Week 6.docx

**Menopause** - Define menopause and primary ovarian insufficiency - Describe common clinical manifestations of the menopause transition **Perimenopause/Menopause Transition** about 4 years prior to the final menstrual period avg 47 years change in bleeding pattern and horm...

**Menopause** - Define menopause and primary ovarian insufficiency - Describe common clinical manifestations of the menopause transition **Perimenopause/Menopause Transition** about 4 years prior to the final menstrual period avg 47 years change in bleeding pattern and hormonal fluctuations 1. Early transition: lengthening in intermenstrual interval, 40-50 days, FSH levels are high but variable 2. Late transition: skipped cycles, episodes of amenorrhea, and increasing frequency of anovulatory cycles; some may experience heavy or prolonged bleeding. Typically lasts 1-3 years before final menstrual period. Dramatic fluctuations in FSH and estradiol. Other symptoms: hot flashes, sleep disturbances, mood symptoms, vaginal dryness which can lead to dyspareunia, more susceptible to UTI b/c change in mucosa Changes in lipids (increase) and bone loss begins **Symptoms of Menopause:** 1. **Hot flashes**: sudden sensation of heat centered on the upper chest and face that rapidly becomes generalized; lasts for 2-4 minutes; associated with profuse perspiration and occasional palpitations. - Common at night - May persist for 20 yrs after FMP (final period) 2. Sleep disturbances: - May be associated with anxiety or depression - May or may not be related to the hot flashes - Less than 50% start symptoms in early transition 3. Depression: - 2.5 times more likely during the menopausal transition - Risk decreases in early post menopause - Increases with prior history of depression or mood disorder 4. Cognitive changes - Forgetfulness - Difficulties with word retrieval - "brain fog" 5. Vaginal dryness - Genitourinary syndrome of menopause (GSM) 6. Sexual function - Can be impacted in several way depending on the person, some ppl have increased libido b/c no way to get pregnant 7. Joints aches and pain: - Not sure why this happens, but may be r/t estrogen deficiency or rheumatologic disease 8. Breast pain/tenderness - common in early menopausal transition 9. Menstrual migraines: - May worsen in frequency and intensity during menopausal transition - This is due to the estrogen fluctuation What are the long-term consequences of decreased E2 estrogen? - Bone loss highest one year before and two years after final menstrual period - CV disease risk increases after menopause changes in risk factors such as lipid profiles - Body composition gain fat mass and lose lean muscle body shape changes from pear-shaped to apple shaped - Skin changes decreased collagen content of skin and bones - Balance central effect of E2 deficiency - Discuss hormonal changes during the menopause transition - Describe the diagnosis of primary ovarian insufficiency and menopause - Menstrual cycle hx and hx of any menopausal symptoms (hot flashes, sleep disturbances, vaginal dryness) - [Age 40-45 yrs]: irregular menses do Hcg, prolactin, TSH - Over age 45: consider hCG if sexually active without reliable contraception; irregular menses w/ menopause symptoms needs to further workup. Consider prolactin and TSH if having galactorrhea, goiter, tachycardia, proptosis, etc. Asymptomatic with irregular menses check FSH level \>15 to 25 would be reassuring - Over age 45 (health individual) menopause transition/perimenopause: diagnosis based on change in intermenstrual interval with or without menopausal symptoms menopause: 12 months of amenorrhea in the absence of causes - Age 40-45 (healthy individual) diagnosis of menopause transition and menopause same as in individuals \>45 AFTER ruling out other causes (hCG, prolactin, TSH) - Age less than 40 cannot diagnose with menopause transition or menopause, diagnosis in this age group is primary ovarian insufficiency with appropriate work up - Underlying menstrual cycle disorders: PCOS or hypothalamic amenorrhea measure FSH in those developing menopausal symptoms - Using CHCs: do not develop irregular menses or vasomotor symptoms stop CHC and measure FSH 2-4 weeks later - Post hysterectomy or endometrial ablation menstrual bleeding criteria alone cannot be used measure FSH, 25 iu/L in the setting of hot flashes suggests late menopausal transition; postmenopausal FSH is typically higher (70-100) - Irregular menses, sweats, and mood changescould be thinking hyperthyroidism - Menstrual cycle changespregnancy, hyperprolactinemia, thyroid disease - Atypical hot flashes and night sweatsmedications, pheochromocytoma, underlying malignancy, infections - Discuss hormonal and non-hormonal treatment options for menopausal symptoms - Dietary changes- avoid/moderate intake of hot drinks, spicy foods, caffeine, alcohol, and food additives (MSG, sulfites, sodium nitrates) - Adequate water consumption - Exercise: reduces CV disease and strokes, osteoporosis risk, breast and colon CA risk; improves metabolic profile, balance, muscle strength and sleep quality. 150 minutes per week of moderate-intensity exercise and 2 weekly sessions of resistance training. - Vaginal vitamin E - Omega-3 supplements- possible decrease frequency of night sweats - Adequate dietary calcium (1000 mg) and vitamin D (600 iu) - Vaginal lubricants and moisturizers - Clothing and environment- wear layered clothes, breathable fabrics, or moisture-wicking/cooling fabrics, keep room temperature cool, open a window and/or use a fan; use chilled towels and a chilling pillow - Smoking cessation - Stress management! - Good sleep hygiene - CBT for menopause-associated insomnia - Vasomotor symptom intensity and frequency - Mild symptoms will do lifestyle modifications - Moderate to severe symptoms pharmacotherapy is the 1^st^ line - **Cannot have estrogen if had DVT/MI** - Are there contraindications to menopausal hormone therapy? hx of breast cancer coronary heart disease prior VTE or stroke active liver disease unexplained vaginal bleeding high-risk endometrial cancer TIA - Is the patient interested in menopausal hormone therapy? - Coexistence of other menopausal symptoms (may need SSRI/SNRI and menopausal hormone therapy) Contraindications- - Hx of breast CA - Coronary heart disease - Prior VTE or stroke - Active liver disease - Unexplained vaginal bleeding - High-risk endometrial cancer - TIA - **If a woman has an intact uterus must use estrogen and progestin** - **If a woman has no uterus must use estrogen monotherapy** - Start continuous 17-beta estradiol and **cyclic** administration of oral micronized progesterone - For moderate symptoms: transdermal estradiol 0.025 mg twice weekly or oral estradiol 0.5 mg daily - For severe symptoms: transdermal estradiol 0.05 mg twice weekly or oral estradiol 1 mg daily - Withdrawal bleeding: 90% will have monthly withdrawal bleed, and will switch to continuous combined regimen if this is bothersome - Standard E2 dose: transdermal 17-beta estradiol 0.05 mg twice weekly or oral 17-beta estradiol 1 mg daily - Symptoms should begin to resolve 3-4 weeks after initiating therapy, if symptoms persist then increase the dose of estrogen - Transdermal estrogen can decrease the risk of thrombotic activity - Follow-up visit in 6-8 weeks, then maybe increase dose if needed - Vasomotor symptoms last 7.4 years on average - Individualized duration of therapy, attempt taper around 3-5 years - 50% change of symptoms recurrence after stopping therapy - SSRIs/SNRIs are preferred 1^st^ line meds response is more rapid than typical response for depression **paxil is the only FDA approved SSRI/SNRI for hot flashes** can also do Celexa, Effexor, Pristiq, Lexapro not effective: Zoloft and prozac - Gabapentin may be better for those with nighttime hot flashes would start 100 mg every night; could also do 300 mg TID - Recommended strategy: trial an SSRI/SNRI first if ineffective, trial a second SSRI/SNRI If ineffective, trial gabapentin should taper off SNRI/SSRI and start gabapentin before stopping SSRI/SNRI - CAM therapies: CBT, hypnosis, mind-body-based therapies, stellate gangion block **Vulvovaginal Atrophy:** - Decline in serum estrogen levels: thinning of epithelial cells loss of rugae and elasticity shortening and narrowing of vaginal canal reduced vaginal secretions increase in vaginal pH - Primary result of aging (genitourinary syndrome of menopause): can also occur due to conditions or medications that cause hypoestrogenism (i.e. primary ovarian insufficiency, gender-affirming testosterone therapy) **Clinical Manifestations of Vulvovaginal Atrophy:** - Vulvovaginal dryness - Decreased vaginal lubrication during sex - Dyspareunia - Vulvar or vaginal bleeding: postcoital bleeding, fissures - Decreased arousal, orgasm, or sexual desire - Vulvovaginal burning, irritation, or itching - Vaginal discharge: leukorrhea or yellow and malodorous - Urinary symptoms: frequency, dysuria, urethral discomfort, hematuria, recurrent UTI **Pelvic Exam Findings for Vulvovaginal Atrophy:** - Labia minor resorption or fusion - Tissue fragility/fissures/petechiae - Introital retraction - Loss of hymenal remnants - Prominence of urethral meatus - Loss of vaginal rugae - Decreased elasticity - Decreased vulvovaginal secretions/lubrication **Treatment for vulvovaginal atrophy:** **Initial- moisturizers and lubricants** - Moisturizers used routinely 2-3 times per week - Lubricants used only during sex (be mindful of coconut oil because it causes breakdown of latex condoms) - Both methods can be effective to treat vaginal dryness and dyspareunia 2^nd^ line therapy- low dose vaginal estrogen; this is effective for vulvovaginal dryness or discomfort, tissue fragility, dyspareunia, vaginal discharge caused by atrophy, some urinary symptoms. Want to use the lowest effective dose for shortest duration. - Consider adding progestin for 10-14 days per 4-week cycle if the patient has an intact uterus \*check prolactin levels when concerned about the pituitary gland checking for tumor Common Breast Disorders: - Evaluate breast cancer screening recommendations - Identify common breast disorders - Order appropriate diagnostic testing - Develop differential diagnosis for common breast conditions and identify the likely final diagnosis - Develop an appropriate treatment plan for common breast disorders