{"id":416,"date":"2020-08-13T20:34:50","date_gmt":"2020-08-13T20:34:50","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=416"},"modified":"2020-08-13T20:34:50","modified_gmt":"2020-08-13T20:34:50","slug":"menopause","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/advanced-training\/menopause\/","title":{"rendered":"Menopause"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/-vUulihyQOg\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>Duration 10:04<\/p>\n<input type='hidden' bg_collapse_expand='69e9b5536a62c1041203629' value='69e9b5536a62c1041203629'><input type='hidden' id='bg-show-more-text-69e9b5536a62c1041203629' value='Show Teaching Script'><input type='hidden' id='bg-show-less-text-69e9b5536a62c1041203629' value='Hide Teaching Script'><button id='bg-showmore-action-69e9b5536a62c1041203629' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Teaching Script<\/button><div id='bg-showmore-hidden-69e9b5536a62c1041203629' ><\/p>\n<p><a href=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script_menopause_Page_1.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-2397\" src=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script_menopause_Page_1-791x1024.jpg\" alt=\"\" width=\"525\" height=\"680\" title=\"\"><\/a><\/p>\n<p><a href=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script_menopause_Page_2.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-2398\" src=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script_menopause_Page_2-791x1024.jpg\" alt=\"\" width=\"525\" height=\"680\" title=\"\"><\/a><\/p>\n<p>&nbsp;<\/p>\n<p class=\"p2\">Menopause<\/p>\n<p class=\"p3\">Liang A<\/p>\n<p class=\"p4\"><b>Clinical Cases Applicability: <\/b>menopausal symptoms (hot flashes, atrophy), osteopenia\/osteoporosis, menopausal hormone, premature ovarian insufficiency<\/p>\n<p class=\"p4\"><b>Learning Objectives: <\/b><\/p>\n<p class=\"p4\">1. Understand the physiologic changes in estrogen levels and the hypothalamic-pituitary-ovarian axis in menopause<\/p>\n<p class=\"p4\">2. Describe the pathophysiology of the various symptoms of peri-menopause\/menopause<\/p>\n<p class=\"p4\">3. Discuss treatment options for the symptoms of menopause<\/p>\n<p class=\"p4\"><b>What hormonal changes occur in perimenopause and menopause (defined as 1 year of cessation of menstruation)? How does this affect the HPO axis? <\/b><\/p>\n<p class=\"p4\"><b><i>Perimenopause: <\/i><\/b>Reduced ability of aging follicles to secrete inhibin (produced in granulosa cells of developing follicles) <span class=\"s2\">\uf0e0 <\/span>lack of negative feedback from \u2193inhibin <span class=\"s2\">\uf0e0 <\/span>\u2191FSH<span class=\"s2\">\uf0e0<\/span>\u2191ovarian follicular response<span class=\"s2\">\uf0e0 <\/span>maintain overall estrogen levels<\/p>\n<p class=\"p4\"><b><i>Menopause: <\/i><\/b>Ovarian follicles undergo accelerated loss until depletion of follicles <span class=\"s2\">\uf0e0 <\/span>\u2193ovarian steroid hormone (estrogen, progesterone) release <span class=\"s2\">\uf0e0 <\/span>lack of negative feedback <span class=\"s2\">\uf0e0 <\/span>\u2191 GnRH release<span class=\"s2\">\uf0e0<\/span>\u2191 circulating FSH and LH<\/p>\n<p class=\"p4\"><b>What are common symptoms of menopause? What is the pathophysiology? <\/b><\/p>\n<p class=\"p4\"><b>Abnormal uterine bleeding<\/b>&#8211; increased anovulatory cycles; With \u2191unopposed estrogen levels<span class=\"s2\">\uf0e0 <\/span>increasing risk for developing hyperplasia\/carcinoma<\/p>\n<p class=\"p4\"><b>Vasomotor symptoms (hot flashes<\/b>): occur in up to 80% of women; lasts 1-5 minutes, sudden wave of heat that spreads over the body, particularly the upper body &amp; face; associated with sweating, palpitations, anxiety, sleep disturbance<\/p>\n<p class=\"p5\">&#8211; Dysfunction of the thermoregulatory nucleus of the hypothalamus (regulates perspiration &amp; vasodilatation \u2013nucleus activates heat dissipation mechanisms to maintain core body temperature in a regulated range, \u201cthe thermoregulatory zone\u201d)<\/p>\n<p class=\"p5\">&#8211; women with severe vasomotor symptoms <span class=\"s2\">\uf0e0 <\/span>narrower thermoregulatory zone \u2013 minimal changes in core body temperature induce hot flash <b>(figure 1) <\/b><\/p>\n<p class=\"p4\">&#8211; \u2193estrogen <span class=\"s2\">\uf0e0 <\/span>\u2191norepinephrine &amp; serotonin levels <span class=\"s2\">\uf0e0 <\/span>Norepinephrine &amp; serotonin lower the thermoregulatory set point and triggers the heat loss mechanisms <b>(figure 1) <\/b><\/p>\n<p class=\"p4\"><b>Bone loss: <\/b>Normal bone remodeling\u2013 constant resorption of bone carried out by osteoclasts &amp; bone formation by osteoblasts; Osteoblasts produce proteins RANKL and OPG (osteoprotegerin) <b>(figure 2) <\/b><\/p>\n<p class=\"p5\">&#8211; RANKL binds to RANK \u2013 a receptor on the surface of the osteoclast progenitor cells <span class=\"s3\">\uf0e0 <\/span>promotes development of osteoclasts<span class=\"s2\">\uf0e0 <\/span>leads to bone resorption<\/p>\n<p class=\"p5\">&#8211; OPG binds to RANKL preventing it from binding with RANK<span class=\"s2\">\uf0e0<\/span>decreased osteoclast development<\/p>\n<p class=\"p4\">&#8211; \u2193estrogen <span class=\"s3\">\uf0e0 <\/span>\u2191 RANKL production outnumbers OPG <span class=\"s3\">\uf0e0 <\/span>osteoclast development &amp; bone resorption favored <span class=\"s3\">\uf0e0 <\/span>ongoing bone loss over time<\/p>\n<p class=\"p4\"><b>Cardiovascular disease<\/b>: \u2193 estrogen affects lipid profile, with slightly \u2191 LDL <span class=\"s2\">\uf0e0 <\/span>\u2191 risk for CVD<\/p>\n<p class=\"p4\"><b>Skin changes<\/b>: dryness, wrinkles, thinning; \u2193 collagen content, \u2193sebaceous gland secretion, \u2193 elasticity, \u2193 blood supply<\/p>\n<p class=\"p4\"><b>Vulvovaginal atrophy: <\/b>dryness, itching, dyspareunia; \u2193estrogen results in thinning of the vaginal epithelium; Loss of vaginal collagen, adipose tissue, rugae flatten; pH &gt;4.5 (alkaline); for the vulva, \u2193 sebaceous glands, subcutaneous fat loss <span class=\"s2\">\uf0e0 <\/span>shrinkage &amp; retraction of clitoral prepuce &amp; urethra, introital narrowing<\/p>\n<p class=\"p4\"><b>Urinary symptoms<\/b>: incontinence, urgency, recurrent UTIs; \u2193estrogen <span class=\"s2\">\uf0e0<\/span>thinning of urethral and bladder mucosa, \u2191 risk of incontinence from decreased urethral mucosa coaptation or \u201cseal\u201d<\/p>\n<p class=\"p4\"><b>Depression<\/b>: \u2191 risk of new-onset depression in the menopausal transition; unclear if secondary to \u2193 estrogen or symptoms related to menopause (hot flashes, sleep disturbances, etc)<\/p>\n<p class=\"p4\"><b>What are treatment options? <\/b><\/p>\n<p class=\"p4\">Menopausal hormone therapy: goal is to relieve symptoms, especially vasomotor symptoms; minimal dose for shortest amount of time possible<\/p>\n<p class=\"p4\">-For healthy symptomatic women in their 50s, overall risk for complications is low<\/p>\n<p class=\"p4\">-For women with an intact uterus, progestin therapy must be added to estrogen to prevent endometrial hyperplasia &amp; carcinoma<\/p>\n<p class=\"p4\">&#8211; Risks with estrogen+progestin: \u2191 risk of breast cancer, stroke, coronary heart events, venous thromboembolism<\/p>\n<p class=\"p4\">&#8211; Risks with estrogen only: \u2191 risk of stroke &amp; venous thromboembolism<\/p>\n<p class=\"p4\">Vaginal estrogen: low dose estrogen, minimal systemic absorption, improves urogenital symptoms<\/p>\n<p class=\"p4\">SSRIS\/SNRIs, Clonidine, Gabapentin \u2013 alternatives for hot flashes<\/p>\n<p class=\"p4\">Herbal medications: black cohosh, phyto-estrogens (soy) \u2013inconsistent evidence of efficacy <span class=\"s4\">Liang A <\/span><\/p>\n<p class=\"p4\"><b>Figure 1 <\/b><\/p>\n<p class=\"p4\"><b>Figure 2 <\/b><\/p>\n<p class=\"p4\"><b>References: <\/b><\/p>\n<p class=\"p7\"><b>&#8211; <\/b>Hoffman, BL, Schorge, JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Chapter 21 Menopausal Transition. <i>Williams Gynecology, 3e <\/i>New York, NY: McGraw-Hill; 2016.<\/p>\n<p class=\"p7\">&#8211; Casper, RF. Clinical manifestations and diagnosis of menopause. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2017)<\/p>\n<p class=\"p7\">&#8211; Martin, KA, Barbieri, RL. Treatment of menopausal symptoms with hormone therapy. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2018)<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/3VchFH-PFW4\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 5:16<\/p>\n<input type='hidden' bg_collapse_expand='69e9b5536aaa01041100195' value='69e9b5536aaa01041100195'><input type='hidden' id='bg-show-more-text-69e9b5536aaa01041100195' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b5536aaa01041100195' value='Hide Transcript'><button id='bg-showmore-action-69e9b5536aaa01041100195' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b5536aaa01041100195' ><\/p>\n<p>00:09<br \/>\nI&#8217;m Maureen Leupold. I&#8217;m a retired biology professor. I&#8217;ve been retired<br \/>\n00:14<br \/>\nabout three years and Steve and I will have been married for forty five years<br \/>\n00:19<br \/>\nthis year. We have one daughter and a granddaughter. My daughter was adopted<br \/>\n00:24<br \/>\nfrom Paraguay, so it is approximately 11 years ago I was still teaching and I<br \/>\n00:30<br \/>\nstarted to have an irregular period but then I missed the period for long enough<br \/>\n00:37<br \/>\nto think could I be pregnant? And I mean I&#8217;m in my 50s this is crazy but you know<br \/>\n00:43<br \/>\nI mentioned my daughter was adopted so I&#8217;m in I&#8217;m a parent but I never was<br \/>\n00:46<br \/>\npregnant so how would I know. So I had the test and no I wasn&#8217;t. I was beginning<br \/>\n00:51<br \/>\nmenopause and I laugh now but it wasn&#8217;t funny at the time. Then I started<br \/>\n00:57<br \/>\nwith the hot flashes and you know I think they probably started at night. My<br \/>\n01:01<br \/>\nhusband was getting kind of annoyed because I didn&#8217;t go easy into the hot<br \/>\n01:06<br \/>\nflashes at night I&#8217;d throw the covers off you know and the heat would be up<br \/>\n01:11<br \/>\nand then of course you&#8217;d get chilly and you&#8217;d put him back on but that was when<br \/>\n01:15<br \/>\nI started to try some of the herbal supplements so I think I tried three<br \/>\n01:19<br \/>\ndifferent things like black cohosh and you know a couple of the blends that<br \/>\n01:23<br \/>\nyou&#8217;ll find on the internet and I gave him I gave everybody about a month trial<br \/>\n01:28<br \/>\nto see is it going to work and nothing really worked and the worst of it was<br \/>\n01:32<br \/>\nstanding in front of students and at the time I was you know I was teaching a<br \/>\n01:38<br \/>\nhigh school class on the college campus along with you know the young adults but<br \/>\n01:42<br \/>\nyou know standing in front of a group of teenagers and just have your face turn<br \/>\n01:47<br \/>\nbeet beet red and start to sweat and you know try to carry on it did just it was<br \/>\n01:53<br \/>\ndifficult so I finally went to my physician and requested to go on the<br \/>\n01:59<br \/>\nhormone replacement therapy and I stayed on that for quite a while.<br \/>\n02:03<br \/>\nIt was always standard protocol to warn a woman that there could be some risks<br \/>\n02:08<br \/>\nassociated with going on hormone replacement therapy so I know that I got<br \/>\n02:13<br \/>\nthe standard story about what to be concerned about<br \/>\n02:18<br \/>\non going on that. I went on the hormone replacement therapy in the summertime and<br \/>\n02:24<br \/>\nI was more-or-less getting ready to go back to school in the fall and not have these<br \/>\n02:28<br \/>\nsymptoms and you know by the time school started I was good and it seemed like<br \/>\n02:33<br \/>\nyou know the miracle drug being able to just eliminate hot flashes. It was<br \/>\n02:38<br \/>\namazing. I did try to go off it. I was probably on it maybe five six years and<br \/>\n02:45<br \/>\nI just decided I&#8217;m just going to stop this and I went cold turkey and that was<br \/>\n02:49<br \/>\na very large mistake so I went back on it again.<br \/>\n02:54<br \/>\nIn total, I was on it for eight years. I finally went off of it last summer so it<br \/>\n02:59<br \/>\nwas around July and probably immediately gained about ten pounds you know over<br \/>\n03:05<br \/>\nthe course of a month or two which is very frustrating because I didn&#8217;t really<br \/>\n03:08<br \/>\nchange anything. I&#8217;ve gotten it somewhat under control since but the hot flashes<br \/>\n03:15<br \/>\nstarted up again the hot flashes in the lack of sleep<br \/>\n03:18<br \/>\nthat&#8217;s probably the very worst thing that happens. I really walked into a<br \/>\n03:23<br \/>\ncompletely unprepared you know and in how silly that I thought I could have<br \/>\n03:27<br \/>\nbeen pregnant when it was really the start of menopause you know when you<br \/>\n03:30<br \/>\nthink about it. But it&#8217;s very frustrating that I didn&#8217;t feel like I knew what was<br \/>\n03:37<br \/>\nabout to hit. Even today I want to know is why hasn&#8217;t there been more research<br \/>\n03:42<br \/>\ninto this? I just wonder are there large studies on other ways to help ease the<br \/>\n03:49<br \/>\nsymptoms of menopause especially hot flashes so given that I still have<br \/>\n03:55<br \/>\nsymptoms I&#8217;m still trying various things in order to ease especially the hot<br \/>\n04:00<br \/>\nflashes. I have this little fan blowing on me all night long. Very helpful with<br \/>\n04:05<br \/>\nthe hot flashes. I have a little mister in order to get a little coolness on my<br \/>\n04:13<br \/>\nface. I bought these sports towels and you<br \/>\n04:17<br \/>\nwet this and wring it out and it stays cooler than a normal wash cloth.<br \/>\n04:21<br \/>\nI&#8217;m still trying things over-the-counter to see if there&#8217;s any help to be had.<br \/>\n04:27<br \/>\nMagnesium supplements were one thing. I am currently trying this paradin<br \/>\n04:35<br \/>\nC compound it&#8217;s a vitamin C compound and jury&#8217;s still out on that because I&#8217;ve<br \/>\n04:40<br \/>\nonly started that a couple weeks ago and then some of the other things that I&#8217;ve<br \/>\n04:43<br \/>\ntried over time. In the end I&#8217;m back to where I started in so many ways because<br \/>\n04:49<br \/>\nI still have hot flashes and I&#8217;m very affected by the lack of sleep that they<br \/>\n04:54<br \/>\ncause.<br \/>\n04:59<br \/>\n(Music)<br \/>\n05:02<br \/>\nBlueCross BlueShield is a proud sponsor of Second Opinion<br \/>\n05:06<br \/>\nlive fearless. Second Opinion is produced in conjunction with UR medicine<br \/>\n05:11<br \/>\npart of University of Rochester Medical Center Rochester New York<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\ufeff Duration 10:04 Duration 5:16 &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":160,"menu_order":8,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-416","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/416","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=416"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/416\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=416"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}