Pc615 Module 5 Test 2

Front 1

Define menopause

Back 1

Menopause is defined as the point in time following 12 consecutive months of amenorrhea and occurs in response to normal physiologic changes in hypothalamic-pituitary-ovarian axis.

Front 2

Define Perimenopause fluctuation

Back 2

During the perimenopausal period, occurring 2-8 years prior to the last period, and for the 12 months of the amenorrhea preceding menopause, fewer ovarian follicles develop in each menstrual cycle. The follicles that do develop are less responsive to FSH, and the ovaries produce less estradiol, progesterone and androgens. Thus, the normal negative feedback effect from elevated estrogen and progesterone levels on hypothalamic production of GnRH is lost, and anterior pituitary production of FSH and LH continues.

Irregular menstrual cycles, characterized by longer or shorter cycles, heavier or lighter flow, periods of amenorrhea, and worsening or newly developed premenstrual symptoms, are common during this time. Eventually ovarian follicle production stops, estrogen and progesterone levels remain low, FSH and LH levels remain high, and menstruation ceases

Front 3

When is the postmenopausal period?

Back 3

The post menopausal period refers to the first five years or so following menopause when hormonal fluctuations are often still present

Front 4

How do levels of the FSH change between the reproductive years and after menopause

Back 4

under 40 m IU/L in menopause, but is NOT diagnostic for menopause

Front 5

How do levels of Estrogen change between the reproductive years and after menopause

Back 5

Estradiol (E2): most potent estrogen, main estrogen produced during the reproductive years, and is present in low amounts in the postmenopausal years following peripheral conversion of androstenedione. Estriol (E3): is secreted by the placenta and synthesized from androgens produced by the fetus during pregnancy, and is present in non pregnant women in small amounts as a byproduct of estradiol and estrone. Estrone (E1): the weakest estrogen, is the primary estrogen present in postmenopausal women, children and men. In the postmenopausal period, estrone is produced by adipose coversion of androstenedione secreted by the adrenals (95%) and to a lesser extent the ovaries (5%), and metabolism of estradiol.

Front 6

How do levels of Testosterone change between the reproductive years and after menopause

Back 6

although the ovaries no longer produce functional follicles, the corticostromal and hilar cells of the stromal tissue are steriodogenic and produce significant levels of both androstenedione and testosterone for many years. Circulating levels of androstenedione in post-menopausal women are approximately half those of pre-menopausal women. Conversely, circulating levels of testosterone remain relatively constant in women who are either pre- or post-menopausal, partly due to the effect of high FSH and LH levels that stimulate the ovarian stromal tissue to increase testosterone production.

Front 7

How does Menopause effect Thyroid disease and depression:

Back 7

Thyroid disease affects women more than men and increase with age.
o Depression increase at midlife d/t sx of hormone fluctuation and midlife stressors.
o Depression rates are 3 times as high in perimenopausal women as they are in premenopausal women.

Front 8

How does Menopause effect Osteoporosis

Back 8

o Reduced bone strength (density and quality). Density is the volume of the bone, whereas quality refers to rate of turnover, bone structure, mineralization, and accumulated damage.
o Primary osteoporosis: associated with aging and affects more women than men. Adults achieve peak bone mass between 30-35, after which time the rate of bone resorption exceeds bone formation and mass slowly declines. Loss of estrogen causes a rapid rate of bone loss in the first year after menopause, between 1-5 %, then slows to 1% per year.
o Secondary: occurs in response to medications (corticosteroids, anticonvulsants, and methotrexate) or diseases (hyper thyroidism, chronic liver disease, malabsorption, GI disease). Affects men or women at any age.
o Gold standard for dx is bone mineral density scanning measurement, by dual-energy xray absorptiometry, which is used to evaluate BMD at the spine, hip or waist. Osteopenia: T score is -1 to -2.5, osteoporosis is -2.5 or less. Z score is used in children, and provides a comparison for the patient with a age-matched mean.
o Quantitative CT can be used for spine measurement: useful in arthritis (less likely to reflect osteocytes).
o Osteoporosis/osteopenia puts a woman at risk for fractures…following a hip fx, there is a 10-20% increase in mortality, 30-40 % of the survivors have permanent disability, and 24-50% never return to independent living
o Prevention is key.
o Calcium: Pre menopausal women and post menopausal women on HT need 1000mg of calcium per day. 1200 mg /day fro perimenopausal or premenopausal women over age 50, 1500 per day for post menopausal women not taking HT and women older than 65,
o Vitamin D: 400-800 IU/day
o Weight bearing and resistance exercises, fall prevention (ID fall risk such as visual or hearing impairments, neurological impairments, medications that can increase the risk for falls, loose cords or rugs), avoiding tobacco and moderating alcohol intake
o Forward bending at the waist is discouraged for women with established osteoporosis d/t to the possible risk of vertebral compression fractures.
o Medication management for women with t scores of -2.0 or lower, t scores of -1.5 who have one or more risk factors, and those with previous hip or vertebral fractures.
o Repeat BMD testing is recommended one year after treatment is started, then every 2-5 years after levels stabilize, two satisfactory BMD results, and the woman’s medical condition is stable. See table on page 265 for treatment options

Front 9

How does Menopause effect Cancer

Back 9

o In 2004, the leading cause of cancer among women was lung and bronchus, followed by breast and colon. Increase risk as women age. Lifetime risk of breast ca is 1 in 7 women

Front 10

How does Menopause effect Overweight and obesity:

Back 10

o Not necessarily r/t menopause, but rather aging… +5 # at midlife, average. r/t slowing of metabolism, decrease of activity… therefore, decrease calorie intake and increase activity
o Distribution of body fat changes-in young women, adipose tissue accumulates at the hips and thighs (pear shape), as women age, adipose tissue is redistributed, accumulates at the waist (apple shape).
o Abdominal adiposity and weight gain are significant health issues,(BMI > 30 and waist > 35 cm), r/t negative body image and the greater risk for developing insulin resistence that can lead to CVD and DM.
o Obesity is associate with osteoarthritis, cholecystic disease, urinary incontinence, and cancer (breast, endometrial, colorectal)
o BMI > 27 is associated with increase frequency of hot flashes, night sweats, sore, stiff back, neck and shoulders.

Front 11

How does Menopause effect Cardiovascular disease

Back 11

o Number one cause of mortality for both men and women in US
o 500,000 women die each year
o After the age of 50, 50% of all deaths among women are r/t CVD, including, HTN, valvular heart disease, coronary artery disease, or coronary heart disease, stroke, arrhythmias, CHF, and congenital heart defects
o Women at increased risk following menopause d/t changes in cholesterol levels…LDL and very low density lipoprotein levels decrease. HDL levels decrease somewhat.
o General risk factors include:smoking, sedentary lifestyle, stress, obesity, pre-existing htn, abnormal serum lipids, DM

Front 12

How does Menopause effect DM

Back 12

o Risk factors: overweight, BMI > 25, abdominal adiposity, sedentary lifestyle, insulin resistence, hx of gest. Diabetes, hx of polycystic ovarian syndrome, family hx of diabetes. HTN and dyslipemia also predispose
o Prediabetes: impaired fasting glucose levels (100-125 mg/dl), impaired GTT (2 hours post 75 gm load-140-199): 30-40 % will develop DM within 5 years.
o DM increases risk for CVD, stroke, infections, foot ulcers, peripheral vascular disease, peripheral neuropathy, nephropathy, and retinopathy
o Perimenopausal women find it difficult to manage d/t fluctuations in hormone concentrations. Insulin resistence increases with reduced levels of estrogen, causing higher serum glucose levels. Progesterone has a converse effect on glucose, causing lower levels d/t increase in insulin sensitivity that accompanies falling progesterone concentrations.
o After menopause, glucose levels tend to be lower, because insulin sensitivity increases and insulin use is more efficient as estrogen and progesterone concentrations stabilize.
o As other midlife changes occur (like weight gain and slowed metabolism), this can affect glucose levels, therefore, numerous adjustments in medications and regimens are often necessary to maintain adequate glucose control

Front 13

Identify lifestyle modifications for management of menopausal symptoms

Back 13

Lifestyle modifications:

Dietary Changes:
o substances linked with more frequent or severe hot flashes include sugar, caffeine (coffee, chocolate, etc), spicy foods and alcohol. Avoidance or moderation is recommended.
o Increase water intake (because of the augmented insensible loss of fluids through sweating). Also may help with reducing symptoms of skin dryness, and reduces discomfort with hot flashes an sweating. 6-8 glasses per day. Women with incontinence may need to limit it for social situations or at night.

Exercise:
o Lower levels of activity have been linked with a higher frequency of menopausal symptoms, esp: forgetfulness, difficulty sleeping, heart pounding or racing, and stiffness or soreness.
o Higher levels of activity have been associated with reduced severity of menopausal symptoms such as vasomotor symptoms, depression, and forgetfulness. Exercise also reduces cardiovascular and osteoporosis risks, improves sleep, and assists with maintaining a healthy weight, relieving stress, reducing moodiness, and improving mental function.

Vitamins and supplements:
o Calcium (1200-1500mg/day) and Vit D (400-800 IU/day) are needed for post menopausal women to maintain bone strength.
o Vit E (up to 800 IU/day): small improvements or no changes in hot flashes in clinical trials. A recent meta analysis indicated that Vit E did not provide a reduction in overall mortality, CVA, or Cardiovascular death. Reduced risk for developing Alzheimer’s.
o Beta carotene: slightly increased risk for all-cause mortality (HUH???)
o B vitamins: are known to reduce homocysteine levels (high levels are associated with CVA, CVD, Alzheimer’s, and osteoporotic fracture). Daily supplementation with a MVI containing B vitamins (folate, b6, and b12) helps to reduced homocysteine levels and also to partially compensate for the lack of fruits and vegetables in the American diet.
o Iron: MVI’s with iron should be avoided unless there is a documented need for iron supplementation, as excess iron can cause negative effects on the cardiovascular system or liver over time.

Vaginal lubricants and moisturizers:
o Are used to relieve vaginal dryness and dyspareunia caused by reduced vaginal secretions. Several nonhormonal water based preparations are available OTC (KY, Astroglide, Lubrin, and Moist Again). Either used for daily comfort for vaginal dryness and during sexual activity.
o Longer acting vaginal moisturizers (Replens, KY long lasting vaginal moisturizers) may be more appropriate for some women. They replenish and maintain fluids in the vaginal epithelial cells and provide longer relief. Moisturizers may be beneficial for women who experience daily discomfort and can reduce vaginitis by supporting a normal pH.
o Caution women against using any oil-based products, such as Vaseline, as these can injure vaginal tissue and are not easily removed. Vitamin E oil, applied topically to the vaginal walls, are an exception to this rule—it can provide relief for vaginal dryness without interfering with condom or diaphragm function, and does not irritate.
o Other products that contain oils or fragrances should also be discouraged as they often cause vaginitis or irritation. Douching is not effective for moisturizing and will remove normal flora, thus increasing the risk for infection
.
Clothing and environment:
o Wear layered clothing, breathable fabrics (cotton or linen), or wicking fabrics—said to reduce discomfort with hot flashes and sweats.
o Avoid turtlenecks, polyester or silk, (as these do not allow circulation or absorb sweat), extra layers (slips, full length stockings)
o Keep air temperature cool, keep a window open, use a fan, ingest cold beverages (reduces core body temp)

Smoking Cessation:
o Smoking is associated with increased morbidity/mortality (CVD, cancer), earlier age at menopause, increased rate of bone loss, increased prevalence of all menopausal symptoms (except vaginal dryness).
o The most successful smoking cessation program is one that the woman is interested in. She needs to be both interested in quitting and motivated to quit.
o Support from a clinician, and use of medication or patches can improve cessation rates.

Stress Management:
o Stress increases menopause sx, can cause poor sleep, increase depression/moodiness
o Midlife women face many stressors: health changes, financial concerns, loss of parent, children leaving home, relationship struggles
o Individualize stress management: regular exercise, relaxation techniques, deep breathing, yoga, tai-chi, baths, reading, massage, spirituality, or religion
o Effectively managing stress is associated with less intense and fewer hot flashes
o Yoga breathing, a variation of paced respiration, can enhance relaxation and reduce hot flashes. Yoga breathing—deep inhalation over 4 counts, holding for seven, exhaling for eight counts.

Sleep:
o Evaluate the cause of sleep disruptions—important for developing the plan for management
o If sleep disruption is r/t hot flashes or other menopausal sx, use light blankets, cotton sleep wear, wicking pajamas, well ventilated room
o If not: good sleep hygiene (cue the brain that it is time for sleep)
-regular routine prior to bedtime such as brushing teeth, changing into sleepwear…
-do something relaxing—like reading a book, warm beverage, warm bath
-avoid activities that stimulate the mind—like watching TV, stimulating book, work, or exercise
-reserve the bedroom for sleep and sex
-establish regular times for sleep and waking
-avoid stimulants like caffeine (can last up to 20 hours in the system), alcohol (initially a sedative, but can cause fragmented sleep, or rebound wakening), nicotine (increased sleep latency, reduces overall sleep duration), exercise (will benefit sleep quality, reduce sleep latency, and increase time spent in deep sleep, BUT timing is important… exercise before bed can cause sleep latency)
o For those with short sleep duration: sleep restriction therapy can be tried…first, identify the current average sleep duration. Go to bed 4 hours PRIOR to the determined time for wakening, and to get up at the predetermined wake time. She needs to stay awake except for the determined sleep time (no napping). After she is sleeping more than 95% of the time for several nights consistently, the time to go to bed is moved to one half hour earlier. Continue this pattern until the desired sleep time is achieved.

Mental function:
o Expect a slow decline in mental function with age
o Some women have a bothersome cognitive change that develops as menopausal sx occur.
o Can be associated with lack of sleep or high levels of stress or medical problems
o The first step is a complete comprehensive assessment to identify potential causes of the cognitive problems
o Simple memory aids may help
o Using an appointment calendar, using lists
o Participate in stimulating mind activities… like crossword puzzles, or other activities that can help maintain cognitive function

Front 14

Identify pharmacologic options modifications for management of menopausal symptoms

Back 14

Pharmacological options:

o NAMS recommends lifestyle changes along or in combination with nonprescription remedies for women with mild vasomotor sx.
o Prescription systemic hormones are the standard for women with moderate to severe symptoms.
o FDA defines moderate to severe hot flashes as 7-8 episodes per day or at least 60 per week.
o Hot flashes will eventually resolve without medication in most women.
o Cochrane group study (meta-analysis): system ET/EPT reduced hot flash severity and frequency significantly more than placebo
o Some anti-depressants, anti-hypertensives, and anti-convulsants also reduce vasomotor sx (NAMS, 2004) see page 273 for table….
--Effexor- immediate response
--Prozac-immediate response, taper when discontinuing
--paxil—immediate response, taper when discontinuing
--neurontin—(anti convulsant) avoid use of antacids within 2 hours
--clonidine (anti hypertensive), available as a patch, less effective
than the others, taper when discontinuing
o Out of all the estrogen/progesterone products, there is NO evidence to claim that one product is superior to another for symptom relief.
o There is NO FDA approved therapy for treating hot flashes in women at high risk for or who have been dx with breast cancer. Nonhormonal agents may provide hot flash relief for women who have had breast cancer. Herbal alternatives to HT should be used with caution because they can have estrogen like activity.
o Prior to prescribing HT, it is extremely important to review any cautions or contraindications to hormone use. Weigh the risk vs. benefit, scientific uncertainty with each pt in order to individualize treatment options.
o Data from WHI and HERS support the increased risk for breast ca, Coronary heart disease, thromboembolism, stroke and dementia when HT is used.
o This data must be inferred with caution to women under the age of 50 who begin HT.
o Breast cancer risk is increased after five years of use, and progesterone may contribute to that risk (NAMS, 2004)
o Women considering the use of HT should have the recommended screening tests for health promotion and disease prevention, in addition to a complete history and physical examination. Pay special attention to personal and family hx of health problems that would contraindicate ET/EPT use.
o Once they are considered candidates, then explain the various protocols for administering HT: ET alone (for women without an intact uterus); EPT continuously or sequentially; local ET; or estrogen-androgen therapy

Front 15

Identify complimentart and alternative therapy modifications for management of menopausal symptoms

Back 15

Complementary and alternative therapies:
o Visits to alternative providers now exceed visits to primary care clinicians. (most people don’t report these visits to their PCP)

Natural versus bioidentical hormones:
o Women seek “natural” hormones, believing they are less likely to cause harmful side effects than manufactured hormones. However, “natural” refers to any product with principal components that originate from plant, animal or mineral sources, which also encompasses pharmaceutically manufactured hormones…as these are derived from animal, plant, and mineral sources.
o “natural” does not necessarily= identical to what a women’s body produces
o “bioidentical” hormones are equivalent to the hormones produced in women’s bodies.
o Bioidentical hormones are available through prescription from usual and compounding pharmacies, including estrogens (estrone, estriol, and 17 beta-estradiol), and progesterone (in a micronized form)
o Estrogens available through compounding pharmacies are Tri-est and Bi-est. These products contain 80% estriol, but since they contain significant amounts of estradiol, they may require progesterone for endometrial protection. Estriol can be compounded into a vaginal cream also.

Herbals:
o Many women seek herbals for relief of hot flashes or other sx, few studies exist to offer their safety or efficacy.
o These products are not regulated by the FDA because they are “diet supplements”, the regulations that do exist are poorly enforced.
o This raises questions about purity, contents, and consistency from package to package or even tablet to tablet.
o Various preparations of the same herbal product can contain vastly different amounts of active ingredients (extract vs. tincture)
o Many products come with mixtures of various different herbs in a single preparation, making dosing difficult
o Little is known about the interactions between herbals and prescription products
o See table on page 281 for more info:
-Black cohosh-used for vasomotor sx
-Chastetree berry-menstrual irregularity
-Dong quai-gyn conditions, contraindicated with warfarin
-evening primrose oil-hot flashes, mastalgia
-ginkgo- memory changes
-ginseng-generic “tonic”, improved mood, fatigue
-kava-irritability, insomnia (banned in several countries d/t hepatotoxicity, contraindicated with depression)
--licorice root-menopause related sx.
--passion flower-sedative
--st. john’s wort-vasomotor sx, irritability, depression
--valerian root-sedative, anti-anxiety
--wild yam-menopausal sx

Progesterone Creams:
o FDA regulations are not currently enforced for these products—raises the questions about purity and content
o Creams include Phytogest, Progest, Endocreme and Pro-Dermex, progesterone content varies from 2-700 mg. these can be prescribed through compounding pharmacies
o Although some women taking systemic estrogens may want to use progesterone creams for endometrial protection to avoid systemic progesterone effects, there is no data that supports the use of progesterone creams for endometrial protection.
o At least one study supports the use of transdermal progesterone cream for improvement of vasomotor symptoms, as compared with controls.
o Topical progesterone creams may be promising IF future research supports these findings.

Acupuncture:
o Research findings for the relief of menopause related sx have been contradictory
o One small study identified no differences in subjects treated with electroacupuncture vs. controls.
o A more recent study identified significant reductions in hot flashes and sleep disturbances in women treated over a 6 week period with acupuncture at menopause sx-specific sites as compared with controls who were treated with a general tonic acupuncture
o Further research is needed

Front 16

Differentiate estrogen therapy (ET), estrogen plus progestogen therapy (EPT), and hormone therapy (HT).

Back 16

Estrogen Therapy (ET):
o Prescribed exclusively for women who have had a hysterectomy since the documentation in 1975 that unopposed estrogen increases risk for endometrial hyperplasia and cancer.

Estrogen-Progesterone Therapy: (EPT):
o Taken sequentially (CS-EPT) or continuously (CC-EPT).
o In the sequential regimen, estrogen is taken daily with the addition of progesterone in a cyclic fashion, usually on days 1-12 of the month.
--one frequent side effect is that most women will have a withdrawal bleed monthly. To avoid this, the continuous regiment was developed.
o In the continuous regimen: estrogen and progestogen are taken daily
o Another option includes pulsed combination therapy wherein the progestogen is taken for two days followed by a day off in a repeating pattern. This was to reduce potential side effects from the progestogen, however, breakthrough bleeding is usually more common with this regimen.
o A less frequently used regimen: cyclic regimen, where estrogen is taken daily for the first 21 days of the cycle, and progestogen is added for days 12-21. a withdrawal bleed usually occurs between days 22 and 28, during which neither estrogen nor progestogen is taken. Menopausal symptoms usually rebound when the estrogen is not taken, therefore, few women opt for the cycylic regimen.

Estrogen Compounds:
o Estrogens that are bioidentical and transformed into human estrogens-such as 17-beta Estradiol, etriol, and estrone
o Synthetic estrogens analogs: ethinyl estradiol
o Nonhuman estrogens: CEE, which is the most widely used estrogen and has been studied in the majority of clinical trials, including WHI and HERS.
o Estrogens differ in target tissue response and in dose equivalency
o Administered either systemically (oral tablets, or transdermal patches) or locally (creams, tablets, rings)
o The vaginal ring containing 0.5 mg or 0.1 mg/day of estradiol acetate over three months is the only local treatment that has been effective in treating hot flashes (NAMS, 2004).
o Local treatment with estrogen theoretically avoids systemic absorption, however, in a review of the studies on vaginal preparations, the ring was found to have slightly more systemic absorption
o Women who want to avoid systemic effects, such as breast cancer survivors, should probably use a different preparations until more evidence is available.

Progestogens:
o Progestoges are hormones that possess progestational properties
o MPA is the most commonly prescribed, but others are being used with more regularity, such as micronized progesterone (bioidentical), norgetimate, and norethindrone acetate

Estrogen-Androgen Therapy:
o Theorized to improve the loss of libido in post-menopausal women, however, there are too few randomized clinical trials to prove that testosterone plus estrogen is more effective than estrogen alone
o One study of 40 women showed no significant differences in levels of self-reported sexual enjoyment and desire
o Another study found significantly improved levels of sexual desire, arousal, and fantasies, in women taking testosterone and estrogen plus testosterone
o Additional clinical trials are currently being conducted
o Side effects of androgens include: alopecia, acne, deepening of the voice, and hirsutism

Front 17

Plan of Care and patient education regarding HRT:

Back 17

o NAMS recommending intiating ET and EPT as lower than standard doses, such as 0.3 mg CEE, 0.25-0.5 mg 17-beta estradiol patch, or the equivalent.
o Studies show adequate vasomotor relief, but endometrial protection has NOT been evaluated in long term trials.
o Vasomotor symptoms usually begin to resolve in 2-6 weeks after initiating HT
o Patients should be offered anticipatory guidance about management of side effects, should they occur
o Research evidence has absolved HT from contributing to weight gain, however, fluid retention may make women feel like they are gaining weight.
o Patients should return for a f/u visit in 6-8 weeks to evaluate their progress, if the initial ET/EPT is not adequate, in can be increased or taken on a daily divided dose schedule.
o The decision to continue or discontinue HT should be revisited at least annually, as some women will have sx for a few months to a year, while others are symptomatic for years and may need to continue HT up to five years.
o When discontinuing, HT should be tapered to avoid rebound sx. There are no particular guidelines, but NAMS advises gradually decreasing the dose or gradually lengthening the time between doses.

Front 18

List the absolute contraindications to estrogen use and to progestogen use

Back 18

Estrogen absolute contraindications:
o Known or suspected breast cancer
o Known or suspected estrogen-dependent neoplasia
o History of uterine or ovarian cancer
o History of coronary heart disease or stroke
o History of biliary tract disorder
o Undiagnosed, abnormal genital bleeding
o History of or active thrombophlebitis or thromboembolic disorders

Progestogen absolute contraindications:
o Active thrombophlebitis or thromboembolic disorders
o Liver dysfunction or disease
o Known or suspected cancer of the breast
o Undiagnosed abnormal vaginal bleeding
o pregnancy

Front 19

Identify potential side effects of HT and strategies for their management

Back 19

Estrogen Adverse Effects:
o Uterine bleeding
o Breast tenderness
o Nausea
o Abdominal bloating
o Fluid retention in extremities
o Headache
o Dizziness
o Hair loss

Adverse effects of EPT:
o Mood changes
o Possible increased uterine bleeding than if taking ET alone

Management of HT side effects:
o Fluid retention: decrease salt intake, maintain adequate water intake, recommend an herbal diuretic or mild prescription diuretic
o Bloating: Change to low-dose transdermal estrogen, lower the progestogen dose to a level that still protects the uterus, change progestogen or try micronized progesterone
o Breast tenderness: decrease estrogen, change estrogen, decrease salt intake, change progestogen, decrease caffeine and chocolate consumption
o Headaches: change to transdermal estrogen, decrease estrogen and/or progestogen, change to a CC-EPT regimen, ensure adequate water intake, decrease salt intake, caffeine or alcohol use.
o Mood changes: lower the progestogen dose, change to a CC-EPT regimen, ensure adequate water intake, restrict salt, caffeine, and alcohol consumption
o Nausea: take hormones with meals, change estrogen, change to transdermal estrogen, decrease estrogen or progestogen

Front 20

Risk factors (primary and secondary) for osteoporosis

Back 20

o Reduced bone strength (density and quality). Density is the volume of the bone, whereas quality refers to rate of turnover, bone structure, mineralization, and accumulated damage.
o Primary osteoporosis: associated with aging and affects more women than men. Adults achieve peak bone mass between 30-35, after which time the rate of bone resorption exceeds bone formation and mass slowly declines. Loss of estrogen causes a rapid rate of bone loss in the first year after menopause, between 1-5 %, then slows to 1% per year.
o Secondary: occurs in response to medications (corticosteroids, anticonvulsants, and methotrexate) or diseases (hyper thyroidism, chronic liver disease, malabsorption, GI disease). Affects men or women at any age.

Front 21

Assessment options for osteoporosis

Back 21

o Gold standard for dx is bone mineral density scanning measurement, by dual-energy xray absorptiometry, which is used to evaluate BMD at the spine, hip or waist. Osteopenia: T score is -1 to -2.5, osteoporosis is -2.5 or less. Z score is used in children, and provides a comparison for the patient with a age-matched mean.
o Quantitative CT can be used for spine measurement: useful in arthritis (less likely to reflect osteocytes).
* Osteoporosis/osteopenia puts a woman at risk for fractures…following a hip fx, there is a 10-20% increase in mortality, 30-40 % of the survivors have permanent disability, and 24-50% never return to independent living
* Prevention is key.

Front 22

Management options for osteoporosis

Back 22

* Calcium: Pre menopausal women and post menopausal women on HT need 1000mg of calcium per day. 1200 mg /day fro perimenopausal or premenopausal women over age 50, 1500 per day for post menopausal women not taking HT and women older than 65,
* Vitamin D: 400-800 IU/day
* Weight bearing and resistance exercises, fall prevention (ID fall risk such as visual or hearing impairments, neurological impairments, medications that can increase the risk for falls, loose cords or rugs), avoiding tobacco and moderating alcohol intake
* Forward bending at the waist is discouraged for women with established osteoporosis d/t to the possible risk of vertebral compression fractures.
o Medication management for women with t scores of -2.0 or lower, t scores of -1.5 who have one or more risk factors, and those with previous hip or vertebral fractures
* Repeat BMD testing is recommended one year after treatment is started, then every 2-5 years after levels stabilize, two satisfactory BMD results, and the woman’s medical condition is stable. See table on page 265 for treatment options