrophy due to?
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an deficiency in estrogen which causes thinning of the vaginal epithelium
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Estrogen therapy doe not appear to be effective for the treatment of……
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urinary incontinence
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What are 3 common physical findings in a menopausal woman?
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1. pale vagina 2. loss of normal rugae 3. vaginal pH 6.0-7.5
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What are 2 factors that are strong predictors if menopausal woman will experience depression?
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Prior hx of depression or PMS
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What are the 3 long-term issues resulting from menopause?
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1. Osteoporosis 2. Cardiovascular disease 3. Dementia
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Define Menopause
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12 months of amenorrhea in women over age 45 in the absence of other biological or physiological causes
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What do follicles produce less of after age 40?
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Inhibin
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_____ has an inverse relationship with ______
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FSH; Inhibin
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What should always be included on the DDx in a women with amenorrhea?
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Hyperthyroidism/thyroid disorder
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What is the best approach to diagnosing the menopausal transition?
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longitudinal assessment of menstrual cycle history and menopausal symptoms
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Are serum FSH, estradiol, or inhibin levels useful for diagnostic purposes?
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NO!
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What are the advantages of OCP with perimenopausal symptoms?
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Prevention of ovarian/endometrial cancer Reduction of benign breast disease Improved bone density Control of erratic vasomotor symptoms Stabilizing of irregular bleeding
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Oral contraceptive SHOULD NOT be used in what population?
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Women over 35yrs who SMOKE
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What are other contraindications of OCPs?
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Active liver disease/hepatitis Deep vein thrombophlebitis Breast Cancer
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OCPs until age _____ if no contraindications
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51yrs
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Check _____ on day 5-7 in pill free wk
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FSH
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FSH >_____ = menopausal
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25 –> switch to HRT
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4 indications for HRT
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1. osteoporosis prevention and treatment 2. urogenital atrophy/dryness 3. vasomotor symptoms 4. if symptomatic after oophorectomy
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HRT is NO LONGER used for prevention of what?
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Coronary Artery Disease
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Hormonal therapy should be limited to the __________ duration and __________ dose
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shorted duration and lowest dose
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What are the 8 absolute contraindications to HRT?
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1. Endometrial carcinoma 2. Estrogen dependent tumor 3. Unexplained vaginal bleeding 4. Recent MI 5. Recent thromboembolic event 6. Stroke 7. Pancreatic disease 8. Active gall bladder disease
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What are some relative contraindications to HRT?
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HTN atypical breast lesions DM Hx of gall bladder dz Migraines endometriosis Fibrocystic breast dz Uterine fibroids obesity seizures hx of DVT or PE
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Vaginal Cream (Premarin, estrace, ogen), E-string, Vagifem, Femring are all examples of what?
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Vaginal estrogen
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How often is the E-strong replaced?
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every 3 months
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If using the femring what needs to occur id woman has intact uterus?
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need to add progesterone
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When progestins are added to estrogen if uterus is intact what rates are lower?
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endometrial hyperplasia and carcinoma
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What are the 6 contraindications to progestins?
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1. breast cancer 2. undx vaginal bleeding 3. chronic liver disease 4. thromboembolism 5. pregnancy 6. gall bladder disease
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Prometrium is a type of what?
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Natural progesterone
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What is important to know about pt if prescribing promethium?
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CHECK if have peanut allergy
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Medroxypregesterone acetate (Provera), Northindrone, Levonorgesrol are examples of what?
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synthetic progestins
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Name 2 non-systemic progestins
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Mirena IUD Crinone (suppositories)
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Activella, Prempro, Climarapro Patch, Combipatch are examples of what?
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Low dose estrogen/progesterone combination product
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Vivelle dots, Climara, Estraderm, Menostar patch, Femring, Divigel, Evamist are examples of what?
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Hormone patches, rings, gels, and sprays (bypass the liver when metabolized)
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Name the 3 preventions for osteoporosis
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1. 1500mg Calcium daily 2. 800-1000IU Vit D daily 3. Weight bearing exercises
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What are the 3 alternatives to hormone therapy for prevention/treatment of osteoporosis?
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1. SERMs (Selective Estrogen Receptor Modulators) 2. Bisphosphonates 3. Parathyroid hormone
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Ralofexine is an example of?
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SERM
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What are the 2 negative symptoms that SERMs cause?
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Hot flashes and increased risk of blood clots
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Aledronate and Risedronate are examples of?
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Bisphosphonates
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Bisphosphonates may cause…
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esophageal irritation
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Estroven and Ramifemin are examples of what?
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Black Cohash
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What is the only OTC FDA approved med for hot flashes?
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Black Cohash (Remifemin/Estroven) – 20mg bid
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Red Clover, Mexican yam effect on hot flashes?
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no real good evidence
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Freshly ground flaxseed or linseed is indicated in what 2 symptoms?
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Hypercholesterolemia Hot Flashes
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Define post-menopausal bleeding
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bleeding that occurs after 12months of amenorrhea
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Post-menopausal bleeding cannot be associated with ….
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HRT (or may be prolonged/heavy if associated with HRT)
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All methods of HRT may yield….
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bleeding
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How long will most women bleed when placed on HRT
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3mos
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2 Population of pts using HRT that need evaluation…
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1. on HRT for 6mos and bleeding 2. Pts with intact uterus on unopposed estrogen
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Menopause is the cessation of periods for how long?
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the cessation of menstrual periods for 12mos
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at what age does our fertility start to decline?
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29yrs old
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at about what age does menopause occur?
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51.4 years in normal women
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By 2020, how many million women in US will be menopausal
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60M
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Life expectancy is 84.5 yrs, women will live ? more years after menopause
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~30
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When is perimenopause?
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Defined as the 2-8 years preceding menopause Ends one year after the last menstrual period
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Can menstrual irregularities occur during perimenopause?
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Yes, Ovarian function waxes and wanes, Less frequent ovulation, Normal cycles are interspersed with anovulatory (estrogen-only) cycles [this is when women at 50 get prego by accident] Irregular menses, breakthrough bleeding, DUB
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T/F, During perimenopause there are fluctuations in serum conc of FSH and estradiol
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True
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During perimenopause, which out of the following rise? Inhibin B, FSH, progesterone
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FSH
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T/F High FSH and low estradiol values may be suggestive of menopause but not confirmatory
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True also note: A single serum FSH value in the postmenopausal range, even with undetectable estradiol levels does not provide reliable evidence that menopause has occurred.
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perimenopause follicular phase abnormalities are prevalent at what yr of age?
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40
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perimenopause follicular phase abnormalities: does the phase shorten or lengthen?
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shorten
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During perimenopause, follicular phase abnormalities such as irregular cycles, follicular phase shortening, and residual follicle units # only in thousands, are prevalent at what age?
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40yo
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Follicles develop more rapidly in response to increased FSH, dizygotic twinning peaks at 37! So FSH is higher, what is going on w/ estradiol?
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It levels at mid cycle and in the luteal phase are lower
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Ovarian follicles are depleted during perimenopause, and the ovary no longer secretes what hormone?
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Estradiol
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During perimenopause, Ovarian production and secretion of androgens continue, and where is the major source of estrogen in menopausal women?
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conversion of androstendione to estrone. Estrone is a less potent estrogen than estradiol.
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What kinds of disorders can declining ovarian function lead to?
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ovarian d/o: functional ovarian cysts, hemorrhagic cysts. (Diagnosis of these disorders may be achieved using ultrasound, laparoscopy or laparotomy.)
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What are the symptoms of menopause?
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Breast pain Hot flashes Migraines -headaches may worsen in frequency and intensity during the menopausal transition Skin changes Joint pain or stiffness Impaired balance Or no symptoms at all!
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What are Potential Clinical Manifestations of Menopause?
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Change in bleeding patterns Vasomotor symptoms [hot flashes, variable as well] Sleep disturbance [insomnia often earliest sx] Genitourinary symptoms -Vaginal dryness/urogenital atrophy-dyspareunia Sexual dysfunction Depression Long-term issues -Osteoporosis -Cardiovascular disease -Dementia
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Potential Clinical Manifestations of Menopause: what are potential Changes in Bleeding Patterns?
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Anovulatory bleeding/Chronic anovulation Oligomennorhea (lasting 6mos or more) Heavy dysfunctional uterine bleeding (DUB)
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What is the Anovulatory bleeding/Chronic anovulation d/t?
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-due to progesterone deficiency -long periods of unopposed estrogen exposure can cause anovulatory bleeding
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What diagnostics should be performed for the changes in bleeding patterns?
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Endometrial biopsy should be performed for the above persistent conditions to rule out endometrial hyperplasia, which can be a prerequisite to endometrial cancer. Transvaginal ultrasound can also be performed to evaluate the thickness of the endometrium (normal thickness is < 5mm)
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What is the most common acute change during menopause?
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vasomotor sx’s: Sleep disturbance secondary to hot flashes. -fatigue, irritability, depression, difficulty concentrating
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up to what percent of women in some cultures experience hot flashes?
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75%
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What percent actually seek medical attention?
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20%
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Are hot-flashes self-limited? whats the pathophys?
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yes; unknown
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What is Vaginal dryness/urogenital atrophy d/t?
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Due to estrogen deficiency causing thinning of the vaginal epithelium and vaginal atrophy
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Can yo do stuff about vaginal dryness/atrophy?
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Yes! [lubrication can be helpful. If lost rugae, have to put estrogen in there and using vaginal estrogen cream is very helpful and its localized (low systemic abs)! talk to women about these options in perimenopause yrs]
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Atrophic Vaginitis, Atrophic Urethritis Symptoms=
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sx’s can include itching ,irritation and dyspareunia (painful intercourse) [on exam, vagina will have lost its rugae, making sex uncomfortable, looking pale and dry]
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what can Atrophic Vaginitis, Atrophic Urethritis predispose to?
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May predispose to both stress and urge urinary incontinence Although data are conflicting, estrogen therapy does not appear to be effective for the treatment of urinary incontinence.
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Are recurrent UTI’s a clinical manifestation of menopause?
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yes!
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What do you see on exam of GU system?
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-Pale vagina -Lack of the normal rugae (vaginal folds) -Vaginal pH 6.0 to 7.5 (<4.5 in the reproductive years) -Increase in pH and vaginal atrophy may impair protection against vaginal and urinary tract infection
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What are manifestations of menopause concerning sexual dysfxn?
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Decreased vaginal lubrication -Estrogen deficiency -Decrease in blood flow to the vagina and vulva -Vaginal dryness and dyspareunia Decrease in elasticity of the vaginal wall Shortening and narrowing of the vaginal vault Continuing sexual activity may prevent these changes! Responsive to estrogen therapy -? Decreased sensation in the clitoral and vulvar area
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Is depression associated with menopause?
answer

Yes! Prior history of depression or PMS-strong predictor: Characterized by frequent mood changes, irritability, nervousness Depression during the perimenopausal years Nonhormonal events -aging parents -empty nest -chronic illness, and physical limitations
question

Long term issues of menopause
answer

-Osteoporosis [estrogen can be used to tx osteoporosis, not first line, but if have other indications it can improve menopause sx’s too] -Cardiovascular disease [risk more than doubles at menopause] -Dementia [seen w/ inc freq. with low estrogen levels]
question

Woman over age 45 in the absence of other biological or physiological causes, do you want further diagnostic evaluation?
answer

No further diagnostic evaluation for women in this group! Measuring serum FSH, estradiol, or inhibin levels unnecessary
question

Women <45 years with irregular periods or amenorrhea, blood work? hx Q's?
answer

Blood work for HCG, prolactin, TSH, FSH Assessment/History- A good history is important -menstrual cycle history -menopausal symptoms vasomotor flushes, vaginal dryness -[wt changes will change period, stress levels will]
question

Making the dx of menopause, labs?
answer

FSH inverse relationship with Inhibin Follicles produce less Inhibin after age 40 FSH rises note: Postmenopausal response to hormone therapy cannot be monitored by measuring FSH Suppression of FSH persists due to lack of inhibin.
question

ddx of amenhorrhea?
answer

-Hyperthyroidism/ thyroid disease Irregular menses, sweats, mood changes -Pregnancy -Hyperprolactinemia -Atypical [more freq] hot flashes and night sweats -Medications -Malignancies -Carcinoid -Pheochromocytoma
question

Treatment of Perimenopausal Symptoms [anyone in 40s 50s]
answer

Oral contraceptives
question

What are advantages of using OCPs?
answer

Prevention of ovarian cancer and endometrial cancer Reduction of benign breast disease -30% reduction fibrocystic disease -60% reduction fibroadenomas, 40% other lumps Decrease dysmenorrhea, mittleschmertz [unilateral lower ovarian pain], menorrhagia and anemia Improved bone density – women lose 8-10% of bone mass from age 35-50, OC use counters the premenopausal losses Control of erratic vasomotor symptoms Stabilization of irregular bleeding
question

What is the big Oral contraceptives CAUTION (for tx of perimenopausal sx’s)?
answer

Do not use use if over 35 years old and smoking [inc risk for DVT big time and coagulopathy in general] Contraindications including but not limited to: Active liver disease/hepatitis Deep vein thrombophlebitis Breast Cancer
question

Transitioning From OC’s to HRT, what is basically the difference?
answer

the dose, [the dose of HRT is significantly smaller than OCP’s]
question

What kinds of things are you looking at when switching from OCP’s to HRT?
answer

OC’s until age 51 if no contraindications 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 Can switch w/o testing at age 50
question

Indications for HRT
answer

Osteoporosis prevention and treatment Urogenital atrophy-vaginal dryness Vasomotor symptoms [estrogen is really the only thing that helps this] If symptomatic after oophorectomy, (removal of ovaries)
question

Benefits of Estrogen
answer

-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
question

What were the outcomes of the world health initiative study that investigated long-term benefits and risks of HRT? What was the major problem with the study?
answer

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 -potential risks outweighed benefits the prob: avg age at enrollment =63yo so that’s one problem, on avg 12yrs postmenopausal when entrolled, most hadn’t been put on estrogen previously and were put on it for first time and that ultimately was the problem.
question

What did follow up studies show?
answer

within 5yrs it is safe to use estrogen therapy as far as CV risk, but if farther out then if >5yrs out then higher CV risk. So it should be safe and actually be CV beneficial if women are within 5yrs of menopause and have no other significant risk factors for CV dz. [controversial topic, depends on doc, on pt]
question

**Hormone therapy should be limited to what duration and what dose? [shortest/longest and lowest/highest?]
answer

Shortest duration and Lowest dose
question

WHIMS: World health initiative memory study Designed to evaluate postmenopausal estrogen and progesterone and its effect on the reduction of the risk of dementia in women over age 65foudn what?
answer

HRT and cognitive function: no clinically significant difference in either group
question

What are Absolute Contraindications to HRT ?
answer

Endometrial carcinoma Estrogen dependent tumor Unexplained vaginal bleeding Recent myocardial infarction Recent thromboembolic event Stroke Pancreatic disease Active gall bladder disease
question

What are some relative contraindications to HRT? Things you have to consider benefits/risks for the pt
answer

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 PE
question

What’s the perspective Tana wants us to remember in regards to breast cancer?
answer

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 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.
question

For many newly menopausal women with moderate to severe symptoms, do benefits will outweigh risks?
answer

Yes [they will get so much sx relief from hormones and the risks are low]
question

What are the diff types of Vaginal Estrogen? [for vaginal dryness, inc UTIs, etc] [Tana loves this!!]
answer

Vaginal cream- Premarin, Estrace, Ogen [can be messy] E-string-Estradiol ring inserted in the vagina Changed every three months [not as messy too] Vagifem-Preloaded applicator vaginal tabs [Tana uses this] Femring 0.05/0.1- Placed vaginally Systemic absorption, add progesterone with intact uterus
question

When is progestin added to estrogen? why?
answer

when uterus intact Lower rates of endometrial hyperplasia lower rates of endometrial carcinoma no increase in benign breast lesions
question

Contraindications to Progestins
answer

Breast cancer Undiagnosed vaginal bleeding Chronic liver disease Thromboembolism Pregnancy Gall bladder disease
question

Progestins: Systemic Preparations
answer

Natural Progesterone -Prometrium- micronized peanut oil base- check peanut allergy! -Crinone 4% and 8% suppositories, Common Synthetic -Medroxyprogesterone acetate (Provera) -Norethindrone -Mirena IUD- levonorgesrol [not typically used postmenopausally but perimenopausally is a nice option]
question

Progestational SE’s
answer

BLEEDING Over progesteronization of uterine lining Atrophy Continuous spotting PMS SYMPTOMS Depression/ Anxiety Other mood changes Bloating HA MASTODYNIA Prometrium contraindicated if peanut allergy!
question

Progestin Non Systemic products that are available:
answer

Mirena IUD, Crinone (many combo products available as well)
question

Hormone Patches, Rings, Gels and Sprays.
answer

Provide other alternative Bypass the liver when metabolized Examples: Vivelle dots Climara/ ClimaraPro Estraderm .05, 0.1 mg/day estradiol Menostar patch 14 mcg/day estradiol Approved for the prevention of osteoporosis Combipatch Femring Divigel, EstraGel Evamist
question

Bioidentical hormones considerations?
answer

Custom-made by a compounding pharmacy Not FDA controlled Plant derived Identical safety issues to other prescription hormones No scientific evidence to support claims of increased efficacy or safety No Black box warning [a lot of variability in these]
question

T/F Postmenopausal hormone therapy (HT) should not be initiated or continued for the prevention of cardiovascular disease or other chronic diseases at any age
answer

True
question

T/F HT still 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.
answer

True
question

T/F Additional research on the benefits and risks of HT initiated early in menopause is not warranted.
answer

False
question

Preventative Health Care for women in perimenopause
answer

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
question

Lifestyle changes for perimenopausal women
answer

Addressing use of tobacco, alcohol and other substances Obesity and Physical Activity Adequate Sleep Nutrition Sexuality Spiritual Health
question

Alternatives to Hormone TherapyFor Prevention of Cardiac Disease
answer

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

Alternatives to Hormone TherapyFor Prevention / Treatment of Osteoporosis
answer

-Calcium intake 1500 mg daily -Vitamin D 800-1000 IU daily. Enhances calcium absorption -Weight-bearing exercise regularly -SERMS [but do cause hot flashes so careful in perimenopausal women] -Bisphosphonates
question

Alternatives to Hormone Therapy: Prevention of Hot flashes
answer

Lifestyle changes -Avoid hot spicy foods -The layered look -Lower thermostat -Exercise -Relaxation, biofeedback Over-the-counter remedies -Soy [estrogenic, may improve bone density], Phytoestrogens [may help] -Dong Quai -Black Cohash -Remifemin, Estroven FDA approved, mildly effective for hot flashes -Red clover maybe, Mexican Yam?, Flaxseed [good for lowering cholesterol] or Linseed Prescription -Clonidine patch: blood pressure medicine [not best choice dont want to give orthostatic HoTN] -Antidepressants: SSRI’s ie Effexor, Paxil -Neurontin (Gabapentin) [anecdotally not helpful or used really]
question

Is there convincing evidence that soy foods are connected to breast cancer?
answer

No
question

What is the one herb that’s been tested and proven to be mildly effective in reducing hot flashes?
answer

Black Cohosh
question

Criteria for post menopausal bleeding
answer

-Bleeding that occurs after 12 months of amenorrhea (Excluding pregnant and breast-feeding women) – Post Menopausal Bleeding not associated with hormone replacement -Prolonged (10-14 days) or heavy bleeding associated with hormone replacement -Bleeding associated with non-phasic hormone replacement after 3-6 months
question

All methods of HRT may yield
answer

bleeding-Breakthrough bleeding ranges from 10-40%. Most women will bleed the first three months [should happen after 6mos] Vaginal administration of estrogen for urogenital symptoms of estrogen deficiency may rarely stimulate the endometrium Unopposed oral estrogen (without progesterone) in women with a uterus can cause hyperplasia and endometrial carcinoma
question

Post Menopausal Bleeding: Patients Using HRT Needing Evaluation
answer

-On hormones for 6 months or more and bleeding -Patients with intact uterus on unopposed estrogen Yearly endometrial biopsies Transvaginal ultrasounds check endometrial stripe
question

Cyclical Combined HRT: Bleeding OK if cyclic?
answer

Yes, Evaluate only if bleeding is irregular, prolonged or heavy
question

How do you evaluate pts using HRT on hormones for 6mos or more & bleeding, or pts with intact uterus on unopposed estrogen?
answer

Yearly endometrial biopsies Transvaginal ultrasounds check endometrial stripe
question

If a pt is on a cyclical combined HRT, is bleeding ok?
answer

Only if it is cyclic! Evaluate only if bleeding is irregular, prolonged or heavy
question

Case 1: 35 yo G1 P0101 female is here for her annual exam and c/o hot flashes and amenorrhea for 12 months. She doesn’t know why she is not having periods and her hot flashes are disruptive to her sleep and daily activities. DDx Tests
answer

[pregnancy, early menopause, US?] [maybe we can just talk thru these?]
question

Case 2: 45 yo G2 P2002 female presents with c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. She smokes ½-1 ppd cigarettes and would like to quit. DDx Tests
answer

question

Case 3: 65 yo Asian female presents to your office to start HRT. She heard it would help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an occasional hot flash. She is 5’4″, 108 lbs. Her history is significant for a wrist fx 2 yrs ago. She takes calcium faithfully.
answer

[no sx’s and it only helps protect heart if taken within 5yrs of menopause..?]
question

Case 4: 49 yo female c/o unbearable hot flashes.. She can’t sleep very well and wakes up 3 times a night drenched in sweat. She has a high power job as a CEO and symptoms are effecting her job performance. Her PMH is significant for breast cancer 2 years ago. How can you help alleviate her symptoms and improve her quality of life?
answer

question

Case 5: 53 yo began continuous HRT 4 wks ago. She is now having some vaginal spotting after being amenorrheic for 14 months. She is concerned. DDX Tests
answer

question

menopause occurance
answer

begins earlier for smokers, mean is age 51
question

risk assessments
answer

cardiovascular, osteoporosis
question

FSH
answer

over 40 =menopause
question

symptoms
answer

dry skin, dry eyes, dry vagina, irregular periods, hormonal instibility,
question

first risk of menopause
answer

cardiovascular risk d/t lipid solubility changes
question

second risk of menopause
answer

osteoporosis, loss of bone density, risk for fracture
question

highest risk for OP
answer

thin, white smoker lack of exercise, low calcium, high caffeine intake
question

PPI for gerd
answer

give Calcium Citrate
question

vitamin D
answer

recommendations: 800-1200units daily test vit d, 25 hydroxy vit d
question

OP labs
answer

serum ca, creatinine, 25hydroxy vit d, alk phos, celiac panel, TSH, testosterone, 24hr urine ca, na, cr.
question

Perimenopausal
answer

do not write for hormones- can still get pregnant! Enc mirena IUD, low dose OCP
question

prometrium (progestine)
answer

makes drowsy, so it treats insomnia, take with estrogen made from soy, not for pt with nut allergy
question

Menopause definition
answer

Permanent cessation of menses resulting from diminishing ovarian follicular function demonstrated by 12 consecutive months of amenorrhea.
question

Median age of menopause onset
answer

51 years (range 40 – 55)
question

Perimenopause definition
answer

AKA menopausal transition time – time before menopause and the first year following menopause
question

Symptoms of perimenopause related to declining estrogen
answer

Anovulation Dysfunctional uterine bleeding Extended menstrual cycle intervals Oligomenorrhea
question

Sx of menopause directly related to LACK of estrogen
answer

Vaginal dryness Vulvar/vaginal atrophy Vasomotor sx (night sweats, hot flashed)
question

Sx associated with menopause w/o a proven link to estrogen deficiency
answer

Arthralgia Depression Insomnia Migraines Mood swings Myalgia Urinary frequency Cognitive changes (memory, concentration)
question

During menopause FSH and LH INCREASE/DECREASE
answer

Increase
question

During menopause estradiol and progesterone INCREASES/DECREASES
answer

DECREASE
question

During menopause what is the primary estrogen available?
answer

Estrone not estradiol
question

How is estrone primarily made?
answer

Converted peripherally from andostenedione and is less potent
question

How must a menopausal woman with an intact uterus be treated?
answer

Estrogen+progestin to reduce the risk of endometrial hyperplasia and endometrial cancer
question

How must a menopausal woman who has had a hysterectomy be treated?
answer

Unopposed estrogen
question

Contraindications to estrogen replacement therapy (ERT)
answer

1. Abnormal / undiagnosed genital bleeding 2. Breast cancer (hx/suspected/known) 3. Hx of DVT or PE 4. Estrogen dependent neoplasia 5. Pregnancy 6. Stroke or MI in the past year 7. Liver dysfunction / disease
question

Estrogen and progestin MoA
answer

ERT, alone or w/progestin, replaces diminished levels of endogenous hormones Combined estrogen-progestin therapy includes progestin to prevent endometrial hyperplasia and cancer
question

When should a pt on HRT (hormone replacement tx) contact her dr.?
answer

1. Unusual vaginal bleeding 2. Abdominal tenderness, pain, swelling 3. Coughing up blood 4. Disturbances of vision or speech 5. Dizziness or fainting 6. Lumps in breast 7. Numbness or weakness in armo ro leg 8. Severe vomiting or HA 9. Sharp chest pain or shortness of breath 10. Sharp pain in the calves
question

Severe adverse drug events of HRT
answer

1. Risk of thromboembolism, stroke, coronary heart disease, breast cancer (identified by Women’s Health Initiative Trial)
question

Benefits of HRT
answer

Reduced fractures Reduced colorectal cancer
question

Most common adverse drug events of estrogen
answer

1. Breast tenderness 2. Heavy / irregular bleeding 3. HA 4. N
question

Most common adverse drug events of progestin
answer

Depression HA Irritability
question

Estrogen drug-disease interactions
answer

Estrogen may make the following worse: 1. Depression 2. Hypertriglyceridemia (avoid TD product) 3. Thyroid disorder (increase in thyroid supplement) 4. Impaired hepatic function 5. CVD disorders 6. Colethiasis 7. GERD
question

Estrogen drug-drug interactions – drugs that DECREASE estrogen effect
answer

Decreases in estrogen effect caused by 1. CYP 3A4 inducers 2. Barbiturates 3. Rifampin 4. St. John’s wort 5. Phenytoin
question

Estrogen drug-drug interactions – drugs that INCREASE estrogen effect
answer

Increases in estrogen effect caused by 1. 3A4 inhibitors 2. Azole antifungals 3. Macrolide antibiotics 4. Ritonavir
question

HRT monitoring
answer

Sx improvement Adverse effects Appropriate health maintenance (annual mammograms)
question

List the oral estrogen only products (brand)
answer

Premarin Cenestin, Enjuvia Estradiol, estrace, gynodiol Estropiptate, Ortho-Est, Ogen Estratab, Menest
question

Brand Premarin
answer

Generic conjugate equine estrogens (CEE)
question

Brand Cenestin, Enjuvia
answer

Generic synthetic conjugated estrogens
question

Brand Estradiol, estrace, gynodiol
answer

Micronized estradiol
question

Brand Estropiptate, Ortho-Est, Ogen
answer

Estrone sulfate
question

Brand Estratab, Menest
answer

Esterified estrogen
question

List the transdermal (TD) HRT products (brand)?
answer

Estraderm, esclim, Alora, Vivell Climara, Fempatch, Menostar Climara Pro Combipatch Estrasorb Estrogel Evamist
question

How often are patch HRT products applied?
answer

Once – Twice weekly.
question

Which vaginal estrogen product has systemic absorption?
answer

Femring vaginal ring
question

Which HRT products contain estrogen and progestin
answer

Climara Pro Combipatch
question

List the oral estrogen progestin HRT combo products
answer

Activella Femhrt Prempro Premphase
question

List the combination estrogen-androgen products
answer

Estratest HS, covaryx HS Estratest
question

Angrogen (testosterone) for menopause MoA
answer

Androgens = precursor to estrogen production by the ovaries and peripheral sites Androgens act at receptor sites or are converted to estrogen
question

Androgen replacement improves which menopausal sx?
answer

Decreased libido Decreased energy Diminished well-being
question

Who can receive testosterone therapy during menopause?
answer

Only women who are also receiving estrogen therapy
question

List the relative contraindications to andorgen therapy
answer

Androgenic alopecia Hirsutism Moderate – severe acne
question

What are testosterone ADE’s?
answer

Fluid retention Decreased HDL and TGs Hepatic dysfunction Hepatocellular carcinoma (prolonged use @ high doses)
question

What are phytoestrogens?
answer

Plant compounds (isoflavones, lignans, and coumestans).
question

What are food sources of phytoestrogens?
answer

Soy, edamame, tofu, flaxseed, alfalfa sprouts
question

Evidence for phytoestrogens
answer

Improvement in vaginal sx, decrease loss in bone density, lipids, weight, blood pressure
question

Evidence lacking for which sx for phytoestrogens?
answer

All other symptoms.
question

def of natural menopause?
answer

12 consecutive mo of amenorrhea with no obvious pathologic cause (usu 50+ y.o.)
question

def of induced menopause?
answer

bilateral oophorectomy or iatrogenic ablation of ovarian function causes permanent cessation of menstruation
question

def of perimenopause?
answer

few years before to 12 mo. after FMP when menstrual cycle and endocrine changes occur
question

def of premature menopause?
answer

<40 y.o., whether natural or induced
question

def of premature ovarian insufficiency?
answer

<40 y.o. leading to permanent or transient amenorrhea
question

def of early menopause?
answer

well before 51 y.o. but usually under age 45
question

def of early postmenopause?
answer

time period within 5y after FMP
question

primary indication for systemic HT at menopause?
answer

vasomotor sx (hot flashes, night sweats)
question

most effective tx for vaginal sx of menopause?
answer

estrogen therapy (local if vaginal sx are sole indication, plus then don’t need progesterone challenge)
question

sexual function problems of menopause?
answer

dyspareunia (painful intercourse), diminished libido
question

what meds are helpful for sexual function problems of menopause?
answer

HT for dyspareunia, not effective for diminished libido
question

effect of HT on urinary health?
answer

systemic ET may worsen or provoke urge incontinence; local ET may reduce recurrent UTI risk; unclear if ET is effective for overactive bladder
question

HT effect on psych?
answer

– can improve QOL (better mood, fewer menopause sx); but not approved for this goal – progesterone can worsen mood w/hx of PMS or MDD
question

effect of HT on bone health during menopause?
answer

reduces postmenopausal osteoporosis and fractures, esp if initiated early on after menopause
question

what meds for bone health during menopause?
answer

HT for postmenopausal osteoporosis and fractures; bisphosphinates can be used if pts don’t want HT but might have worsened bone quality and risk of weird fractures
question

effect of HT on CVD risk?
answer

– reduces CHD risk if initiated in younger women; longer tx leads to lower risk and mortality (but not primary indication for HT) – increases risk of ischemic stroke (not hemorrhagic) – VTE risk increases after initiation then decreases over time
question

effect of HT on diabetes risk?
answer

decreases new DM onset but inadequate evidence
question

effect of HT on endometrial cancer?
answer

unopposed systemic ET leads to higher endometrial cancer risk; if woman has uterus give progesterone challenge; if no uterus better to give ET alone
question

effect of HT on breast cancer?
answer

HT increases risk if used more than 3-5 yrs; incresaes cell prolif, breast pain, mammo density (harder to find tumors)
question

effect of HT on ovarian cancer?
answer

conflicting evidence
question

what cancers are known to be more likely in women on HT?
answer

– endometrial (if unopposed sys estrogen) – breast (if >3-5 yrs of use) – ovarian (conflicting evidence) – lung (may promote growth if hx of lung cancer)
question

effect of HT on lung cancer?
answer

if hx of lung cancer, HT may promote growth
question

effect of HT on cognition?
answer

increases dementia incidence if HT started >65y.o.; unclear if started early
question

effect of HT on ovaries?
answer

may be protective against premature ovarian failure
question

effect of HT on overall mortality?
answer

may reduce total mortality if started early; not if started >60y.o.
question

how to dose HT?
answer

– lowest effective estrogen dose; can add local ET if persistent vaginal sx – lowest progesterone exposure
question

what are bioidentical hormones?
answer

– custom-made HT formulations compounded at pharmacy according to provider – dose based on salivary hormone testing (may be unreliable)
question

what should be done prior to HT initiation?
answer

mammography within 12 mo
question

what happens if women on HT discontinue meds?
answer

50% chance of vasomotor sx recurring (regardless of whether tapered or abruptly discontinued)
question

What is Lichen sclerosus?
answer

chronic vulvar disorder usually seen in 5th or 6th decade. Thought to be an autoimmune response. porcelain-white papules and plaques (cigarette paper). NEED biopsy to confirm
question

What is Lichen planus?
answer

Inflammatory disorder most likely related to cell-mediated immunity. Can lead to scarring. some will have oral lesions as well. Pruritic purple papules
question

How do you treat Lichen sclerosus?
answer

high-potency topical steroids (clobetasol) daily for 4 weeks then qod then twice weekly
question

How do you treat lichen planus?
answer

high-potency topical steroids. Must monitor for SCC
question

What other vulvar disease should you be aware of?
answer

Paget’s – rare (adenocarcinoma) but if see it also think breast or colorectal
question

What medication is most commonly associated with sexual dysfunction
answer

SSRI
question

What medication is useful with hypoactive sexual desire disorder?
answer

transdermal testosterone short term (< 6 months)
question

UTI in non-pregnant females
answer

Bactrim DS bid x 3 days Cipro 250 bid x 3 days Marobid bid x 7 days
question

Natural HRT
answer

plants do not make Estrogen. they make sterols which have an estrogen-like effect →phytoestrogens soy and isoflavines → vasomotor for 2 yrs st. johns’ wart→depression for 2 yrs black cohash→vasomotor for 6 months
question

HRT and Breast cancer
answer

EPT → small ↑ risk (RR1.24) most studies do not show ↑ risk with E use alone + fan history is NOT contraindication for HRT
question

HRT and heart disease
answer

should not use HRT for CHD prevention
question

HRT and VTE
answer

if have h/o vet, stroke, tia or immobilized then should discontinue HRT
question

Autonomy
answer

right of patient to make own choice
question

beneficence
answer

the welfare of the patient
question

justice
answer

avoid discrimination (race, religion)
question

veracity
answer

deal honestly with patients and colleagues
question

routine lab screenings for gyn patients
answer

glc/fbs →q 3 years at age 65 lipid→q 5 years at age 45 TSH →q 5 years at age 50 dexa→q 2 years at age 65 Ua→q year at 65
question

T score
answer

std deviation from mean bone density of a normal young adult population a decrease of 1 sd will double risk of fracture
question

Z score
answer

std deviation from mean bond density of a reference population of same age, sex and race
question

screening for osteoporosis
answer

every 5 years from age 65 on OR every 2 years if on treatment Treat if T is -2 without risk factors or if -1.5 with risk factors
question

Osteopenia
answer

T score -1 to -2.5 SD (50%)
question

Osteoporosis
answer

T score < -2.5 SD (15%) Dexa (hip and spine are best) peak age of bone is 30 coritcal is 75% and trabecular is 25% (more surface area though)
question

osteoporosis treatment
answer

bisphosphonates →inhibits osteoclasts and ↑ bone density 50%. take on empty stomach and stay upright SERM (reloxifene)→Pro estrogen effect on bone and anti estrogen effect on endometrium and breast
question

Lipid profiles
answer

Tc <200 Tg 60 LDL <130 (<100 if high rush, <70 if very high risk) check after 9-12° fast
question

When should bone mineral density testing start?
answer

age 65 young if + risk factors re-screen every 2 years
question

How much calcium should you take daily?
answer

1,000mg daily 1,500 mg daily if > 65
question

What causes SUI?
answer

impairment of the pubourethral ligaments.
question

How do you treat BV?
answer

Flagyl 500 mg bid x 7 days OR clindamycin 300 mg bid x 7 days
question

What do you use for failed yeast infections?
answer

boric acid 600 mg capsules daily for 14 days
question

What is a positive test for BV?
answer

Need 3 out of 4 1. gray discharge 2. pH > 4.5 3. + amine test 4. > 20% epithelial clue being clue cells
question

How do you treat Trichomoniasis?
answer

Flagyl 500 mg bid x 7 days
question

HRT risks
answer

Increased risk of clot 34 vs 16 per 10,000 woman-years, Increased risk of breast cancer 38 vs 30 per 10,000 women years decreased hip fracture 10 vs 16 per 10,000
question

What thickness of endometrium excludes endometrial cancer?
answer

less than or equal to 4 mm – does not require EMB
question

How do you assess PMD
answer

either with EMB or U/S do not need both
question

When does fecundity decline?
answer

age 32 more rapidly at age 37
question

when should you start screening for colorectal cancer?
answer

age 50 and every 10 years
question

What SERM can treat osteoporosis?
answer

raloxifene – prevent and treat decrease bone tissue resorption by osteoclasts and therefore inhibit bone loss
question

What thrombotic effects are associated with SERMs?
answer

raloxifene and tamoxifen are associated with increased risk. RR 3.1
question

What breast candidates are appropriate for SERMs?
answer

Should be at high risk of developing breast cancer (ductal ca in situ, lobular ca in situ, ductal hyperplasia with atypia, strong family history)