Term
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Definition
derived from the Greek words for "month" (men) and "cessation" (pausis)
a natural event in a woman's life - a predictable organ-system failure
ovaries are not self replenishing organs; a women is born with the ability to ovulate a finite number of times
natural menopause: the ovaries fail on their own
surgical menopause:
ooverectomy - ovary/ies are removed and uterus remains
hysterectomy - uterus removed; cervix is left unless there is ovarian cancer
total hysterectomy - uterus and both ovaries removed
in the above cases reproductive abilities are gone
partial hysterectomy - uterus and one ovary is removed |
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Term
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Definition
peri-menopause
menopause
post-menopause |
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Term
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Definition
the years prior to menopause (when symptoms commence) and also the first year after menopause
peak levels of estrogen start to fall (around age 40)
the levels of estrogen start to fall b/c the most dominant follicles will be stimulated earliest; with aging, the weaker follicles are stimulated and do not produce as much estrogen
most women do not notice this decrease in estrogen initially
the average age of menopause is 51
the strongest predictor of when a woman will go through menopause is when their mother when through menopause (also sisters are strong predictors of age of menopause)
peri-menopause also includes the 1st year of menopause: menopause is the last menses, the last menses is determined after one year of no menses
menses will become more irregular later in life |
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Term
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Definition
permanent cessation of menstruation which occurs when the ovaries stop producing the hormones estrogen and progesterone
nautral menopause is recognized to have occurred once a period of 12 months has lapsed after the last menstrual period, and for which there is no other obvious cause
no specific indication marks the beginning of menopause other than the onset of symptoms
treat the symptoms of estrogen deprivation, not treating menopause |
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Term
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Definition
when one year has lapsed since the last menstrual period
some women may still continue to experience menopausal symptoms for several years following their last period |
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Term
| patient characteristics that determine how they will utilize estrogen |
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Definition
weight:
increased fat = milder symptoms for longer
a thin person = severe symptoms that don't last very long b/c estrogen is lipophilic and depots in adipose tissue
patients that suddenly lose weight after menopause can experience symptoms 10-20 years after menopause b/c of release of hormones from the fat
look at family history to determine the severity of symptoms
dose related estrogen ADRs: N/V, edema, headache, BREAST TENDERNESS (most common); can use these to determine if the women is sensitive to estrogen |
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Term
| will contraceptives delay the onset of menopause? |
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Definition
oral contraceptives do not delay menopause
oral contraceptives very rarely suppress ovulation (post-ovulatory effects that prevent fertilization)
patients may still be ovulating while taking oral contraceptives |
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Term
| symptoms of menopause: hot flashes |
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Definition
the hallmark and the most commonly associated symptom with menopause
this is just one of several symptoms that may occur letting a woman know that menopause is on its way
these symptoms tend to be experienced by the majority of women and are due to the declining levels of estrogen in the body
the body is now moving into a state of readjustment and learning to live without estrogen
women who have surgical menopause will have more severe hot flashes than women with natural menopause b/c it is more sudden (no tapering)
cannot predict when they will occur; more likely at night but can be at any time
can last minutes to hours to days
may have physical symptoms with the hot flash: flushing, sweating
can have symptoms of a hot flash without the signs of a hot flash |
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Term
| symptoms of menopause: hot flashes and night sweats |
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Definition
very common
a sensation of heat spreads over the body, in particular the head, face, and chest and is often accompanied by flushing and sweating, followed by a chill |
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Term
| symptoms of menopause: vaginal dryness |
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Definition
not something openly discussed but a symptom that is regularly experienced
the lining of the vagina needs estrogen to stay lubricated and elastic
loss of elasticity causes dryness leading to uncomfortable intercourse
lubricants can be used to counteract this (but will not help with elasticity)
everything in the female reproductive system is estrogen dependent except for the cervix
as estrogen levels decline, these tissues atrophy
vaginal smooth muscle starts to atrophy and becomes more stiff; vaginal elasticity is lost and dryness occurs = pain during intercourse |
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Term
| symptoms of menopause: urinary symptoms |
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Definition
the urethra and bladder also rely on estrogen to function properly
the loss of estrogen reduces elasticity causing problems such as an increased need to urinate, pain or burning when urinating, or bladder infections
increased rates of urinary incontinence |
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Term
| symptoms of menopause: loss of libido |
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Definition
loss of interest in sex or reduced sex drive may occur due to decreased estrogen levels, or as a result of tiredness and stress as the body changes its patterns
decreased libido due to decreased levels of androgens
vaginal dryness, a change in skin sensitivity, tiredness due to hot flashes, and the sense of just not wanted to be touched are other common factors
libido is testosterone driven
in women, the main source of testosterone is estrogen |
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Term
| other typical symptoms of menopause |
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Definition
aches and pains
irritability, tiredness
loss of concentration
headaches
crying spells and depression
women who have PMS are more likely to have more severe post-menopauseal symptoms |
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Term
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Definition
use signs and symptoms initially
FSH can be used, but may not be clearly diagnostic until the patient is truly post-menopausal
if symptoms are present but there is no FSH increase, consider thyroid disease
FSH > 30 is typically considered diagnostic for menopause
FSH will begin to increase for several years prior to menopause |
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Term
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Definition
no treatment is indicated if no symptoms are present
all post-menopausal women should receive calcium therapy if not contraindicated
women should be taking 1000-1250 mg of calcium per day
do not go above 1500 mg/d b/c of risk of calcifications, coronary events, and kidney stones
weight bearing exercise is indicated for all women who can tolerate it
hormone replacement therapy is indicated only for perimenopausal symptoms or some cases of osteoporosis |
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Term
| estrogen replacement therapy (ERT) vs. hormone replacement therapy (HRT) |
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Definition
ERT may ONLY be used in women without a uterus
HRT (combination of estrogen and progestin) must be used in women with intact uterus
the only function of progestin is to protect against uterine hyperplasia
uterine hyperplasia is a strong risk factor for uterine cancer
estrogen stimulates endometrial growth
up to 3 months of unopposed estrogen is okay, but a progesterone needs to be added if the women has a uterus
at 3 months the risk of endometrial hyperplasia increases (increased endometrial growth) = risk factor for endometrial cancer
cyclic vs. continuous HRT: progesterone can be given daily - the only reason progesterone is there is to blunt the effects of estrogen
progesterone can be given cyclically - when withdrawn, the women will have a period |
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Term
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Definition
undiagnosed abnormal uterine bleeding
history of estrogen sensitive tumor
breast
uterus
history of thromboembolic disease
stroke
DVT, PE
active liver disease
estrogen is converted in the liver, may become toxic with estrogen
also increases risk of thrombosis independent of estrogen
heavy drinking - do not recommend ERT b/c of risk of thrombosis and active liver disease; alcohol also worsen hot flashes
thrombosis is the #1 deadly side effect of ERT |
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Term
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Definition
postmenopausal ERT is typically dosed at much lower levels than is used in oral contraceptives
dose conversion:
0.635 mg conjugated estrogens = 5 mcg of ethinyl estradiol
ERT is trying to mimic the hormone loop, so the doses are much lower
give the minimum amount of estrogen for the shortest amount of time
conjugated estrogens are a type of estrogn; there are 20 different types of conjugated estrogens
conjugated EQUINE estrogens have more patient variability than with synthetic estrogens
plant based estrogens are even more variable than equine estrogens
will get more predictable response with prescription estrogens than with plant estrogens
plant estrogens have all the same ADRs and cautions as prescription products |
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Term
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Definition
unopposed estrogen is associated with endometrial hyperplasia and carcinoma; may only be used in women without a uterus
progesterone withdrawal (withdrawal bleed) required at a minimum of every 3 months if cyclic regimen used
in last ten years continuous suppression of the endometrium with combined therapy has become popular |
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Term
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Definition
if bleeding is heavy and irregular, try cyclic regimen first for cycle control; may try switch to continuous after one year
younger women tend to have less irregular bleeding with cyclic regimens
continuous better for women who are amenorrheic or older than 50
younger women, surgically menopausal tend to need more estrogen at first; may need to titrate dose/schedule
continuous combined HRT: breakthrough bleeding is a problem (will not have a regular menses)
cyclic HRT is of benefit if the patient has unacceptable breakthrough bleeding, then can try to switch to continuous
the later the menopause, the better they will respond to continuous HRT
the younger the patient, the more estrogen they will need to blunt their symptoms (b/c their estrogen levels haven't dropped as much as older patients) |
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Term
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Definition
use of testosterone supplements (estratest)
postmenopausal ovary does produce testosterone; but much less than in premenopausal state
supplementation may improve libido and hot flashes
adverse effect on lipid profile
possible for liver toxicity
typically only used for 3-6 months to "kick-start" the libido
the only reason to give testosterone is to increase libido
oral testosterone WILL cause hepatotoxicity; topically can be given instead to bypass the first pass effect
estratest: ask the patient if they have had a hysterectomy b/c there is not a progesterone component |
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Term
| side effect management: management of bleeding |
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Definition
expect some irregular spotting for the first three months, especially with continuous progestins; if persists can try increasing progestin dose or switching to cyclic regimen
investigate irregular bleeding if it occurs after the first 6 months
always need to evaluate unscheduled bleeding on cyclic regimens
withdrawal bleed should occur at the end or after the progestin is administered
BTB: switch to cyclic schedule or increase progesterone dose
balance of estrogen and progesterone that is maintaining the uterine health
if there is more progesterone than estrogen it will prevent the endometrial lining from developing
if you are giving a high dose of progesterone then withdraw it, it will cause bleeding
estrogen stimulates endometrial growth
progesterone stops endometrial growth
the balance between estrogen and progesterone is important
during pregnancy, may need to give progesterone to prevent endometrium from getting thicker b/c it may not be perfused
in continuous combined HRT: give estrogen and slightly more progesterone so the endometrial lining never develops |
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Term
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Definition
b/c of first pass effect of the liver, oral products are more likely to cause drug induced hepatotoxicity
estrogen increases HDL (more than any other drug therapy), lowers LDL (a little), and increases TGs (significantly)
how can this be avoided?
the 1st pass effect causes the lipid effects; give a transdermal product instead
high TGs is generally a problem in patients with diabetes (TGs follow glucose) |
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Term
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Definition
the only difference between transdermal and oral products: you don't get the lipid effects with transdermal
HAVE TO ASK THE PATIENTS: HAVE YOU HAD A HYSTERECTOMY?
they still need a progesterone component |
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Term
| topical vaginal estrogen products |
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Definition
may be useful for treating vaginal dryness and dyspareunia (pain during intercourse)
should not be used as lubricant for sexual activity
systemic absorption does occur, but to a much lesser degree than with oral or trandermal products
extreme caution must still be used when patients have history of estrogen dependent tumor or thromboembolism
absorption depends on:
surface area (if the patient has had a baby)
if used prior to intercourse (should not do!!!)
if used after intercourse (can increase systemic absorption if there are vaginal tears)
how deeply the product is applied
should use topical vaginal estrogen products at bedtime |
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Term
| women's health initiative study: the study that caused people to stop using ERT in everybody |
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Definition
WHI Outcomes:
estrogen and progesterone increased risk of:
breast cancer (almost double the risk)
blood clots
stroke
heart disease
estrogen alone increased risk of:
stroke
cannot remove the progesterone b/c that WILL cause endometrial cancer |
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Term
| non-hormonal treatments of hot flashes |
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Definition
anti-depressants, anti-hypertensives, and natural products (for a person with a contraindication to HRT)
black cohosh: herbal product with estrogenic effects; should not be given to a patient with a contraindication to estrogen
soy products and yam products: should not be given to a patient with a contraindication to estrogen
antihypertensives: clonidine (only drug that has shown effectiveness); blood pressure goes up during a hot flash, but clonidine works b/c of the effect on the brain; large doses of clonidine; ADRs = hypotension; cannot use clonidine prn for hotflashes, will not work
anti-depressants: TCAs or SSRIs
20-50% of women will respond to these other options; trail and error |
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Term
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Definition
start at the lowest possible dose and keep going for 6 months and slowly taper them off
keep decreasing until the hotflashes come back then taper up and taper back down
risk for breast cancer is more significant after 4 years of HRT |
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