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Define "menopause"
Menopause is the permanent cessation of menses resulting from diminishing ovarian follicular function.
It is defined as 12 consecutive months of amenorrhea.
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What is the median age of onset in the US for menopause?
Median age of onset is 51 years of age (range 40-55).
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Define "perimenopause"
Perimenopause, also called the menopausal transition, is the time before menopause and the first year following menopause.
Ovarian function and production of estrogen decline during this time, and menstrual cycles may be irregular.
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Symptoms of perimenopause related to declining estrogen
- Anovulation
- Abnormal uterine bleeding
- Extended menstrual cycle intervals
- Oligomenorrhea
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Define "anovulation"
- Anovulation is a condition in which the ovary does not release a ripened egg each month as part of a woman's normal cycle in her reproductive years.
- Naturally, with no egg available for sperm, a woman cannot become pregnant.
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Define "oligomenorrhea"
- Oligomenorrhea (or oligomenorrhoea) is infrequent or very light menstruation.
- More strictly, it is menstrual periods occurring at intervals of greater than 35 days, with only four to nine periods in a year.
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What are the three (3) V's symptoms of menopause directly related to lack of estrogen
- Vaginal dryness
- Vaginal atrophy (atrophic vaginitis) - is thinning and inflammation of the vaginal walls due to a decline in estrogen
- Vasomotor symptoms - night sweats, hot flashes
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Symptoms associated with menopause, but without link to estrogen deficiency
- arthralgia
- depression
- insomnia
- migraines
- mood swings
- myalgia
- urinary frequency
- cognitive changes (memory & concentration loss)
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Pathophysiology of menopause
- 1. Loss of ovarian follicular activity
- 2. Ovarian production of estradiol & progesterone diminishes
- 3. FSH & LH concentrations increase
- 4. Primary estrogen available is now estrone (which is converted peripherally from androstenedione & is less potent), not estradiol
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Define "hysterectomy"
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist.
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Treatment for postmenopausal women with an intact uterus
estrogen & progestin to reduce the risk of endometrial hyperplasia & endometrial cancer
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Treatment for postmenopausal women who have had a hysterectomy
unopposed estrogen
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What are the contraindications to estrogen replacement therapy (ERT)?
- Genital bleeding
- Breast cancer
- Hx of DVT or pulmonary edema
- Estrogen-dependent neoplasia
- Pregnancy
- Stroke or MI
- Liver disease
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Define "neoplasia"
Neoplasia is the abnormal proliferation of cells.
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What is the most effective therapy for moderate to severe vasomotor symptoms related to menopause?
- Estrogen derivatives, such as:
- Premarin® (Conjugated Estrogens)
- Estrace® (Estradiol)
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What are the common side effects of estrogen derivatives?
- Breast tenderness
- Heavy/irregular bleeding
- Headache
- Nausea
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In what specific population do estrogen derivatives increase the risk of endometrial cancer?
In women with a uterus, unopposed estrogen increases risk of endometrial cancer
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What are the common side effects of progestin derivatives?
- Depression
- Irritability
- Headache
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Which method(s) can be used to diminish the SE of estrogen?
- Starting off with a low dose
- Change to another product/route
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Which method(s) can be used to diminish the SE of progestin?
- Change to another product/route
- Change from a continuous to a cyclic regimen
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Patient instructions & counseling on the uses of estrogen & progestin
- Patients should be instructed to immediately report any unusual vaginal bleeding
- Patients should be instructed to contact their PCP promptly for any ACHES symptoms
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Which method can be used to diminish the hypertriglyceride effect caused by estrogen?
Switch to a transdermal product
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What are the precursor hormones to estrogen production by the ovaries & peripheral site?
Androgens (testosterone)
Ovarian testosterone production declines with menopause.
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When can testosterone therapy be initiated in postmenopausal women?
women who are receiving concurrent estrogen therapy
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What are the three (3) contraindications to androgens therapy?
- androgenic alopecia
- hirsutism
- acne
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What are the SEs of androgens?
- fluid retention
- decrease HDL
- decrease TG
- hepatic dysfunction
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The long-term use of androgens (testosterone) in women can cause what?
Hepatocellular carcinoma
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What is the advantage of estrogen plus continuous progestin in HRT?
Menses only lasts for first 8-12mo of tx
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What is the disadvantage to Estrogen plus cyclic progestin in HRT?
Regular menses every month until tx is d/c
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Name one (1) non-drug therapy that can be used to control vaginal symptoms in postmenopausal women?
phytoestrogens
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