Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
93 Cards in this Set
- Front
- Back
|
What causes menopause? |
Ovaries become depleted of follicles and produce less estrogen --> lack of estrogen leads to the majority of symptoms |
|
|
When does menopause typically happen in the U.S.? |
- Median age is 52 years - Between 40-58 years for most women |
|
|
How do we define menopause? |
12 months without a cycle |
|
|
What are the symptoms of menopause? |
- Hot flashes - Vasomotor symptoms - Atrophic vaginitis - Dyspareunia - Sexual dysfunction - Sleep disturbance - Concentration difficulties |
|
|
What are the benefits of menopausal hormone therapy? |
- Decrease in vasomotor symptoms / hot flashes - Improvement in atrophic vaginitis symptoms - Prevention of osteoporosis |
|
|
Patients receiving hormone therapy who have a uterus must take what measure? Why? |
Must receive estrogen WITH progesterone to decrease the risk of endometrial cancer related to unopposed estrogen |
|
|
What is the most effective treatment for atrophic vaginitis? |
Estrogen, especially when used topically - if topical and in low doses probably does not require coverage with progesterone even in women with an intact uterus |
|
|
What are the manifestations of atrophic vaginitis? |
- Vaginal dryness - Dyspareunia - Urge incontinence - Recurrent UTI |
|
|
What are the risks of menopausal hormone therapy? |
- Combined E&P use >3 years increases the risk of breast cancer - Use of unopposed systemic E in women with a uterus, increases endometrial cancer risk - Beginning HT >60 years increases the risk of CAD - HT increases risk of stroke at least for first 1-2 years of use - HT for menopausal symptoms should use lowest effective dose for shortest possible time |
|
|
What time period of using E&P increases the risk for breast cancer? |
>3 years |
|
|
At what point does HT increase the risk for CAD? |
Beginning it at age >60 years |
|
|
At what point does HT increase the risk of stroke? |
At least for the first 1-2 years of use |
|
|
What are the risk factors to consider when evaluating a patient for HT? |
- Age - Family and personal history of heart disease, stroke, breast cancer, blood clots, or osteoporosis - Medications |
|
|
What factors of quality of life play into the decision to use HT? |
- How bothersome are the menopausal symptoms? - What are the patient's preferences in taking medication vs. herbal preparations? - What are her fears? |
|
|
What is the role of the doctor and the patient in deciding to use HT? |
- Doctor is to counsel and provide information - Responsibility of decision making falls on the patient, as only she can balance her quality of life against the risks she is willing to accept |
|
|
What initial history should you take in a postmenopausal woman with vaginal bleeding? |
- Detailed description of recent bleeding and any associated symptoms - Last menstrual period - Other female problems or bleeding problems - Family history of cancer, bleeding problems, or female problems - Detailed meds, including PRN and/or supplements - Review health maintenance (last Pap, mammogram) |
|
|
What are the recommended screening exams for women in their fifties without any specific symptoms or risk factors? |
- Mammogram - Pap smear - Colon cancer screening |
|
|
What are the recommendations for screening mammograms? |
- USPSTF: biennial screening for women 50-74 years - ACOG and ACS: annual screening for women >40 years - Need to have a shared decision making process with women to individualize these recommendations |
|
|
What are the recommendations for screening for colon cancer? |
Recommended from 50-75 - Annual guaiac-fecal occult blood test (3 samples) vs Fecal Immunochemical Test (1 sample); FIT is more sensitive --> if positive, need colonoscopy - Colonoscopy: allows for biopsy, recommended if family history, change in bowel habits, or any rectal bleeding |
|
|
What are the recommendations for Pap smears? |
- Start at age 21, repeat q3y until 30y - 30-65y: Pap + HPV q5y or Pap alone q3y - For women with possible gynecologic pathology or risk factors (HIV, immunosuppression, DES exposure in utero, hx of cervical cancer) may require more frequent Paps - These guidelines do not prohibit more frequent testing if physician feels it is indicated or if pt requests more frequent screening (insurance coverage will likely end though) |
|
|
What screening is not indicated for women in their 50s without risk factors? |
- Osteoporosis - DEXA scan (>65y or younger who have equivalent fracture risks) - Ovarian cancer - CA-125 - not indicated as a screening tool |
|
|
Mrs. Parker is a 55-yo post-menopausal woman on daily E&P with a history of hypothyroidism on levothyroxine, who presents with intermittent light vaginal bleeding for past 2 weeks without associated cramping. Her LMP was 3y ago, she is G2P2 w/ menarche at 11y, and she has no history of abnormal Paps and no family history of cancers.
What diagnoses are on your differential? |
- Cervical polyps - Endometrial hyperplasia - Hormone-producing ovarian tumors - Endometrial cancer - Proliferative endometrium |
|
|
What is the most common cause of vaginal bleeding in postpartum and peri-menopausal women? |
Cervical polyps |
|
|
When are cervical polyps most common? When are they rare? |
- More common: post-partum, peri-menopause - Rare: pre-menstrual, post-menopausal |
|
|
What changes to the endometrium can cause abnormal uterine bleeding? |
- Endometrial hyperplasia w/ or w/o atypia - Endometrial cancer - Proliferative endometrium |
|
|
How often does simple endometrial hyperplasia progress to cancer? |
<5% of patients |
|
|
How often does atypical complex endometrial hyperplasia progress to cancer? |
25% of patients (careful monitoring and treatment is important) |
|
|
How commonly are hormone-producing ovarian tumors the cause of post-menopausal bleeding? |
- These tumors are rare - Most ovarian cancers do not cause post-menopausal bleeding or other significant symptoms - Post-menopausal bleeding is one of several symptoms associated with a higher risk for ovarian cancer (6.6 fold increased risk) |
|
|
What are possible symptoms of ovarian cancer? |
- Pelvic or abdominal pain - Increase in abdominal size or bloating - Difficulty eating or feeling full |
|
|
What ranking is endometrial cancer in terms of most common cancers in women? |
4th |
|
|
What is the most concerning diagnosis that must be evaluated for in a woman with post-menopausal bleeding? |
Endometrial cancer |
|
|
When should you consider endometrial cancer as the diagnosis? |
- Post-menopausal bleeding - Women >35y with symptoms of anovulatory bleeding (spotting, menorrhagia, metrorrhagia) |
|
|
How common is abnormal vaginal bleeding in patients with endometrial cancer? |
90% |
|
|
What is the term for bleeding that is a normal response to estrogen stimulation in premenopausal women? |
Proliferative endometrium |
|
|
Who can get a proliferative endometrium? |
- Premenopausal women - normal response to estrogen stimulation - Post-menopausal women w/ higher estrogen states |
|
|
What is proliferative endometrium difficult to distinguish from? |
Simple endometrial hyperplasia |
|
|
Mrs. Parker is a 55-yo post-menopausal woman on daily E&P with a history of hypothyroidism on levothyroxine, who presents with intermittent light vaginal bleeding for past 2 weeks without associated cramping. Her LMP was 3y ago, she is G2P2 w/ menarche at 11y, and she has no history of abnormal Paps and no family history of cancers.
Why is normal bleeding with hormone replacement unlikely? |
This patient has been on daily HRT for >12 months; bleeding in the first 12 months of HRT can be normal, but bleeding after 12 months of therapy always requires further evaluation |
|
|
What physical exam needs to be done in a post-menopausal patient with bleeding? |
- Pelvic exam - Neck exam - Skin exam |
|
|
What should you look for on pelvic exam in a post-menopausal woman with bleeding? |
- Vulvar or vaginal lesions - Signs of trauma - Cervical polyps or dysplasia - Pap smear - Bimanual exam - assess size and mobility of her uterus |
|
|
What bimanual exam finding is worrisome for uterine cancer? |
Firm, fixed uterus |
|
|
What should you look for on neck exam in a post-menopausal woman with bleeding? |
Evaluate thyroid for goiter or nodules, as thyroid disease is one of several systemic diseases that can cause dysfunctional uterine bleeding |
|
|
What should you look for on skin exam in a post-menopausal woman with bleeding? |
- Look for evidence of bleeding disorders, like bruises - Jaundice and hepatomegaly might signify an underlying coagulopathy via liver disease |
|
|
What are the symptoms of atrophic vaginitis? |
- Vaginal dryness - Dyspareunia - Urinary symptoms - Vaginal pruritus |
|
|
What urinary symptoms might a woman with atrophic vaginitis have? |
- Recurrent UTIs - Urinary frequency - Dysuria |
|
|
How can you treat patients with urinary symptoms and atrophic vaginitis? |
Local / topical estrogen may help women with urge incontinence and recurrent UTIs; we're not sure if estrogen helps with overactive bladder, and there is conflicting evidence about its effect on stress incontinence |
|
|
How can you treat patients with vaginal pruritus and atrophic vaginitis? |
Local symptoms are usually best treated with topical estrogen in the form of either a vaginal cream or an estrogen ring, which is an estrogen impregnated ring inserted into the vagina |
|
|
What are the physical exam findings in a patient with atrophic vaginitis? |
Smoother vaginal mucosa and cervix, related to post-menopausal changes from decreased estrogen levels |
|
|
What are the risk factors for endometrial cancer? |
- Unopposed estrogen therapy - Tamoxifen - Obesity - Anovulatory cycles - Estrogen-secreting neoplasms - Early menarche (<12) - Late menopause (>52) - Menstrual cycle irregularities - Nulliparity - Hypertension - Diabetes - History of breast cancer or colon cancer - Age |
|
|
What is protective against endometrial cancer? |
- Smoking - OCPs |
|
|
How does age affect risk for endometrial cancer? |
Incidence more than doubles (from 2.8 / 100,000) in those aged 30-34 compared to those aged 35-39 years (6.1 / 100,000) |
|
|
In a post-menopausal woman with abnormal bleeding what further evaluation should be done to evaluate for endometrial cancer? |
- Transvaginal U/S - Endometrial biopsy - CBC - TSH |
|
|
In a post-menopausal woman with abnormal bleeding, why should you get a transvaginal U/S? |
- May be the most cost-effective initial test in women at low risk for endometrial cancer who have abnormal uterine bleeding - Evaluate the thickness of the endometrium; if <4mm (some say <5mm) it is reassuring - Also evaluate for leiomyoma (fibroid) or focal uterine masses, as well as ovarian pathology - May miss endometrial polyps and submucosal fibroids |
|
|
What thickness of endometrium on transvaginal U/S is reassuring in a patient you are evaluating for endometrial cancer? |
<4 mm (some say <5 mm)
More workup may not be needed unless the bleeding continues |
|
|
How effective is a transvaginal U/S for detecting endometrial cancer and abnormalities? |
- Endometrial cancer: 96% sensitive - Endometrial abnormality: 92% sensitive |
|
|
In a post-menopausal woman with abnormal bleeding, why should you get an endometrial biopsy? |
- Histologic evaluation of endometrium after D&C is traditional gold standard for evaluating post-menopausal bleeding and for abnormal bleeding in younger woman at high risk for cancer - Office-based sampling using the Pipette device is widely used and has sensitivity for detecting endometrial cancer in post-menopausal woman as high as 99% - Endometrial biopsy will obtain a tissue sample that can be sent to pathology to look for evidence of hyperplasia or cancer |
|
|
In a post-menopausal woman with abnormal bleeding, why should you get a CBC? |
Helpful to demonstrate absence of anemia and thrombocytopenia; abnormal result would trigger further systemic evaluation |
|
|
In a post-menopausal woman with abnormal bleeding, why should you get a TSH? |
Thyroid disorders may cause abnormal uterine bleeding and are associated with an increased risk for endometrial cancer |
|
|
In a post-menopausal woman with abnormal bleeding, why is an FSH and LH not necessary? |
During menopause, as aging ovarian follicles become more resistant to FSH and LH stimulation, the ovarian granolas cells produce less inhibit. Major role of inhibit is negative feedback regulation of pituitary FSH secretion and synthesis. With less inhibin production, circulating FSH and LH increase. Sufficiently elevated FSH can be used to confirm menopause.
FSH and LH would not be helpful in this case as the patient has already met criteria for being post-menopausal by the fact that she has not had any menses in more than a year. |
|
|
When should women be screened for osteoporosis? |
USPSTF: all women >65 years and for younger women who have an equivalent risk to the average 65-year old white female (9.3% 10-yr risk of any osteoporotic fracture) |
|
|
What are the risk factors for osteoporosis? |
- Corticosteroid use - Family history of osteoporosis, especially if a first-degree relative has fractured a hip - Previous fragility fracture defined as a low-impact fracture - Smoking - Heavy alcohol use - Lower body weight (<70 kg) - Caucasian race |
|
|
What strategies can be used to prevent osteoporosis? |
- Smoking cessation - Calcium intake of 1200 mg / day - Adequate intake of vitamin D - Weight bearing exercise |
|
|
Does the USPSTF recommend supplementation of calcium and vitamin D for preventing osteoporosis? |
Current evidence is insufficient to assess the balance of benefits and harms of daily supplementation of >400IU of vitamin D3 and 100mg of calcium for primary prevention of fractures in non-institutionalized post-menopausal women
Recommend against daily supplementation with lower doses for the primary prevention because they have not demonstrated benefit at this dose, and increase the risk of nephrolithiasis (kidney stones) |
|
|
What is the recommendation for calcium / vitamin D intake in otherwise healthy women at risk for osteoporosis? |
Consume an average of 1200 mg of calcium and 600 IU of vitamin D daily
Increasing dietary intake should be the first line approach, but supplements can be used when adequate daily intake cannot be achieved and when vitamin D deficiency is demonstrated |
|
|
What are the functions of vitamin D? |
- Calcium absorption - Bone health - Muscle performance - Balance and risk of falling |
|
|
What are the chief dietary sources of vitamin D? |
- Fortified milk - Fortified cereals - Egg yolks - Salt water fish - Liver |
|
|
What kind of exercise is best for preventing osteoporosis? |
Lifelong weight-bearing exercise (bones and muscles work against gravity as the feet and legs bear the body's weight) and muscle strengthening can improve agility, strength, posture, and balance, which may reduce the risk of falls. May also modestly increase bone density.
Examples of weight bearing exercise - walking, jogging, Tai-Chi, stair climbing, dancing, tennis. |
|
|
What are the consequences of osteoporosis? |
- Fractures following even minimal trauma - Most commonly to vertebrae, hip, distal radius, and proximal humerus |
|
|
How does the lifetime risk of fracture for a 50-year old woman compare to her risk for endometrial or breast cancer? |
Lifetime risk of fracture exceeds the risk for endometrial / breast cancer |
|
|
What is the average one year mortality rate for patients with hip fractures? |
20-25% |
|
|
What is associated with hip fractures? |
- Significant loss of independence - 15-25% of previously independent patients require require nursing home placement for at least one year - Less than 30% of patients regain their pre-fracture level of function |
|
|
What are some strategies to prevent falls in patients with osteoporosis? |
- Checking and correcting vision and hearing - Evaluating any neurological problems - Reviewing prescription meds for side effects affecting balance - Provide a checklist for improving safety at home |
|
|
How do you diagnose osteoporosis? |
DEXA scan - T-score of -1.0 to -2.5 is consistent with decreased bone density of osteopenia - T-score of <-2.5 indicates osteoporosis |
|
|
What is osteopenia? |
Degree of bone decline since peak bone mass; usually not an indication for treatment aside from lifestyle - DEXA scan: T-score from -1.0 to -2.5 |
|
|
What are the treatment options for osteoporosis? |
- Bisphosphonates (Alendronate/Fosamax, Risedronate/Actonel, Ibandronate/Boniva, Zoledronic Acid) - PTH (Forteo) - Estrogen replacement therapy - Calcitonin |
|
|
What is the function of bisphosphonates? |
Potent inhibitors of bone resorption and reduce bone turnover, resulting in increase in bone mineral density |
|
|
What are the benefits of bisphosphonates? |
Decrease the risk of vertebral and non-vertebral fractures |
|
|
Which bisphosphonates are available in the generic form, making them more affordable? |
Alendronate (Fosamax) Risedronate (Actonel) |
|
|
Which form of bisphosphonate comes in an IV prep and is given annually to patients who do not tolerate oral bisphosphonates? |
Zoledronic acid |
|
|
What are the benefits of the parathyroid hormone (Forteo)? |
Anabolic drug approved for patients with osteoporosis at high risk for fracture - Given subcutaneously and has been shown to decrease fracture risk by 50-65% - Does not have demonstrated efficacy and safety beyond 2 years and is quite costly |
|
|
When can you use PTH for osteoporosis treatment? |
Only effective for 2 years; quite expensive |
|
|
How effective is estrogen replacement therapy for treating osteoporosis? |
Decreases the fracture risk by 20-34% - Indicated primarily for short-term treatment of moderate to severe vasomotor symptoms - Not recommended for long-term use |
|
|
What are the benefits of calcitonin for osteoporosis? |
Reduces vertebral fractures, but not hip or other fractures |
|
|
What is the procedure for an endometrial biopsy? |
(1) Verify that the patient understands the procedure and risks of (1) bleeding or (2) rarely uterine perforation; sign consent form (2) Have patient get into the lithotomy position and insert speculum (3) Use betadine to cleanse cervix (4) Use tenaculum (forceps w/ sharp hook) to grasp cervix on superior / anterior portion (5) Insert pipelle into os and obtain specimens from at least 4 different areas of uterus (6) Withdraw pipelle and place samples into formalin; remove tenaculum and speculum (7) Specimen is sent in formalin to lab |
|
|
What treatments are clearly safe and probably effective in the management of hot flashes? |
- Mind and body practices such as yoga, tai chi, go gong, and acupuncture - SSRIs and SNRIs - Prescription meds such as clonidine and gabapentin |
|
|
Which medications for hot flashes are not clearly safe? |
- Phytoestrogens (soy and red clover) - Botanicals (black choose, don qui, kava) |
|
|
Case: 75yo man presents with loss of speech discrimination and complains of difficulty understanding speed and conversation in noisy areas.
What is the most likely diagnosis? |
Presbycusis |
|
|
Case: 75yo man presents with loss of speech discrimination and complains of difficulty understanding speed and conversation in noisy areas.
What is the next step in evaluation? |
- Presbycusis is a diagnosis of exclusion - Hearing aids are underused in presbycusis, but are potentially beneficial for most types of hearing loss, including sensorineural loss - Consequently, referral to an audiologist for testing and considering of amplification with a hearing aid may be an important step |
|
|
What is presbycusis? |
Age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination |
|
|
What are the physical exam findings in a patient with presbycusis? |
Normal |
|
|
What are the conditions in the differential diagnosis of presbycusis? |
- Cerumen impaction - diagnose w/ otoscopy - Otosclerosis - diagnose w/ otoscopy - Central auditory processing disorder - diagnose when pt can hear sounds w/o difficulty but has difficulty understanding spoken words |
|
|
What is a "functional assessment"? |
An evaluation process that gauges a patients ability to manage tasks of self-care, household management, and mobility |
|
|
What are the goals of preventive services for the elderly? |
Optimization of quality of life, satisfaction with life, and maintenance of independence and productivity |
|
|
What do you evaluate on a functional assessment of a geriatric patient? |
Ability to manage: - Tasks of self-care - House-hold management - Mobility |
