Menopause

Question 1

How is menopause clinically defined? Avg age?

Answer 1

• Clinically - 1 yr no menses w/o other explanation

- Avg age = 51.4 yo

Question 2

What changes occur in perimenopause?

Answer 2

• Dec inhibin B as # oocytes dec
• FSH rises (esp if meas in early follicular phase around day 3) *first clinical sign**
• Follicular phase length shortens (2-4 days)
• Low Anti-Mullerian hormone

Question 3

What changes occur in early menopause transition?

Answer 3

• Hallmark = diff of 7 days or more in length of consecutive cycles
• FSH still elevated but variable
• Inhibin and AMH still low
• LOOP cycles (luteal out of phase event) - 2nd follicle recruited –> prolonged secretion of estradiol; inc estrogen –> migraine, inc bleeding, breast tenderness
• Dec fertility but pregnancy can still occur

Question 4

What changes occur in late menopause transition?

Answer 4

• 60 + days w/o menses
• More extreme fluctuations in hormones –> symptoms
• Greater incidence of anovulation
• Lasts 1-3 yrs
• FSH generally elevated but not a reliable diagnostic test

Question 5

Primary Ovarian Insufficiency

Answer 5

• Menopause at < 40 yo
• Causes - genetic (Fragile X), adrenal insufficiency, autoimmune, chemo/radiation –> follicular dysfunction or depletion
• About half have follicles which can function intermittently –> conception
• Present w/ dysfunctional bleeding, oligo or amenorrhea
• Labs - FSH, prolactin, estradiol, thyroid tests and karyotype
• Tx - hormone replacement b/c inc risk bone loss, CVD, cognitive impairment (use until avg age of menopause then treat like anyone else going thru menopause)

Question 6

7 Major Physiological Changes / Symptoms

Answer 6

• Skeletal - dec bone mass and inc fracture risk
• Metabolic - inc insulin resistance / central fat
• Cardio - inc total and LDL cholesterol, dec endothelial function, inc risk heart disease
• Neuro - dec memory or cog function (“fog”) and insomnia (can exacerbate)
• GU - vaginal dryness, urinary frequency, urgency, dysuria, vaginal atrophy
• Vasomotor - hot flashes
• Dec Libido - may improve when treat vaginal pain but no association w/ hormone therapy and inc libido

Question 7

Systemic v Local Tx (+ some considerations)

Answer 7

• For systemic symptoms … hormone therapy
  
  • Contraindications
  • If intact uterus, give w/ progesterone
  • Consider using COCs or LNG IUD if still fertile
  • Transdermal estrogen has lower clot risk than oral
• For vaginal symptoms … topical estrogen (cream, tablet, ring)
• Can also use SSRI/SNRI if not good hormone candidate- Venlafaxine, escitalopram
• Gabapentin and Clonidine sometimes used

Question 8

Risks v Benefits of Hormone Therapy for Menopause

Answer 8

• Risks - clots (1.5 to 2X greater), stroke (1.5 to 2X greater), mixed results for CVD and breast cancer
• Benefits - symptom relief, dec risk osteoporosis and fracture
• DO NOT USE IF ASYMPTOMATIC