Updated: 12/11/2019

Menopause

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Questions
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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
  • Epidemiology
    • mean age in the US is 51
    • early menopause is associated with cigarette smoking
  • 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
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
Prognosis, Prevention, and Complications
  • Complications
    • osteoporosis
    • coronary artery disease
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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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? Review Topic | Tested Concept

QID: 103362
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Hormonal replacement therapy with estrogen alone

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Hormonal replacement therapy with combined estrogen/progesterone

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Hormonal replacement therapy with progesterone alone

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Paroxetine

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Gabapentin

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