Updated: 12/1/2021

Menopause

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  • Snapshot
    • A 52-year-old female presents with a feeling of heat beginning in the face, neck, and chest followed by profuse sweating in the upper body that lasts five minutes.These episodes are happening repetitively throughout the day and disturb her sleep at night. Her last menstrual period was over six months ago.
  • Introduction
    • Permanent cessation of menstruation secondary to
      • oocyte depletion leading to decreased estrogen and progesterone
      • hot flash symptoms a result of declining levels of estradiol-17β
    • Premature menopause is defined by menopause before age 40
    • Post-menopausal women lose the protective effects of estrogen with increased risk for
      • osteoporosis
      • heart disease
  • Epidemiology
    • Mean age in the US is 51
    • Early menopause is associated with cigarette smoking
  • Presentation
    • Symptoms
      • hot flashes and sweats
      • sleep disturbance
      • mood changes and depression
      • vaginal atrophy and dryness
      • dysuria
      • urge incontinence
      • dyspareunia (painful intercourse)
      • osteoporosis
      • menstrual cycle is no longer normal with no premenstrual symptoms
  • Evaluation
    • This is a clinical diagnosis
    • Elevated serum FSH (> 30 mIU/mL)
      • depletion of ovarian follicles leads to a drop in estrogen and results in elevated FSH and LH
    • Androstenedione levels do not change
    • Estrogen levels will be low
      • Majority of estrogen produced by adipose tissue during menopause
    • DEXA scan (at 65 years or older)
      • a T-score of -2.5 or less is significant
        • indicates osteoporosis
        • treatment is recommended
  • Differential
    • Premature ovarian failure
    • Rule out other conditions that can cause amenorrhea
      • pregnancy, thyroid disease, and hyperprolactinemia
  • Treatment
    • Estrogen hormone replacement therapy (HRT)
      • estrogen AND progesterone
        • progesterone needed if uterus is present to avoid endometrial hyperplasia from unopposed estrogen stimulation which can increase risk of malignancy
      • estrogen ONLY therapy
        • if uterus is no longer present (as there is no increased risk due to lack of endometrium)
        • total abdominal hysterectomy with bilateral salpingo-oophorectomy
      • indications for HRT (in a healthy woman < 60 years and no contraindications)
        • vasomotor symptoms
        • mood lability/depression
        • vulvovaginal atrophy
      • benefits of HRT
        • relief of menopause symptoms
        • decrease risk of heart disease and stroke
        • decrease osteoporosis
        • decrease dementia
      • risks of HRT
        • endometrial CA
        • breast CA (controversial)
        • deep venous thrombosis/pulmonary embolism
        • breast pain
      • contraindications of HRT
        • deep venous thrombosis/pulmonary embolism
        • patient at high risk for breast cancer or has breast cancer
          • breast cancer may contain receptors for estrogen and progesterone which can worsen cancer if stimulation by HRT
        • breast pain (due to estrogen stimulation)
        • liver disease (chronic hepatitis)
          • estrogen is metabolized in the liver
      • route of administration
        • topical estrogen used if mainly vaginal symptoms
    • Alternative drugs for vasomotor symptoms
      • SSRIs (paroxetine)
      • SSNRIs
      • clonidine
      • gabapentin
  • Complications
    • Oosteoporosis
    • Coronary artery disease
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(M2.GN.17.71) A 54-year-old G2P2 presents to her gynecologist's office with complaints of frequent hot flashes, malaise, insomnia, and mild mood swings for 2 weeks. She has also noticed some pain with intercourse and vaginal dryness during this time. She is otherwise healthy besides hyperlipidemia, controlled on atorvastatin. She has no other past medical history, but underwent hysterectomy for postpartum hemorrhage. She is desiring of a medication to control her symptoms. Which of the following is the most appropriate short-term medical therapy in this patient for symptomatic relief?

QID: 103362

Hormonal replacement therapy with estrogen alone

52%

(11/21)

Hormonal replacement therapy with combined estrogen/progesterone

33%

(7/21)

Hormonal replacement therapy with progesterone alone

10%

(2/21)

Paroxetine

5%

(1/21)

Gabapentin

0%

(0/21)

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