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62 Cards in this Set
- Front
- Back
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describe the events during premenopause
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-decline in ovarian fx and increase of anovulatory cycles
-absence of ovulation, decrease levels of ovarian hormones(estradiol, progesterone) -loss of negative feedback; increased levels of gonadotropic hormones (FSH, LH) -menstrual cycle length increases -increased menstrual irregularity |
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what is the pathophysiology of decreasing ovarian fx and weight with age
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-decreased number of ovarian follicles which undergo ovulation
-without maturation, estradiol production, ovulation, and progesterone secretion do not occur |
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what are the clinical manifestations of approaching menopause?
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-menstrual irregularity, lengthening menstrual intervals, and anovulation
-vasomotor Sx: hot flushes -urogenital atrophy |
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clinical manifestations of approaching menopause are related to the decline in ______
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estradiol
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Levels of ___&______ continually increase to a maximum at 2-3 yrs after menopause (these levels are higher than premenopausal)
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FSH & LH
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residual ovarian follicles become refractory to the________, produce less __________, and exert less ___________.
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1. gonadotropins
2. estradiol 3. negative feedback on the hypothalamic-pituitary-gonadal axis |
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after menopause, the primary estrogen is _________, which is derived from androgens produced in the __________,
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1. estrone
2. adrenal cortex |
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Androgen produced in the adrenal cortex undergo peripheral conversion (aromatization) mostly in the ___________
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adipose tissue
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__________ production is also diminished during the climacteric
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progesterone
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perimenopause consists of three stages which are?
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premenopause, menopause, and postmenopause
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postmenopausal progesterone levels are ________to premenopausal concentrations occurring in the follicular phase of the ovarian cycle
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equal
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acute perimenopausal Sx
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-vasomotor Sx
-genitourinary atrophy -psychogenic effects: mood changes/irritability |
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osteoporosis is a major consequence of __________
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long-term estrogen deficiency
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after premenopausal bilateral oophorectomy, 37-50% pts experience_________
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vasomotor Sx: hot flushes
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what are the characteristics of hot flushes?
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-episodic, rather than continuous
-due to estrogen deficiency in the CNS or estrogen withdrawal -downward resetting of the thermoregulatory center set point -occur as core temp decreases |
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vasomotor Sx of perimenopause
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-hot flushes
-HA -night sweats (hot flushes at night) -insomnia |
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__________is highly effective at relieving these symptoms
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MHT
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S & Sx of genitourinary atrophy
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-thinning and drying of the urinary tract and vaginal tissues
-dryness due to decreased vaginal secretions; easily traumatized tissues or bleeding -atrophic changes in genitourinary organs -vaginal pH changes - |
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vaginal pH changes in genitourinary atrophy predispose pts to ____________
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increased bacterial colonization and infectious vaginitis
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discuss the forms of administering intravaginal estrogen
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-conjugated estrogen vaginal cream
-vaginal ring sustained release delivery system (ring inserted near cervix and estradiol is slowly released over 3 mo to exert local effects) |
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intravaginal estrogen is insufficient amt for relief of ____________
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vasomotor Sx
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The National Menopause Society recommends that estrogen-progestin therapy be prescribed at ________dose for _________time to relieve menopausal Sx such as vasomotor instability and atrophic vaginitis
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1.the lowest effective dose
2.the shortest possible time |
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Endocrine Society states that:
1. _________relieves Sx and normalize vaginal atrophy 2._________ reduces Sx of overactive 3._________reduces incidence of recurrent UTI's |
1. very low doses of vaginal estradiol
2. vaginal or systemic estrogen 3. vaginal estrogen |
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What are the goals of MHT?
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-tx acute perimenopausal Sx
-estrogen combined with a progestin to suppress estrogen-induced endometrial hyperplasia and and cancer in pts with an intact uterus (estrogen alone if no uterus) |
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long-term MHT is NOT USED for what three purposes?
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-primary and secondary prevention of CV dz
-osteoporosis -Alzheimer's Dz |
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what is an endogenous estrogen product used for MHT?
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estradiol transdermal patches
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what is a naturally-occurring estrogens used for MHT?
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conjugated equine estrogens
-oral products (Premarin) |
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actions of transdermal estrogen patches
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-moderate to severe vasomotor Sx associated with menopause
-atrophic conditions caused by deficient endogenous estrogen production -prevention of postmenopausal osteoporosis |
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____is used only in hysterectomized women (women without an intact uterus)
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Estrogen Therapy
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Why are oral progestins used with MHT?
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to decrease the risk of endometrial hyperplasia and CA associated with unopposed estrogen in women with an intact uterus
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describe the recommendations for progestin admin during MHT
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-medroxyprogesterone acetate for at least 12 days a month in cyclical regimens
-daily in continuous regimens |
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indications of estrogen/progestin combined products
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-moderate to severe vasomotor Sx associated with menopause
-vulvar and vaginal atrophy -prevention of osteoporosis |
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dosing schedule for cyclic sequential MHT
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-estrogen daily for days 1-25 of each month
-progestin daily added for 12 days (days 13-25) each month -days 25-30 are hormone free |
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97% incidenceof _____________ starting on day 25 of cyclic sequential MHT. Some pts may experience ________during the period of estrogen therapy
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1. withdrawal bleeding (usually light and painless)
2. return of Sx |
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In cyclic sequential MHT, endometrial CA is avoided if ___________________.
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-progestin component is adequately dosed and of sufficient duration
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what is an advantage of continuous sequential MHT?
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-prevents Sx of estrogen deficiency in pts who experience those Sx on hormone-free days
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what are the characteristics of continuous combined MHT?
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-both estrogen and progestin on all days of the month
-designed to produce amenorrhea (d/c of menses) -after 6 mo, 60-65% are amenorrheic |
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low dose ET/MHT vs standard dose?
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-decreased severity of hot flushes
-improved vaginal maturation index -osteoporosis prevention post menopause when combined with progestin and calcium supplement |
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MHT and Alzheimer's dz?
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-MHT increases the risk of probable dementia in postmenopausal women >/=65yrs
-in studies failed to prevent mild cognitive impairment |
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MHT and endometrial CA?
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--progestin should be added to ET in women with and intact uterus to prevent endometrial hyperplasia and decrease the risk
-hysterectomized women should receive unopposed ET |
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MHT and breast CA?
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-increased risk after 5yrs of use(can be 2-3)
-short courses of MHT for tx of Sx of menopause should be safe(2-3yrs) -women with intact uterus should use other methods to prevent osteoporosis and CAD |
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analysis showed that MHT puts postmenopausal women at increased risk for ______, _________, __________, and a _______
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1. breast CA (26%)
2. stroke (41%) 3. MI (29%) 4. >/= 2-fold increase in PE |
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What benefits did analysis show with MHT use?
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-decreased incidence of hip fracture (33%)
-decreased colorectal CA (37%) |
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short term use of MHT still viewed as safe and effective to a duration of?
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<5yrs
(risks do not outweigh benefits after 5yrs) |
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decision to stop estrogen only trial was based on?
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-increased risk of stroke similar to that in EEP study
-trend toward an increased risk of probable dementia and/or mild cognitive impairment -reduction in hip fxs -no increases in breast CA |
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neither primary nor secondary prevention of _____are achieved with long term MHT
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-CV dz
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increased risk of demetia in postmenopausal women was evident after___and persisted for _____ shown in one study
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1. 1st year
2. the duration of the trial |
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MHT _________the risk for dementia
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doubles
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Neither MHT nor ET increase the risk of __________ in women 50-59
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MI
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lack of benefit or increase in CHD risk with MHT use thought to be due to ________
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harmful effects of MHT in older women starting therapy many years after onset of menopause
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MHT may increase risk of ____________ in postmenopausal women by 64% and the magnitude of the increase is related to _________
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1. gallbladder dz
2. dosing route |
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summary of estrogen + progestin MHT advantages
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-decreased risk of colorectal CA
- decreased risk of fx |
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summary of estrogen + progestin MHT disadvantages
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-increased risk of stroke, blood clots,breast CA, dementia
-no protection against mild cognitive impairment - increased risk of AMI (not for 50-59yr olds) |
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estrogen alone MHT increases risk of?
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stroke
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Mgmt for breast tenderness associated with hormone replacement therapy
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-reduce estrogen dose
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Mgmt for vasomotor Sx associated with hormone replacement therapy
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-increase estrogen dose
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Mgmt for heavy withdrawal bleeding associated with hormone replacement therapy
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- decrease estrogen dose
-switch to a continuous progestin dosing regimen |
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Mgmt for HAs associated with hormone replacement therapy
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-if migraine-like consider d/c
-switch to continuous estrogen therapy |
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Mgmt for bloating associated with hormone replacement therapy
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-switch to a different progestin
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Mgmt for mood alterations associated with hormone replacement therapy
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-decrease progestin dose
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Mgmt for decreased libido associated with hormone replacement therapy
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-add estrogen to regimen
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absolute contraindications to postmenopausal estrogen therapy
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- presence of estrogen-related CA
- undiagnosed abnormal vaginal bleeding -active lever dz or chronic severe liver dysfunction -active thrombophlebitis or thromboembolic d/o - prior complications form estrogen therapy |
