Menopause

Question 1

What is menopause?

Answer 1

• Final menstrual period
  
  • usually confirmed when a woman has missed her period for 12 consecutive months
• It reflects complete or near complete depletion of ovarian follicles and absence of ovarian estrogen secretion
  
  • ​permanent end of fertility

Question 2

• What is the average age of menopause?
• What can influence the onset of menopause?

Answer 2

• Average age: 51
  
  • age ranges from 40 to early 60s
• Age of menopause influenced by genetics, ethnicity, smoking, and reproductive history

Question 3

Definition: Perimenopause/Menopause Transition

Answer 3

• Transition phase
• Begin several years before the final menstrual period.
• Can last 6 years or more
• Ends 1 year after the final menstrual period

Question 4

Definition: Postmenopause

Answer 4

All the years beyond menopause

Question 5

Definition: Premature Menopause

Answer 5

Menopause that occurs before age 40 yrs

Question 6

Transition to Menopause (Late Reproductive - Postmenopasue)

1. Menstrual cycle
2. FSH
3. AMH
4. Vasomotor symptoms

Answer 6

Question 7

What is good evidence for menopause?

Answer 7

1. Vasomotor symptoms (60-85%)
2. Vaginal dryness (30-60%)
3. Sleep disturbances (30-50%):
   
   • 2-fold increase
4. Depressed mood 25-35%:
   
   • 2-fold increase

Question 8

What are the consequences of estrogen deficiency in the postmenopausal years?

Answer 8

1. Increased risk of osteoporosis
2. Increased risk of diabetes
3. Increased risk of CHD and CVD
4. Changes in body composition
   
   • increased fat mass
   • decreased lean body mass
5. Skin changes

Question 9

What is the general consensus on menopausal hormone treatment (MHT)?

Answer 9

MHT is indicated primarily for the relief of vasomotor symptoms and is not indicated for the prevention of chronic disease

Question 10

What are the current indications for MHT?

Answer 10

• Younger symptomatic postmenopausal women less than a decade from final menstrual period and without increased risk for CHD and breast cancer
  
  • Lowest possible effective dose
  • safest route
  • shortest duration for treatment of moderate to severe vasomotor symptoms
  • vaginal dryness
  • osteoporosis prevention and treatment

Question 11

What are the therapeutic effects of combining CEE with Bazedoxifene?

Answer 11

1. relieves VMS and relieves vaginal atrophy
2. blocks bone resorption
   
   • approved for prevention of osteoporosis
3. BZA provides endometrial protection and an alternative to progestogen therapy for women with a uterus who are averse to vaginal bleeding, breast tenderness, or altered mood.
4. No additive risk of VTE than CEE or BZA alone

Question 12

What should be avoided with MHT?

Answer 12

1. Unexplained vaginal bleeding
2. Stroke
3. TIA
4. MI
5. Breast cancer
6. Endometrial cancer
7. Pulmonary emboli
8. VTE
9. Acute liver disease

Question 13

When should you use caution with MHT?

Answer 13

1. Diabetes
2. Hypertriglyceridemia
3. Active gall bladder disease
4. Increased risk of breast cancer
5. Increased risk of CVD
6. Migraine with aura

Question 14

What can be used for isolated GU symptoms?

Answer 14

1. vaginal estrogen
2. ospemifene

Question 15

When can vaginal estrogen be used?

Answer 15

• For isolated vaginal symptoms
  
  • systemic and vaginal estrogens are effective
  • vaginal dryness
  • dyspareunia—given its potent local effect (creams, gels, etc.) and minimal degree of systemic absorption
• Progestin therapy not required with these very low dose vaginal estrogens

Question 16

What is **ospemifene **and when is it used?

Answer 16

SERM taken orally for atrophic vaginitis and dyspareunia

Question 17

What are non-hormonal alternatives for vasomotor symptoms (VMS)?

Answer 17

1. SSRI/SNRI-paroxetine, venlafaxine, etc
2. Gabapentin
3. Clonidine

Question 18

Pearls:

1. Estrogen has important systemic effects affecting the risk of:
2. Estrogen is the most effective treatment for _________ _________
3. Estrogen therapy is safe for:
4. Unopposed estrogen is contraindicated in ….
5. MHT or HRT is not advised in ___________ _______ for disease prevention

Answer 18

1. Estrogen has important systemic effects affecting the risk of:
   
   • cardiovascular disease
   • osteoporosis
   • endometrial and breast cancer
2. Estrogen is the most effective treatment for vasomotor symptoms
3. Estrogen therapy is safe for:
   
   • majority of symptomatic, younger, healthy postmenopausal women
   • short term use for treatment of vasomotor symptoms
   • osteoporosis prevention and treatment
4. Unopposed estrogen is contraindicated in women with a uterus
5. MHT or HRT is not advised in asymptomatic women for disease prevention