Menopause

Question 1

Clinical definition of menopause

Answer 1

>12 months of amenorrhea due to depletion of ovarian follicles

Question 2

Median age for natural menopause

Answer 2

51 years

Question 3

___ is the first and principal hormone to be lost in perimenopause

Answer 3

Inhibin is the first and principal hormone to be lost in perimenopause

Consequentially, FSH increases, and estrogen increases in turn.

Question 4

As women progress towards menopause, the ___ shortens

Answer 4

As women progress towards menopause, the follicular phase shortens

Question 5

Why are perimenopausal women at high risk for endometrial hyperplasia and endometrial cancer?

Answer 5

1. The downstream effect of low inhibin raises estrogen levels
2. There are frequently anovulatory cycles, meaning that endometrium is exposed to unopposed estrogen signaling for longer periods

Question 6

Hormone profile of perimenopause vs menopause

Answer 6

• Perimenopause: Low inhibin, high estradiol, high FSH, normal LH
• Menopause: Low inhibin, low estradiol, high FSH, high LH

Question 7

Etiology of hot flashes in perimenopause and menopause

Answer 7

It is hypothesized that subacute estrogen withdrawal increases neurotransmitter concentrations (serotonin and norepinephrine) in the hypothalamus thermoregulatory center, which has the effect of narrowing the “thermoregulatory zone” and decreasing the barrier for vasomotor thermoregulatory responses.

Question 8

Mechanism of osteoporosis in menopausal patients

Answer 8

Estrogen is a major positive regulator of osteoprotegrin.

When estrogen levels drop, osteoprotegrin levels drop, and thus there is more free RANKL to stimulate osteoclast development and activation.

Question 9

Effects of hypoestrogenemia on cardiovascular health

Answer 9

Low estrogen increases levels of circulating LDL, increasing risk of atherosclerotic disease.

Question 10

Menopausal vulvovaginal atrophy

Answer 10

Lack of estrogen stimulation leads to thinning of vaginal epithelium and loss of vaginal collagen, adipose tissue, and sebaceous glands.

The result is dryness, itchiness, and dyspareunia

Question 11

Hypoestrogenemia and the lower urinary tract

Answer 11

Hypoestrogenemia decreases urinary epithelium thickness, aka atrophic urethritis, increasing risk for incontinence and UTIs.

Also increases risk of stress incontinence from pelvic organ prolapse, since those structures may also become atrophic in the absence of estrogen.

Question 12

Menopausal hormone therapy

Answer 12

• Goal is to use the minimal dose for the shortest amount of time possible to overcome menopausal symptoms
• Defends bone integrity and decreases symptoms of menopause
• Risks of estrogen + progesterone therapy in women with a uterus:
  
  • Breast cancer, stroke, VTE, coronary heart disease
  • However, it is protective against colon cancer as well
• Risks of estrogen only therapy in women without a uterus:
  
  • Stroke, VTE

Question 13

Alternatives to menopausal hormone therapy

Answer 13

• Gabapentin (mechanism unknown)
• Clonidine (central alpha 2 agonist, acts directly in thermoregulatory center)
• SSRIs / SNRIs (act directly in thermoregulatory center)

Question 14

Commonly touted herbal menopause remedies

Answer 14

Black cohosh

Phytoestrogens

Both have questionable evidence and are not recommended for treatment.

Question 15

Vaginal estrogen for menopausal symptoms

Answer 15

May be used for vulvovaginal or urinary symptoms of menopause

Effective for these symptoms and is not absorbed systemically in any significant amount.

Question 16

Menotropin

Answer 16

Mixture of gonadotropins extracted from the urine of postmenopausal women (since their LH and FSH is so high)

These purified gonadotropins can be used to stimulate ovulation in pre-menopausal women

Question 17

Symptoms of menopause are typically milder in ___ women

Answer 17

Symptoms of menopause are typically milder in obese women

Think about it – they have higher aromatase expression and estrogen at baseline.

Question 18

Preventing osteoporosis in postmenopausal women

Answer 18

1. Weight bearing exercise
2. Daily vitamin D3, 2000 IU
3. Daily calcium, 1200 mg