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Which of the following is NOT a clinical feature of menopause?
Which hormone levels are expected to be high during menopause?
FSH levels are checked on two occasions to confirm menopause.
True
Hot flashes are caused by an increase in estrogen levels.
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What are two syndromes associated with menopause?
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What is the primary cause of menopause?
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A common symptom of menopause is _____, which can lead to discomfort during intercourse.
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Match the following clinical features with their descriptions:
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In hypergonadotropic hypogonadism, FSH and LH levels are found to be ______.
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Match the hormone with its corresponding change during menopause:
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At what age does menopause typically occur worldwide?
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Primary ovarian insufficiency occurs when menopause happens before the age of 40.
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What is the first sign of perimenopause?
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Menopause is defined as amenorrhea for _____ months followed by permanent cessation of menstruation.
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Match the following terms with their definitions:
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What is the most common cause of central precocious puberty?
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Café au lait spots are a characteristic feature of McCune Albright Syndrome.
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What are the two types of precocious puberty?
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The most common cause of heterosexual precocious puberty is _____.
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Match the following investigations with their purposes:
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What is the maximum duration recommended for postmenopausal Hormone Replacement Therapy?
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Micronized oral progesterone is considered the drug of choice (DOC) for hormone replacement therapy.
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List two contraindications for Hormone Replacement Therapy.
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Estrogen plus Mirena provides a __________ benefit in perimenopausal women with hot flushes.
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Match the following terms with their descriptions:
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What is the main mechanism by which bisphosphonates work?
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Bone mineral density (BMD) is primarily affected by changes in trabecular bone.
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At what age should a patient be evaluated for osteoporosis according to the diagnosis criteria?
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Menopause-related symptoms generally start ____ to ____ years before actual menopause.
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Match the following fracture types with their corresponding descriptions:
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Which treatment option is appropriate for a woman with an intact uterus experiencing hot flushes?
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Calcium requirement increases for menopausal women compared to women of reproductive age.
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Name one medication listed as a selective serotonin reuptake inhibitor (SSRI) used for hot flushes.
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The primary treatment for senile vaginitis is local _____ therapy.
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Match the following treatment options with their corresponding conditions:
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What is the main source of DHEA-Sulphate in females?
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Excessive androgen levels in females can lead to conditions such as hirsutism and virilization.
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What is the primary function of androgens during intrauterine life?
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Androgens primarily bind to _____ and Albumin.
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Match the following effects with their corresponding terms:
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What is a condition commonly associated with decreased cervical discharge leading to vaginal dryness?
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Hormone Replacement Therapy (HRT) is given to prevent coronary artery disease (CAD).
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Name one commonly used Selective Estrogen Receptor Modulator (SERM) that can lead to vaginal dryness.
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Increased frequency of urination and urinary incontinence are symptoms of _____ associated with menopause.
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Match the SERMs with their usage:
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Which of the following is an indication for Hormone Replacement Therapy?
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Estrogen + Progesterone (E + P) HRT increases the risk of endometrial cancer when the uterus is present.
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What is the ideal duration for Hormone Replacement Therapy?
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The primary advantage of estrogen only HRT is the reduction in _____ and osteoporosis.
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Match the following HRT types with their primary characteristics:
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Study Notes
Menopause
- Menopause is the permanent cessation of menstruation in a woman of menopausal age who has experienced amenorrhea for at least 12 months.
- The average age of menopause worldwide is 51 years, while in India, it is 47 years.
- Premature menopause, now referred to as Primary Ovarian Insufficiency (POI), occurs before the age of 40 and is characterized by secondary amenorrhea and infertility.
- Late menopause, characterized by the non-occurrence of menopause in women aged 55 or older, requires an endometrial biopsy due to the increased risk of endometrial cancer.
- Perimenopause, previously known as climacteric, is a transitional phase leading to menopause, marked by hot flushes and an increase in cycle length by at least 7 days.
- Menopause is a clinical diagnosis, and no hormonal tests are required for confirmation.
- POI mandates laboratory tests for confirmation.
Hormonal Profile During Menopause
- Estrogen levels decrease during menopause.
- Estriol (E3) is the most common estrogen found in the body.
- Androgen levels decrease during menopause.
- Levels of Anti-Müllerian Hormone (AMH) and Inhibin decrease.
- Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) levels increase.
Physiology of Menopause
- Menopause is characterized by the apoptosis of ovarian follicles.
- The decrease in ovarian hormones leads to a loss of negative feedback on the pituitary gland.
- This results in an increase in FSH and LH levels.
- The elevated FSH and LH are excreted in the urine.
- Human Menopausal Gonadotropins (HMG) are extracted from the urine of postmenopausal women.
Hypergonadotropic Hypogonadism
- Secondary amenorrhea in combination with elevated FSH and LH levels indicates hypergonadotropic hypogonadism.
- The next diagnostic step is to measure estrogen levels.
Note
- Pregnancy is characterized by secondary amenorrhea accompanied by increased estrogen and progesterone levels.
- Elevated FSH levels and decreased LH levels indicate premature ovarian failure.
Hot Flashes/Flushes
- Vasomotor symptoms, including hot flashes, are the most common symptom of menopause.
- They are caused by a decrease in estrogen levels.
- Hot flashes are characterized by a sudden, intense heat-like feeling on the face, followed by sweating, often with accompanying palpitations or tachycardia.
- They are most frequent at night, known as night sweats, interfering with sleep.
Puberty and Precocious Puberty
Causes of Precocious Puberty
Central/True Precocious Puberty
- Idiopathic (most common).
- Brain tumors (10%): Hamartoma, Glioma, Ependymoma.
- Infection: TB meningitis.
- Continuous GnRH administration.
- GnRH antagonist use.
Peripheral Precocious Puberty
- Isosexual: Increased estrogen:
- Granulosa cell tumor of the ovary.
- Chronic hypothyroidism (due to similar alpha subunit of LH and FSH).
- Heterosexual: Increased androgen:
- Androgen-producing tumor of the ovary.
- Congenital Adrenal Hyperplasia (CAH).
Management of Precocious Puberty
- Treat the underlying cause.
McCune Albright Syndrome
- McCune Albright Syndrome is characterized by:
- Café au lait spots.
- Polyostotic fibrous dysplasia.
- Precocious puberty.
Pathogenesis of McCune Albright Syndrome
- A mutation in the G-protein coupled receptors (FSH receptors) activates signaling pathways, leading to ovarian activation and increased estrogen levels.
Investigations for McCune Albright Syndrome
- Bone age estimation.
- FSH and LH levels (for differentiating between central and peripheral precocious puberty).
- Estrogen levels.
- Thyroid-Stimulating Hormone (TSH) levels.
- Magnetic Resonance Imaging (MRI) of the brain.
- Ultrasound (USG) of the pelvis and abdomen.
Investigations for Heterosexual Precocious Puberty
- Testosterone levels.
- Dehydroepiandrosterone sulfate (DHEA-S) levels (to determine the source: ovary or adrenals).
- 17-hydroxyprogesterone (17-OH progesterone) levels (to rule out Congenital Adrenal Hyperplasia (CAH).
Note
- Polycystic Ovarian Syndrome (PCOS) is the most common cause of heterosexual puberty development.
- Congenital Adrenal Hyperplasia (CAH) is the most common cause of heterosexual precocious puberty.
Hormone Replacement Therapy (HRT)
HRT - 1
Basis of HRT
- Postmenopausal symptoms are related to estrogen deficiency.
- Hormone Replacement Therapy (HRT) provides relief from menopausal symptoms.
Indications for HRT
- Postmenopausal women with severe hot flushes.
- Primary Ovarian Insufficiency (POI).
- Low estrogen conditions:
- Turner's syndrome.
- Swyer's syndrome.
- Androgen Insensitivity Syndrome.
- Surgical oophorectomy.
Types of HRT
- Estrogen (E) only HRT: Used when the uterus is absent.
- Estrogen + Progesterone (E+P) HRT: Used when the uterus is present.
Mechanism of Action (MOA) of HRT
- Estrogen: Relieves hot flushes.
- Progesterone: Protects the endometrium from cancer development.
Minimum Duration of HRT
- Ideal duration: As long as estrogen is being administered.
- Minimum duration: 12 days per cycle.
Advantages and Disadvantages of HRT
| HRT Type | Advantages | Disadvantages |
|---|---|---|
| E only HRT | - Decreases hot flushes. - Decreases osteoporosis. - Decreases colorectal cancer risk. | - Increases venous thromboembolism (less with transdermal E). - Increases endometrial cancer risk if uterus present. - Increases ovarian cancer risk if present. |
| E + P HRT | - Decreases hot flushes. - Decreases osteoporosis. - Decreases colorectal cancer risk. - Decreases endometrial cancer risk. | - Increases venous thromboembolism. - Increases ovarian cancer risk (if present). - Increases breast cancer risk. |
Factors Associated with HRT
- HRT does not safeguard against Coronary Artery Disease (CAD) in women aged 60 or older.
- It doesn't increase the risk of cervical cancer.
HRT - 2
Most Commonly Used HRT
Estrogen
- 17β-Estradiol (DOC):
- Route: Transdermal or oral.
- Dose:
- Oral: 1 mg/day, starting at 0.5 mg/day.
- Transdermal: 0.05 mg/day, starting at 0.025 mg/day.
- Conjugated Equine Estrogen (CEE): Obsolete.
Progesterone
- Micronized oral P (DOC): Dose: 100-200 mg/day.
- Dydrogesterone (DOC).
Duration of Postmenopausal Therapy
- Maximum: 5 years.
- Up to menopausal age.
Indications of HRT
- Primary Ovarian Insufficiency (POI).
- Turner's syndrome.
- Swyer's syndrome.
- Absent uterus due to:
- Hysterectomy due to endometrial cancer.
- Endometriosis.
- Endometroid tumor of the ovary.
- Supracervical/Subtotal hysterectomy.
Contraindications of HRT
- History of Deep Vein Thrombosis (DVT), stroke, or Coronary Artery Disease (CAD).
- History of breast cancer.
- Undiagnosed vaginal bleeding (endometrial cancer).
- Acute liver biopsy.
- Hypertriglyceridemia (Absolute C/D).
- Severe uncontrolled hypertension (HTN).
Important Points Regarding HRT
- No contraceptive benefit.
- Estrogen + Mirena: Contraceptive benefit in perimenopausal women experiencing hot flushes.
- Indications for Fluoxetine (DOC) for hot flushes:
- Age < 60 years.
- Onset of menopause < 10 years ago.
- Hot flushes present and HRT contraindicated.
General Gynecology
Menopause-Related Symptoms
- Experienced by perimenopausal and menopausal women.
- Appear 3-4 years before menopause.
- Subside automatically within 5 years after menopause.
- Correspond to the time of LH surge.
- Symptoms:
- Severe hot flushes.
- Sleep disturbances.
- Interference with daily routines.
- Only indication for postmenopausal HRT.
Osteoporosis
- Definition: Quantitative bone defect.
- ↓ Bone Mineral Density (BMD) primarily affects trabecular bone.
- ↓ Estrogen leads to ↓ bone mass.
Clinical Features of Osteoporosis
- Patient complains of backache.
- Increased risk of fractures.
- Fracture types:
- Vertebral fracture (T12-L3).
- Neck of femur fracture.
- Colles fracture.
Diagnosis of Osteoporosis
- Indication: Age ≥ 65 years.
- Site: 1st to 4th lumbar vertebrae and neck of femur.
- BMD Measurement:
- T-score: Patient's BMD compared to a young woman’s.
- Z-score: Patient’s BMD compared to a woman of the same age.
Treatment of Osteoporosis
- DOC (Drug of Choice): Bisphosphonates.
- Mechanism: Affect osteoblasts.
- Examples:
- Teriparatide.
- Strontium.
Risk of Coronary Artery Disease (CAD)
- Estrogen's Cardioprotective Role:
- ↑ HDL (High-density lipoprotein).
- ↓ LDL (Low-density lipoprotein).
- ↑ NO (Nitric Oxide) in vascular endothelial cells.
- ↓ Estrogen at menopause leads to ↑ CAD.
- Incidence of CAD depends on:
- Comorbidities.
- Smoking habits.
Management of Hot Flashes
| Category | Treatment Options |
|---|---|
| 1st line | HRT (Hormone Replacement Therapy): - Uterus intact: Estrogen + Progesterone (E+P). - Uterus absent: Estrogen only. |
| 2nd line | SSRI (Selective Serotonin Reuptake Inhibitors): - Fluoxetine |
| SERM | Bazedoxifene + Estrogen. - Raloxifene. - Tamoxifen. - Clomiphene. |
| Other drugs | Phytoestrogens (flax seed). - Isoflavones. - Clonidine. - Gabapentin |
Osteoporosis Treatment
| Treatment | Treatment Options |
|---|---|
| HRT | - Uterus intact: Estrogen + Progesterone (E+P). - Uterus absent: Estrogen only. - Raloxifene. - Tibolone (E+P analogues). - Teriparatide. - Denosumab (Rank ligand inhibitor). - Strontium. |
Senile Vaginitis Treatment
| Treatment | Treatment Options |
|---|---|
| Local estrogen therapy | - Cream/gel. - Pessary. - Ring. - Ospemifene or Bazedoxifene + E. |
Calcium and Vitamin D Requirements
| Age Group | Calcium Requirement | Vitamin D Requirement |
|---|---|---|
| Reproductive age | 1000 mg/day | 600 IU |
| Menopausal | 1200 mg/day | 800 IU |
Primary Ovarian Insufficiency
- Causes:
- Chemotherapy/radiotherapy (ovaries are the most radiosensitive pelvic organ).
- Galactosemia.
- Mumps.
- Autoimmune diseases.
- Exhaustion of ovarian follicles before the age of 40 (premature menopause).
Role of Hormone Replacement Therapy (HRT)
- HRT is never given to prevent CAD.
- In women aged 60 or older, HRT slightly increases the risk of CAD (E+P HRT > estrogen-only HRT).
- HRT has no effect on the risk of CAD in women younger than 60.
Senile/Atrophic Vaginitis
- New term: Genitourinary syndrome of menopause.
- Caused by a decrease in cervical discharge leading to vaginal dryness.
Symptoms of Senile Vaginitis
Urinary Symptoms
- Increased frequency of urination.
- Dysuria.
- Frequent urinary tract infections (UTIs).
- Urinary incontinence.
Genital Symptoms
- Dyspareunia.
- Postmenopausal vaginal bleeding (due to atrophic vagina).
Local Examination Findings in Senile Vaginitis
- Shiny vaginal mucosa.
- Loss of vaginal rugosities.
- Thin, atrophied vaginal mucosa.
Note
- Commonly used Selective Estrogen Receptor Modulators (SERMs):
- Clomiphene.
- Tamoxifen.
- Raloxifene (can lead to vaginal dryness).
- SERMs that can be used to manage senile vaginitis:
- Ospemifene.
- Bazedoxifene + estrogen.
Physiology of Androgens
- Intrauterine life:
- Adrenal glands produce androgens.
- Aromatase converts androgens to estrogen.
- Normal levels: < 70 ng/dl.
- Steroid: C19 steroid.
- Receptors: Intracytoplasmic.
- Acts on: Intranuclear receptors.
- Binds: Sex Hormone Binding Globulin (SHBG) > Albumin.
Effect of Androgens on SHBG
- Androgens: ↓ SHBG.
- Estrogen: ↑ SHBG.
Androgens in Females
- Produced by the ovary:
- Androstenedione.
- Testosterone.
- Dehydroepiandrosterone (DHEA).
- Not produced by the ovary (exclusively produced by adrenal glands):
- Dehydroepiandrosterone Sulphate (DHEA-Sulphate).
- Dihydrotestosterone (DHT).
Functions of Androgens in Females
- Pubarche: Growth of pubic and axillary hair.
- Increased libido.
Note
- Androgens in theca cells are converted to estrogen by aromatase in granulosa cells, promoting follicle growth.
- Excessive androgens in granulosa cells are folliculotoxic.
Effects of Excessive Androgens in Females
- Folliculotoxic.
- Inhibits follicle growth and maturation.
- Anovulation.
- Hirsutism.
- Virilization.
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Description
Test your knowledge on menopause with this quiz that covers its clinical features, hormonal changes, and associated syndromes. You will explore symptoms, definitions, and the physiological processes surrounding menopause. Perfect for healthcare professionals or students studying women's health.
