Menopause: UWise, Osmosis, OMed

What are the medical consequences of menopause (what disease risks INCREASE)?

(1) Cardiovascular disease (2) Osteoporosis

Symptoms of menopause

- Hot flashes - Night sweats (can't sleep) - Vaginal dryness (painful sex) - Irritability - Irregular periods/no periods

How to interpret DEXA scan results?

-1 to -2.5 is osteopenia (risk for osteoporosis) Less than -2.5 is osteoporosis

Average age of menopause

51

A 54-year-old G2P2 presents to your office for a health maintenance examination. Her last menstrual period was eight months ago. She complains of severe vasomotor symptoms, vaginal dryness, and dyspareunia, and she desires treatment for her symptoms. She has otherwise been in good health and has no significant past medical or surgical history. Her family history is significant for a mother who has severe osteoporosis at the age of 75 and a grandmother who died of breast cancer at the age of 79. She does not report any smoking, alcohol or drug use. On physical exam her BP=130/78, Pulse=84, BMI=26. The remainder of her exam is within normal limits except for severe vaginal atrophy noted on the pelvic examination. The best recommendation for this patient would include which of the following? A. Lowest effective dose of combination hormone replacement therapy for the shortest duration possible B. Long term hormone replacement therapy to treat her vasomotor symptoms and prevention of osteoporosis C. Testosterone cream D. Progesterone cream E. Biosphophonates

A The American College of Ob-Gyn (ACOG) recommendations on hormone replacement therapy considers *hormone replacement therapy (HRT) the most effective treatment for severe menopausal symptoms* that include hot flashes, night sweats and vaginal dryness. The physician should counsel the woman about the risks and benefits before initiating treatment. ACOG recommends "the smallest effective dose for the shortest possible time and annual reviews of the decision to take hormones." HRT should not be used to prevent cardiovascular disease due to the slight increase in risk of breast cancer, myocardial infarction, cerebrovascular accident, and thromoboembolic events. A woman with an intact uterus should not use estrogen-only therapy because of the increased risk of endometrial cancer. In addition to the same risks as FDA approved treatments, bioidentical hormones such as testosterone and progesterone cream may have additional associated risks. Bisphosphonates are used to treat osteoporosis and will not relieve her symptoms.

A 58-year-old G3P3 woman who has been menopausal since age 50 comes to you for a health maintenance examination. She is in good health, eats a balanced diet, exercises regularly, and has an unremarkable physical exam. Her bone mineral density as determined by central dual energy X-ray absorptiometry is -1.7. She wants to discuss treatment for her osteopenia. What is the next step in the management of this patient? A. Evaluate her risk factors for fracture B. Determine her frequency of exercise C. Assess her exogenous dietary intake of estrogen D. Assess her exogenous dietary intake of progesterone E. Repeat DEXA scan in one year

A The World Health Organization (WHO) defines osteopenia (low bone mass) as -1 to -2.5. The American College of Ob-Gyn (ACOG)) Committee Opinion recommends that physicians interpret T scores between −1.5 and −2.0 in combination with the patient's risk factors for fracture. The authors state: "Clinicians must be careful because the diagnosis of osteopenia often is interpreted as indicating a pathologic skeletal condition or significant bone loss, neither of which is necessarily true. Until better models of absolute fracture risk exist, postmenopausal women in their 50s with T scores in the osteopenia range and without risk factors may well benefit from counseling on calcium and vitamin D intake and risk factor reduction to delay initiation of pharmacologic intervention." Some of the risk factors for fracture include prior fracture, family history of osteoporosis, race, dementia, history of falls, poor nutrition, smoking, low body mass index, estrogen deficiency, alcoholism, and insufficient physical activity.

A 53-year-old G2P2 comes to your office complaining of six months of worsening hot flashes, vaginal dryness, night sweats and sleep disturbances. Her last normal menstrual period was six months ago and she has been experiencing intermittent small amounts of vaginal bleeding. Her medical history is significant for hypertension, which is well-controlled by a calcium-channel blocker, adult onset diabetes, for which she takes Metformin, and hyperthyroidism, for which she takes Propylthiouracil. The patient is 5 feet 7 inches tall and weighs 140 pounds. Blood pressure is 120/70. Physical examination is unremarkable. Which of the following medical conditions in this patient is a contraindication to treatment of menopausal symptoms with hormone therapy? A. Vaginal bleeding B. Hypertension C. Diabetes D. Osteoporosis E. Hyperthyroidism

A The principal symptom of endometrial cancer is abnormal vaginal bleeding. Although the patient's worsening symptoms make treatment an important consideration, the specific organic cause(s) of abnormal bleeding must be ruled out prior to initiating therapy. A tissue diagnosis consistent with normal endometrium or a pelvic ultrasound with an endometrial stripe of <4 mm ought to be documented. In addition, risks and benefits of hormone replacement therapy must be discussed with this patient at length prior to beginning treatment. - *Postmenopausal woman + bleeding = endometrial cancer* - *hormone replacement therapy causes endometrial cancer*

What to give menopausal woman to TREAT osteoporosis?

Bisphosphonates (alendronate)

A 58-year-old G3P3 has been postmenopausal for five years and is concerned about osteoporosis. She has declined hormone therapy in the past. Her mother has a history of a hip fracture at age 82. A physical exam is unremarkable. In addition to weight bearing exercise and vitamin D supplementation, what optimal daily calcium intake should she take? A. None B. 200-300 mg C. 500-800 mg D. 1000-1200 mg E. 1500-2000 mg

D Calcium absorption decreases with age because of a decrease in biologically active vitamin D. A positive calcium balance is necessary to prevent osteoporosis. Calcium supplementation reduces bone loss and decreases fractures in individuals with low dietary intakes. In order to remain in zero calcium balance, *postmenopausal women require a total of 1200 mg of elemental calcium per day*.

A 58-year-old G3P1 presents to your office for her a health maintenance examination. She became menopausal at age 54. Her past medical history is significant for angina. She experienced a Colles' fracture 14 months ago when she tripped and fell while running after her grandson. She has not had any surgeries. She takes no medications and has no known drug allergies. She smokes 10 cigarettes a day and drinks a glass of red wine at dinner. Her father was diagnosed with colon cancer at the age of 72. Physical exam revealed a BP=120/68, P=64, BMI= 22. Her heart, lung, breast and abdominal exams were normal. Pelvic exam was consistent with vaginal atrophy and a small uterus. There was no adnexal tenderness and no masses were palpated. In addition to obtaining a bone mineral density scan, what is the next step in the management plan for this patient? A. Repeat bone mineral density in one year B. Repeat bone mineral density at age 65 C. Begin hormone replacement therapy D. Begin treatment with bisphosphonates E. Test for the presence of biochemical bone markers in the blood

D This patient has many of the major risk factors for osteoporosis including history of fracture as an adult, low body weight and being a current smoker. *Patients who already have had an osteoporotic fracture may be treated w/ bisphosphonates even without a DEXA scan*. Prior to beginning treatment with bisphosphonates, a bone mineral density (BMD) should be documented and repeated at two-year intervals to monitor treatment. DEXA is the test of choice for measuring (BMD). A nuclear medicine bone scan may be useful to rule out a pathologic fracture from metastatic disease. General recommendations for the prevention of osteoporosis include eating a balanced diet that includes adequate intake of calcium and vitamin D, regular physical activity, avoidance of heavy alcohol consumption, and smoking cessation. Bone markers are used in research but are not yet a reliable predictor of BMD. Hormone replacement therapy is not recommended long term for disease prevention especially in patients with cardiovascular disease.

A 54-year-old G4P4 woman who has been menopausal for four years recently underwent a total vaginal hysterectomy and bilateral salpingo-oophorectomy for vaginal prolapse. She comes in for a postoperative check up and complains of hot flashes and wonders why she is experiencing menopause again. Which of the following most likely explains why she is experiencing these symptoms? A. Increased postoperative liver metabolism B. Decreased adrenal estrogen production C. Removal of an occult estrogen-producing tumor D. Decreased circulating androgens E. Cessation of ovarian estrogen production

D. *Postmenopausal woman after oophorectomy gets more menopause symptoms bc ovaries used to make androgens converted to estrogen (no more estrogen since menopause)* Estrogen production by the ovaries does not continue beyond menopause. However, estrogen levels in postmenopausal women can be significant due to the extraglandular conversion of androstenedione and testosterone to estrogen. This conversion occurs in peripheral fat cells and, thus, body weight has been directly correlated with circulating levels of estrone and estradiol. Since menopausal ovaries are known to continue production of androgens, surgical removal of postmenopausal ovaries may result in the resurgence of menopausal symptoms from the abrupt drop in circulating androgens.

Menopausal woman + painful sex NBS?

Diagnosis Vaginal atrophy Give estrogen cream

A 49-year-old G1P1 comes to your office for menopause counseling. She has been experiencing severe sleep disturbances and night sweats for the past four months. She would like to begin hormone therapy, but is concerned because she has elevated cholesterol levels for which she takes medication. You explain to her that hormone therapy has the following effect on a lipid/cholesterol profile: A. Both LDL and HDL levels increase B. Both HDL and LDL levels decrease C. HDL and LDL levels are unaffected D. HDL levels increase and LDL levels are unaffected E. HDL levels increase and LDL levels decrease

E Recent data have confirmed the overall positive effects of hormone therapy on serum lipid profiles. The most important lipid effects of postmenopausal *hormone treatment effects are the reduction in LDL cholesterol and the increase in HDL cholesterol*. Estrogen increases triglycerides and increases LDL catabolism, as well as lipoprotein receptor numbers and activity, therefore causing decreased LDL levels. Hormones inhibit hepatic lipase activity, which prevents conversion of HDL2 to HDL3, thus increasing HDL levels. Hormone therapy is not currently recommended for the primary prevention of heart disease.

Hormone changes in menopause? FSH LH FSH/LH ratio Estrogen GnRH

FSH - increases LH - doesn't increase? FSH/LH ratio - increases (PCOS LH:FSH > 3) Estrogen - decreases GnRH - increases (pulsatile)

Define premature ovarian failure

Menopause before 40

Indications for hormone replacement therapy in menopausal woman?

NONE Hormone replacement therapy increases the risk for endometrial cancer and breast cancer Use HRT for *premature ovarian failure* (menopause < 40yo)

How to diagnose menopause? What tests?

No test!!!! It's just symptomatic

What should a menopausal woman get for contraception?

None -- infertile

Pathophysiology of menopause.

Normal: GnRH --> FSH/LH --> activates many follicles (egg) in ovary --> one ovulates, the others degenerate --> menses AND FSH/LH --> activates ovaries to make estrogen Menopause: the ovaries don't respond to FSH/LH and follicles have either degenerated or no longer respond to FSH/LH. Therefore: estrogen/progesterone are DOWN, no more periods, FSH/LH are up.

What disease to screen for in menopausal woman? How to screen? When to start screening? How often to screen?

Osteoporosis Screen w/ DEXA scan Start at 65 yrs old Screen once a year

Menopausal woman + irregular periods NBS/treatment?

Reassurance

Define perimenopause

The 1-2 years before menopause, when periods become irregular i.e. time between once periods become irregular to once they stop

Define menopause

Time period when menstruation stops

Menopausal woman + hot flashes NBS?

Venlafaxine (SSRI)

What to give menopausal woman to PREVENT osteoporosis?

Vitamin D3 and Calcium

Why not give menopausal woman hormone replacement therapy?

increases risk for endometrial cancer