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Climacteric phase The period of endrocrinologic, somatic, and transitory psychologic changes that occur around the time of menopause. Early menopause LMP before age 45 Late menopause LMP after age 54 Primary ovarian insufficiency Menopause that occurs before age 40 Early menopause transition (stage - 2) Persistent difference of 7 days or more in the length of consecutive cycles. Late menopause transition (stage - 1) 60 or more consecutive days of amenorrhea Luteal out of phase event (LOOP) Explains why some perimenopausal women have elevated estrogen level sometimes...In the early menopause transition, elevated FSH levels are adequate to recruit a second follicle which results in a follicular phase-like rise in estradiol secretion superimposed on the mid-to-late luteal phase of the ongoing ovulatory cycle. Obese women and estradiol levels during menopause Obese women are more likely to have anovulatory cycles with high estradiol levels. They are also more likely to have lower premenopause yet higher postmenopause estradiol levels compared with women of normal weight. (why they are at higher risk of endometrial cancer) Chinese and Japanese women These ethnic groups have lower estradiol levels then white, black and hispanic women. stage +2 late menopause stage: 5-8 years after FMP. Somatic aging predominates. Increased genitourinary symptoms. Stages +1a, +1b, +1c early post menopause: 2 years after FMP. FSH rises, estradiol decreases. VMS predominate. Elevated FSH, LH Endocrine labs after menopause AMH, inhibin B These hormones work during reproductive years to not deplete follicle pool too quickly. Phases during menopause transition and PMS symptoms Menstrual cycle variable, persistent >7 day difference between difference in length of consecutive cycles. How to respond if a patient requests FSH lab? many pitfalls, variable depending on the day of the cycle you draw the lab, normal or low FSH is not helpful. The potentially superior marker of menopause, a lab. AMH DHEA (dehydroepiandrosterone) Adrenal androgens: precursor hromones produced by the adrenal gland that are enzymatically converted to active androgens or estrogens in peripheral tissues.
Location of estrogen receptors Vagina, vulva, urethra, trigone of the bladder Effects of estrogen on tissue maintain blood flow, the collagen, and HA within the epithelial surfaces. Supports microbiome which supports acidity of vagina and protects tissue from pathogens. Vaginal changes with menopause Thinning, loss of elasticity, loss or absence or rugae. Vagina and urethra in menopause vagina narrows, urethra moves closer to the introitus. Stress urinary incontinence Vaginal estrogen and urinary incontinence: what type does it help with? Treatment for FPHL Minoxidil, spironolactone, finasteride, estrogen therapy Late reporoductive years - 3b and - 3a. What happens with menstrual cycles, FSH, AMH, AFC, inhibin?
- 3b: menstrual cycles normal, FSH normal, AMH low, AFC low, inhibin low.
- 3a: subtle menstrual changes, variable FSH, AMH low, AFC low, inhibin low. When it is appropriate to check an FSH during the cycle if you check it? and why? Cycle day #3. Elevated estradiol can suppress FSH giving a falsely normal FSH level. AMH produced by... used to test... Is it a screening tool for fertility? When does it peak? produced by granulosa cells used to test damage to ovarian follicle reserve. If AMH is low, the woman has a low ovarian reserve. not recommended as a screening tool to predict fertility. Peaks at around 25 years old. So before age 25, this test is not helpful. It is influenced by exogenous hormones. Lower in hormonal contraception users, but increases after d/cing. AFC Antral follicle count Number of follicles that are detectable with ultrasound. They are sensitive to FSH and considered to represent the availability pool of follicles. Late menopause transition (-1) FSH level on random draw 25 or higher
Most serum cortisol circulates bound to cortisol binding globulin. Oral estrogen increases the cortisol binding globulin, which increases total cortisol concentration. Oral tamoxifen acts similarly. Transdermal does not increase it, so it has a minimal effect on serum cortisol concentration. Do cortisol levels associate with VMS severity? No, cortisol levels have NOT been associated with more severe VMS. Local DHEA has been proven to help with what? vaginal pain and dyspareunia How to DX POI? Menstrual disturbance-oligomenorrhea or amenorrhea for at least 4 months. AND elevated FSH over 25 on two occasions at least 4 weeks apart. Anyone <40years old who misses 3+ consecutive cycles gets these labs prolactin FSH estradiol TSH pregnancy test treatment of POI 100 microgram estradiol patch 1.25 mg CEE 2mg oral estradiol If intact uterus-progesterone for 12 days of the month. Physiologic is better than continuous hormonal contractption, but if menorrhagia-IUD plus estrogen patch, or if really not wanting to risk pregnancy, continuous HRT can be used. Hair loss. Difference between FPHL and telogen effluvium? FPHL is gradual, telogen effluvium is sudden and usually precipitated by a life stressor, chronic illness, beta blockers or anticoagulants-usually more patchy hair loss. FPHL pattern thinning at the crown of the head and widening of the hair part Treating FPHL MINOXIDIL spironolactone finasteride What ethnicity has the least likely chance of having bad hot flashes? Japanese What ethnicity is the most likely to have bad hot flashes? black more frequent, longer duration. Median length of hot flashes
10 years, early menopause transition women have them the longest. Theories about etiology of hot flashes (6) lower ovarian estradiol thermoregulation zone is narrowed neurokinins-regulate GnRH secretion. KNDy new meds serotonin cortisol and HPI axis dysregulation endothelial dysfunction. VIN low grade-what to do high grade-what to do differentiated VIN- what to do low grade is not precancerous high grade is precancerous-GYN ONC differentiated-wide local excision-high risk of invasive carcinoma. most common type of vulvar cancer squamous cell carcinoma Vulvar disorder commonly misdiagnosed as eczema or dermatitis? paget's disease will not improve on steroids screen for co-existing breast, GI or GU cancer. They are present 20-30% of the time. Normal PVR <100mL systemic and vaginal estrogen will not help with this type of urinary incontinence? will NOT help with stress incontinence. Which topical vaginal estrogen has the highest dose? the vaginal rings FEMRING IS THE HIGHEST Most common cause of vulvovaginitis? BV post menopause burning and diffuse yellow/brown discharge and dyspareunia that does not respond to local ET? desquamative inflammatory vaginitis. treat different with clindamycin or hydrocortisone+ET What hormones are associated with sexual desire in women? circulating androgens Women who have had a BSO experience an abrupt and persistent decline in what hormone? circulating androgen levels HSDD and FSAD were combined into a single dysrunction called female sexual interest/arousal disorder HSDD treatments flibanserin and bremelanotide FGAD treatments (genital arousal disorder) L-arginine, topical alprostadil, wellbutrin, oxytosin. phosphodiesterase inhibitors- lacking in efficacy Eros therapy device $300- vaccum-like the penis pump FOD (orgasmic disorder) treatments directed masturbation is most researched behavioral treatment. Does systemic ET cause fibroids to resume growth? Rarely. They often shrink after menopause.
caution in women with migraine without aura How long can it take for arthralgia from vitamin d deficiency or hypothyroidism to fully resolve? it can take several months. what is th emost common form of arthritis? osteoarthritis what areas of th ebrain have th emost estrogen receptors? hippocampus and prefrontal cortex what is the most common thyroid disorder in women? hashimoto thyroiditis if a patient on levothyroxine is started on estrogen, when do you recheck and what can you anticipate happening? recheck 6-8 weeks later. anticipate that the dose of levothyroxine may need to be increased. oral estrogens increase thyroid binding globulin which in turn reduces the levels of free T4. when is treatment of subclinical hypothyroidism recommended? when the TSH level is higher than 10. are hot or cold thyroid nodules typically most likely to be malignant? cold nodules how does HRT impact gallbladder disease? increases risk of gallstones with oral HRT, lower risk with transdermal. when did they start screening blood for hep c? 1992, so women who have received blood products or organ transplants prior to 1992 may have acquired heptatitis c why do we screen for hep C? most infections become chronic and most are asymptomatic until liver damage is detected years later. Our treatments are improving so if we catch this earlier in people, outcomes will be better all adults born from what year to what year should recieve one time hep c testing? 1945 to 1965 routine screening of all adults for hepatitis c. is it reocmmended? routine screening for all adults is not recommended, however baby boomers are at the highest risk. infection rates are 5x other birth cohorts. what hpv is high risk? 16 and 18 by age 50 what percentage of US women will have acquired a genital HPV infection? 80%-HPV is very common, but it is the high risk ones to worry about what is the most commonly sexually transmitted infection in the US? HPV What percentage of bone loss do women have from the menopause transition? 10 - 12% on average, about 1 t score What t score defines osteopenia
- 1.5 to - 2. what t score defines osteoporosis less than - 2.5 what z score defines osteoporosis before menopause? z score less than 2.0 and a history of a fragility fracture Who is at highest risk of osteoporosis? white and hispanic populations What amount of women require long term care after hip fracture? What amount of women have long term loss of mobility after hip fracture? 1 in 4 women (25%) require long term care
1 in 2 woemn (50%) have long term loss of mobility Asians have ____BMD than white people? lower Black women have ____BMD than white people? higher Over 3 servings of alcohol daily and risk for fracture? 38% for osteoporotic fracture and 68% for hip fracture What 4 ethnic specific versions of FRAX are there? white, asiain, black, hispanic Dairy free diet amount of calicum. How much do they need to supplement? dairy free diet-300mg calcium daily. Needs 800-1200mg Tibolone and osteoporosis where is it approved? why wasn't it submitted for approval in the US and canada? approved in mexico decreased risk of vertebral and nonvertebral fracture increased risk of stroke Why was estrogen not approved for osteoporosis? decreased risk of vertebral and hip fracture in low fracture risk population, but estrogen has not been shown to decrease fracture risk in women with osteoporosis. More prevention than treatment. Black box warning for PTH receptor agonists? osteosarcoma caution using PTH receptor agonists in what condition? hypercalcemia when would you use PTH receptor agonists? someone incredibly high risk for vertebral fracture raloxifene helps with what kind of fractures? vertebral fractures raloxifene risk factors increased risk of death from stroke in high risk patients, estrogen like risk of VTE, worsens hot flashes atypical femur risk in women on bisphosphonate? 1 in 1000 after 2-3 years. Salmon calcitonin and osteoporosis? small increase in spine BMD. daily SQ injections or nasal. Implications of estrogen drop on skin during menopause Decreased fibroblast activity disrupted elastin decreased GAG production Disrupted melanocyte regulation Decreased blood flow and cellular oxygenation effects on keratinocytes Disruption of cellular growth factors and repair enzymes accelerated lipoatrophy Fat pad modification Bone resorptuon
Management of AUB Cocs decrease 7 to 4 days; IUD NSAID - reduce prostaglandin synthesiss which may have a role in aberrant neovasculariation Dosing of NSAIDS for AUB Mefenamic acid 500 mg TID for 5 days or Ibuprofen 600 mg Q6h or 800mg Q8 h for first 3 days Dosing of tranexamic acid for AUB 1300 mg TID for 5 days of menstrual cycle ; causes GI upset GnRH therapy for fibroids Addback therapy can be used to protect against VMS and bone mineral density losss Nonsurgical treatment of fibroids Tranexamic acid and mefenamic acid mirena GnRH Selective progesterone receptor modulators Uterine artery embolization Hysteroscopic myomectomy is most suitable for fibroids smaller than 5cm in diameter Lichen Planus Pruritic, purple, polygonal planar papules and plaques (6 P's) Lichen sclerosis et atrophicus inflammatory condition - autoimmune - antibodies against extracellular matrix. Affects males and females equally - but female genital and perineal region is most commonly affected. Lichen Simplex Chronicus Leukoplakia with thick, leathery vulvar skin associated with chronic irritation and scratching., hyperplasia of the vulvar squamous epithelium lichen planus treatment only when it is symptomatic, these respond to topical corticosteroids. When it has a burning sensation, patients should be prescribed an antifungal lichen sclerosis tx topical steroid (clobetasol) Lichen Simplex Chronicus Treatment Corticosteroid: Triamcinolone 0.1% (Alway start off with low potency then move if it gets worst) Non-pharmo Tx for restless legs and periodic imb movements Remove potential aggravators such as sleep deprivation, alcohol, exercise, caffeine, smoking Sleep hygiene, exercise, warm baths, leg vibration, massage, acupuncture, passive strestching PHarmo tx for RLS Parmipexole and ropinirole Red flags for headache Systemic symptoms (fever, weight loss, rash) Systemic illness malignancy, immunosupression Neurologic symptoms and/or signs in consciousness
Sudden/abrupt onset new onset or progressive New/different from previoux headache hx Abortive therapy for migraine triptans, NSAIDs Preventative therapy for migraines Beta Blockers (propranolol) , Antiepileptic Drugs (divalproex), Tricyclic Antidepressants (amitriptyline) Hormone therapy for headache CAn be used to mitigate falling estrogen levels, no product FDA approved; can add lowdose estrogen supplement during w/d phase of ocp, use continuous HT; if progesterogen causes, switch to micronized What to consider when evaluating women with arthralgia 2/2 to menopause 2/2 to arthritis 2/2 to other rheumatologic condition Causes of myalgia drug induced (statines, fibrates) endocrine (vit D deficiency, thyroid, cushings) Menopause plymyalgia rheumatica Causes of bone pain metagolic (pagets disease) neoplasia (multiple myeloma, metastatic infections fracture Perimenopause STRAW staging
- 2 to +1a; STRAW staging system POI Loss of ovarian follicular activity prior to the age of 40 Prevalence of POI in US 3% T/F Premature menopause is a risk factor for CAD True
- higher risk for abdominal adiposity, dm, dyslipidemia Etiology of premature menopause
- Iatrogenic/Indused (surgery, chemotherapy, cystectomy, hysterectomy, radiation) 2) spontaneous (genetic disorders, x-chromosome disorder (monosomy, trisomy); specific mutations: POF1, POF2, FMR genes
- autoimmune causes: polyendocrine syndromes, other endocrinopathies, non-endocrine auto-immune conditions
- idiopathic
Should calorie intake decrease in post menopause yes likely driven by decreased active energy expenditure HRT on cardiovascular risk factors IN women w/o DM, HRT (oral or transdermal E+/-P) improves lean body mass, reduces abdominal adiposity, improves insulin resistance, improves lipids, decreases BP When to add anti-obesity medication Initiate weight loss medication as adjunct to lifestyle:
- if BMI (27-29.9 in presence of comorbid)
- If BMI >30 and failure of lifestyle Weight loss w/ orlistat ~8% GI lipase inhibitor poop in your pants Weight loss with phentermine/topiramate ER 8 - 12% C/I: glaucoma, hyperthyroid, MAOI SE: insomnia, dry mouth, paresthesias, metabolic acidocis, anxiety, tachy Weight loss with Naltrexone SR/Bupropion SR (Contrave) ~5-6.4% Dopamine and norepinephrine reuptake inhibitor and u-opioid receptor antagonist C/I: htn, seizures, eating disorder, opioid use, SE: nausea, headache Weight loss with liraglutide GLP-1 receptor agonist Dose up to 3mg daily in .6mg steps Weight loss ~7-10% C/I: pancreatitis, fam hx of medullary thyroid, multiple endocrine neoplasia S/E: nausea, diarrhea, vomiting constipation Weight loss with semaglutide ~14-16% GLP-1 receptor agonist Dose up yo 2.4mg daily in slow weekly dose titration C/I: pancreatitis, fam hx of medullary thyroid, multiple endocrine neoplasia S/E: nausea, diarrhea, vomiting constipation How do GLP-1 receptor agonists work? GLP-1s help the pancreas release more insulin, delay stomach emptying, and reduce appetite. Weight loss with pentermine monotherapy Short term, FDA approved for shortterm use (<12 weeks); common practice to prescribe for longer; retrospective data suggests; better weight loss iwth longer use >6m; no increase in AE cardiovascular; no addiction potential I do not believe any of theis
Surgical management of obesity Roux-en-y bypass Sleeve gastrectomy Biliopancreatic diversion iwth duodenal switch Who is eligible for bariatric surgery? BMI > BMI >35 w/ 1 comorbid BMI 30-35 w/ T2DM, poor glycemic control despite lifestyle Non-scarring alopecia Disorders that reduce or slow hair growth without irreparably damaging the hair follicle
- primarily affect the hair shaft scarring alopecia replacement of hair follicles with scar tissue examples of non-scarring alopecia Androgenetic alopecia Telogen Effluvium Alopecia Areata How to treat scarring alopecia Send to derm Androgenetic alopecia Female pattern thinning Genetic predisposition Hromonal factors A slow minaturization over time
- follicular miniturization - finer hair - shorter growth cycle - shorter hair
- longer latent period - delay before new hair starts NOT AN ABRUPT SHED Female pattern thinng: Who when what 50+% of women Can begin in teens Usually NOT androgen excess What did you first notice (ponytail smaller, part wider, see scalp What labs to obtain in fmale pattern thinning TSH, CBC, ferritin ?PCOS? Topical treatment for female pattern thinning minoxidil 5% once daily Systemic treatment for female pattern hair thinning Younger women
- OCP w/ drospirenon
Leiomyosarcoma Stromal sarcoma Which ovarian cancer can you use topical estrogen? Which can you not? Can: HGSOC Germ cell Granulosa cell Cannot: Endometrioid Which types of cervical cancer can ou use topical estrogen All Dosing of vaginal estrogen daily for 2 weeks then 2x weekly Evaluation of incontinence Type:
- provoking factord
- sense of urgency
- Frequency
- Ability to defer Severity and Impact on QoL
- Leak frequency
- Pad use
- Impact on ADL Complexity & Safety
- Bladder emptying
- Blood, stones
- Pain
- Comorbidities Main types of incontinence Stress incontinence Overactive bladder Oveflow incontinence Screening for thyroid disease Every 5 years starting at age 35 Most common thyroid disease Hypothyroidism caused by hashimoto thyroiditis Normal range of serum TSH
.4 mIU/L to 4.5 mIU/L; if TSH level is elevated, free T4 and antithyroperoxidase antibodies should be measured Levo dosing 1.6ug per KG Over 50 start w/ 25ug to 50 with progression every 2-3 weeks until euthyroid is reached Wtih CHD start lower titrate every 6-8 weeks Monitor TSH every 4-6 weeks after any change If patient is treated with thyroid medication starts oral ET; what do yo u need to do and why? TSH levels should e monitored 6-8 weeks later; anticipate that dose of Levo may need to e increased; oral (not transdermal) estrogens increase thyroid binding globuling which reduces FT hyperthyroidism/ grave's disease abnormally high secretion of thyroid hormones Low TSH (persistently less than .1mIU/L in all persons aged 65 and older Bone effects of TSH 3 fold increase in hip fractures for pt iwth excess endogenous thyroid hormone production (i.e. TSH <.1mIU/L) hot thyroid nodule Rarely associated with thyroid cancer Definition of insomnia Sleep complaint that occurs at least 3 times per week for at least 3 months and is associated with distress or impaired daytime personal functioningS Screening tool for eating disorder SCOFF Screening tool for drug abuse DAST Screening tool for intimate partner violence HARK Screening tool for depression PHQ Screening tool for anxiety GAD- 7 Rate of bone loss at menopause An average annual loss of about 2% begining 1-3 years before menopause and lasting 5- 10 years. Acrosss the menopause transition women lose up toe 10-12% of bone loss (one Tscore) After this, women lose about .5% per year By the time a woman is 80, how much bone loss has she lost? 30% Normal T score range for BMD
The benefits fo estrogen abate within a few months after stopping therapy correct What are estrogen agonists/antagonists SERMS (selective estrogen receptor modulators, have weak estrogen agonist properties in bone whil functioning as antiestrogen in female reproductive tissues Raloxifene (Evista) Selective Estrogen Receptor Modulator (SERM) Induces small increases in BMD 60 mg daily for 3 years reduced vertebral fractures by 30% Risk of VTE in elderly women Reduced risk of invasive breast cancer Raloxifene is an appealing treatment options for: younger postmenopausal women with osteoporosis at risk for vertebral but not hip fracture w/o significant vasomotor symptoms Bazedoxifene Selective Estrogen Receptor Modulator (SERM) vertebral fracture risk reduced by 42% over 3 years no effect on nonvertebral risk, no effect on reast cancer irsk proven Combo of bazedoxifene 20 mg and .45 mg CEE daily improves VMS and prevents bone loss in young postmenopausal women Bisphosphonates Fosamax: inhibit bone resorption used in osteoporosis. AE: dysphagia, esophageal ulcer. Nursing: take 1st thing in the morning w/o food, 8oz of water, remain upright for 30mins after taking, if dose missed-skip Fosamax (alendronate) Classification: Bone resorption inhibitor. Bisphosphonate Therapeutic Effects: TX and prevention of post-menopausal and cortico-steroid-induced osteoporosis, Adverse Reactions & side effects: Altered taste, photosensitivity, rash, musculoskeletal pain, fluid overload, esophagitis. Common upset stomach & heartburn, GI effects Nursing Implications & teaching:Take first thing in the AM, before eating anything; then pt MUST remain upright for at least 30 mins! Take only with plain water. Monitor for GI side effects. Use sunscreen to prevent photosensitivity reactions. Risedronate (Actonel) Biphosphate. Taken daily, weekly, or monthly. Zoledronic acid (Reclast, Zometa) Biphosphate. IV annually. After 5 years fo treatment in women with high risk of osteoporosiss, consider switching to denosumab Results in additional gains Denosumab (Prolia)
Monoclonal antibody for postmenopausal women Subcutaneous injection every 6 months salmon calcitonin Reduces bone loss in osteoporosis potent inhibitor of bone resorption STI screening in <25 annual genital chlamy and gonn treatment for gonorrhea 2021 guidelines: ceftriaxone 500 mg IM x1 or ceftriaxone 1g IM x1 if > 150kg If chlamydia not ruled out; doxy 100 BID 7 days when to repeat testing for Chlamydia? 3 months Contraindications to HRT History of endometrial cancer Personal history of breast cancer History of thromboembolic disorders Acute or chronic liver disease Coronary artery disease Elevated triglyc Undiagnosed vaginal bleeding
