Term
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Definition
| menopause occurs after *12 consecutive months of amenorrhea*, for which there is no other obvious pathologic/physiologic cause. it is a normal, natural event - defined as the final menstrual period (FMP). it represents the permanent cessation of menstruation, resulting from *loss of ovarian follicular function* - usually due to aging. |
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Term
| when does aging of the female reproductive tract start? |
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Definition
| at birth, characterized by a steady loss of oocytes through atresia and ovulation (*mostly through atresia). at birth, females have 1-2 million eggs and only ~1,000 by menopause. |
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Term
| is loss of eggs over the lifetime of a female linear? |
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Definition
| no, egg loss accelerates in the 30s. this correlates w/a decrease in fecundity. |
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Term
| what is the median age for menopause? |
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Definition
| 51 y/o. the low end is 40/upper end is 58. |
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Term
| how does smoking affect menopause? |
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Definition
| menopause occurs ~ 1.5 yrs sooner in smokers |
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Term
| what are the 3 types of menopause? |
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Definition
| natural/spontaneous (12 consecutive mos of amenorrhea), induced (sx, chemo, radiation), and premature (< 40 y/o natural/induced) |
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Term
| what is premature ovarian insufficiency/failure (hypogonadotropic hypogonadism)? etiology? dx? (*possible exam question*) |
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Definition
| loss of ovarian function at less than 40 y/o, resulting in amenorrhea. etiology: idiopathic, autoimmune, turner's, and *fragile X*. dx: age or FSH > 40 mIU/mL (x2 mo apart) |
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Term
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Definition
| the span of time when changes occur to the menstrual cycle/endocrine system - which is a few years before the FMP and 12 mos after, resulting from natural menopause. |
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Term
| what happens in perimenopause? |
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Definition
| decreased number of follicles, decreased production of inhibin B, increased production of FSH (which the remaining follicles respond poorly to) - which means the follicular phase becomes shorter, estradiol is variable (inconsistent ovulation), luteal phase progesterone is decreased, and erratic ovulation results in menstrual cycle irregularity and symptoms. |
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Term
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Definition
| menstrual dysfunction - heavy bleeding, can be due to perimenopausal state, may require endometrial ablation. |
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Term
| how young can hot flashes present? |
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Definition
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Term
| do perimenopausal women still require contraception? |
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Definition
| yes - b/c they are still ovulating, albeit irregularly. the conventional rx is low-dose OCPs (20 ug if not contraindicated), which at some point need to be transitioned to HT (hormone therapy - which is a lower dose than low dose OCPs). this transition is determined by taking the pt off OCPs for a couple of weeks, getting an FSH and if it is elevated - moving to HRT. |
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Term
| what are the 2 broad categories of menopause? |
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Definition
| vasomotor symptoms (VMS) and vulvovaginal symptoms (VVA) |
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Term
| what are the VMS associated w/menopause? |
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Definition
| hot flashes and night sweats (profuse hyperhidrosis). this begins as a sensation of intense warmth in the upper body, followed by skin redness (flushing), accompanied by drenching perspiration and followed by a cold, clammy feeling. this typically begins at the head and spreads downward w/total duration 30 sec - 5 min and as many as 2-3/hour. this can be accompanied by palpitations, feeling of pressure in the head, dizziness, faintness, or weakness. |
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Term
| what are the VMS classifications? |
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Definition
| mild: sensation of heat w/o sweating, moderate: sensation of head w/sweating (non-disruptive), and severe: sensation of heat w/sweating (disruptive) |
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Term
| do hot flashes stop after menopause? |
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Definition
| no, they can continue for many years in ~10% of women |
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Term
| what is the exact cause of menopause? (*exam question*) |
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Definition
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Term
| what are the symptoms of VVA associated w/menopause? |
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Definition
| vaginal dryness (burning/itching/irritation), dysuria (burning sensation), urgency (perhaps urge incontinence), frequency, dyspareunia, and post-coital spotting (r/o cervical polyp) |
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Term
| what happens to the vaginal epithelium w/menopause? |
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Definition
| the superficial cell layer goes from making up 15% of the dermis to 1% - much more easily traumatized. |
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Term
| what are some other symptoms associated w/menopause? |
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Definition
| forgetfulness, joint pain/stiffness, formication (itchy crawly skin), etc |
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Term
| what are some possible new onset chief complaints which may signal perimenopause, but are not directly related to the GU? |
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Definition
| palpitations, panic attacks, and depression (20% incidence, and increased during menopause transition, decreased afterwards) |
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Term
| what is the overlap of symptoms between depression and menopause? |
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Definition
| decreased energy, decreased concentration, sleep disruption, wt change, and decreased libido |
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Term
| what was the result of the WHI (women's health initiative)? |
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Definition
| before WHI, internists & cardiologists were prescribing estrogen (HRT) as primary prevention for CHD. after WHI, which showed an increase in breast CA, cardiac disease, and DVTs - women stopped using HRT (now called HT) and a lot of fear + confusion occurred. |
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Term
| following WHI, what is tx for mild VMS? |
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Definition
| reducing core body temp (layers, sleep in cool room), regular exercise, wt management, smoking cessation, and avoidance of known triggers |
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Term
| following WHI, what is tx for moderate-severe VMS? |
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Definition
| systemic HT for disruptive hot flashes/night sweats (this is the primary indication for HT), and if VVA is the pt's only complaint: topical estrogen. |
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Term
| what is the timing component to HT and menopause? |
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Definition
| the optimal time to start HT is *soon after menopause, b/c starting it later may increase CHD risk |
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Term
| what risks are associated w/HT? (*possible exam question*) |
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Definition
| both estrogen (ET) and estrogen+progestin (EPT) increase *ischemic stroke risk - but have no effect on *hemorrhagic stroke risk. |
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Term
| what characterizes VTE (venous thromboembolism) risk with oral HT? |
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Definition
| *oral preps of HT seem to have a higher risk of VTE (PE, DVT) which emerges 1-2 yrs after HT initiation - but the longer the pt is on it the lower the risk becomes. women < 60 are at a lower overall risk for this and transdermal systems may also carry a lower risk (no first pass). |
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Term
| if a pt is on estrogen-only HT and still has a uterus, what is she at risk for? how is this countered? |
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Definition
| endometrial CA (if on ET for 3 years, her risk of endometrial cancer increases 5-fold). therefore, if a woman still has a uterus HT needs to include progestin to protect the uterus (but risk worsening mood). |
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Term
| what ADRs are associated with progestin in HT? how is this dealt with? |
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Definition
| worsening of mood (esp in pts w/a strong hx of: premenstrual syndrome (PMS), premenstrual depressive disorder (PMDD), or clinical depression). therefore current data supports minimizing progestin exposure. off label approaches to this: long-cycle regimens (progestin every 3 mos), vaginal administration, levonorgestrel-releasing IUD, or low-dose estrogen w/o progestin. |
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Term
| what characterizes breast CA risk w/EPT (estrogen+progestin therapy)? |
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Definition
| breast CA risk increases after 3-5 yrs of EPT of *absolute risk* (8 additional cases of breast cancer/10,000 women/yr in the treatment group (vs. placebo)). it is still unclear whether continuous EPT or sequential (3 wks on/1 wk off) affects this risk. |
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Term
| what are "bio-identical hormones"? |
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Definition
| this can refer to custom-made HT formulations for individual pts, but the companies doing this were using non-FDA approved products (E3) so they were ordered to stop. *there are FDA-approved bio-identical hormones: 17-beta-estradiol and oral micronized progesterone. |
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Term
| what can be expected by the pt if they stop HT? |
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Definition
| 50% chance of VMS returning, and that symptom recurrence is similar regardless of whether HT is tapered or stopped abruptly. change in breast CA risk is unknown. the decision to stop HT has to be individualized to each pt. |
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Term
| if a pt stops HT, but still wants tx for VMS - what can be provided? |
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Definition
| off label meds: SSRI, SNRI, clonidine, and gabapentin - but may only get 60% reduction in symptoms. *polycarbophil bioadhesive polymer can be used for vaginal dryness, which carries 60x its wt in water and adheres to the vaginal epithelium - delivering electrolytes/water (as it is negatively charged) into the skin, increasing blood supply to the tissue and transudation of fluids. |
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