Case 4: Susan Weiss

Menopause: Definition

Amenorrhea (12 months) after final menstrual period (FMP)

• Ovarian function loss

Onset: 45-56 years

Menopause: Ovary Changes in Amenorrhea

Decreased ovarian follicles (age) = Decrease estrogen + progesterone = Decrease negative feedback on pituitary gland

• Hypergonadotropic Hypogonadism*: Increase GnRH = Increase FSH/LH

Increase anovulatory cycles

Menopause: Ovary Changes in Vasomotor Symptoms

Low estrogen = Increase norepinephrine + decrease serotonin = Decrease hypothalamus thermoregulation efficacy

• Small temp changes = Big compensatory response

  • Hot flashes

  • Heat intolerance

  • Increased sweating

Menopause: Ovary Changes in GU Symptoms

Low estrogen = Atrophy of…

• Vagina

• Vulva

• Urethra

• Bladder

Vulvovaginal atrophy = Dryness, pruritus, dyspareunia (pain from intercourse)

Lower urinary tract atrophy = Dysuria, incontinence

Menopause: Management

Lifestyle changes

Hormone therapy

Menopause Management: Lifestyle Changes

Vasomotor symptoms

• Diet changes (no caffeine, spicy foods, alcohol)

• Controlling temp (fans, layering clothes)

• Decrease stress

GU symptoms

• Vaginal lubricants + moisturizers

Menopause Management: Hormone Therapy

Systemic:

• No uterus: Estrogen-only

• With uterus: Estrogen + endometrial protection agent (progestin)

Intravaginal:

• Estrogen (Cream, gel capsule, ring)

• DHEA (prasterone)

Menopause Hormone Therapy: Indications

Premature menopause

Severe symptoms

• < 60 years

• Menopause for < 10 years

Menopause Hormone Therapy: Benefits

Symptom relief

Osteoporosis prevention

Menopause Hormone Therapy: Risks

Thromboembolic events

Estrogen-sensitive cancer

Mood swings

Headaches

GI upset

Breakthrough bleeding

Menopause: Complications

CAD + central obesity**

• Estrogen = Decrease cardiovascular risk

• Increase TAG, LDL, weight, HTN

Osteoporosis

• Low estrogen = Decrease bone formation

Postmenopausal Bleeding: Description

Vaginal bleeding ≥ 12 months after FMP (not on hormone therapy)

Postmenopausal Bleeding: Etiology

GU symptoms

• Vaginal dryness + friability

• STIs

Endometrial polyps

Endometrial hyperplasia

Cancer

• Endometrial

• Cervical

Postmenopausal Bleeding: Investigations

Hormone testing

Transvaginal US

Hysteroscopy**

Postmenopausal Bleeding Investigations: Hormone Testing

GU: Increased FSH

Postmenopausal Bleeding Investigations: Transvaginal US

Polyps: Echogenic endometrial mass

Endometrial Hyperplasia/Cancer: Endometrial thickening > 4mm

Postmenopausal Bleeding Investigations: Hysteroscopy

Polyps

Endometrial hyperplasia: + biopsy

Cervical cancer: + biopsy

Postmenopausal Bleeding: Treatment

GU:

• Vaginal moisturizers + lubricants

• Hormone therapy

Polyps:

• Asymptomatic: Monitor

• Polypectomy

Hyperplasia:

• Decrease estrogen → Treat PCOS, obesity

• Progestin + monitoring

• Hysterectomy

Cancer:

• Hysterectomy

• Chemotherapy

• Radiotherapy