MENOPAUSE QUIZ 1 Dr Mona Shroff .

MENOPAUSE QUIZ 1 Dr Mona Shroff www.obgyntoday.info

Round 1 History / Famous Personalities Round 2 Physiology of menopause Round 3 Pharmacology Round 4 Osteoporosis Round 5 Cancer Round 6 VISUAL ROUND Round 7 Cardiovascular & Genitourinary issues Round 8 Mental health & Public Health issues 2 Dr Mona Shroff www.obgyntoday.info

HISTORY / FAMOUS PERSONALITIES R O U 1 N D 3 Dr Mona Shroff www.obgyntoday.info

TEAM A 1.BORN ON JUNE 14 1864 IN GERMANY. 2.HIS FIRST NAME WAS ALOIS. 3.NEUROPATHOLOGIST & PSYCHIATRIST WHO ALONG WITH FRANS NISSL EXTENSIVELY STUDIED THE NORMAL AND PATHOLOGICAL ANATOMY OF CEREBRAL CORTEX. 4 Dr Mona Shroff www.obgyntoday.info

ALOIS ALZHEIMER 5 Dr Mona Shroff www.obgyntoday.info

TEAM B 1.American endocrinologist born on 12 jan 1900. 2.Extensively studied pathophysiology of parathyroid & gave distinction b/w osteoporosis & disorders of calcium metabolism. 3.Pioneer of replacement therapy for menopause & birth control by hormone therapy & has multiple syndromes named after him. 6 Dr Mona Shroff www.obgyntoday.info

FULLER ALBRIGHT 7 Dr Mona Shroff www.obgyntoday.info

TEAM C 1.Born in lausanne, switzerland in 1933, passed away on 15 may 2007. 2.Instrumental in the creation of the european foundation for osteoporosis in 1987, which became the international osteoporosis foundation in 1998. 3.Pioneering work led to the discovery of a new class of therapeutic agents, the bisphosphonates 8 Dr Mona Shroff www.obgyntoday.info

PROFESSOR HERBERT FLEISCH 9 Dr Mona Shroff www.obgyntoday.info

TEAM D Major areas of research interest. Polycystic Ovary Disorder (PCOS), long-term effects of treatment with growth hormone of growth hormone-deficient persons,research ethics besides longstanding interests in the hormone changes occurring with aging in both men and women. Associate Dean for Ethics, David Geffen School of Medicine at UCLA Proposed the estrogen window hypothesis for carcinogenesis of breast carcinoma. 10 Dr Mona Shroff www.obgyntoday.info

PROF. S.G. KORENMAN 11 Dr Mona Shroff www.obgyntoday.info

TEAM E Dr Mona Shroff www.obgyntoday.info 12 In 1929-1930 he succeeded in isolating oestrone, a feat independently accomplished at about the same time by Butenandt in Germany.Butenandt AmericanAmerican biochemist. He received the Nobel Prize in Physiology or Medicine in 1943biochemist Nobel Prize in Physiology or Medicine Worked with biologist Edgar Allen to study the ovarian systems of rats and mice. He later isolated two other related products, oestriol and oestradiol-17

EDWARD DOISY Dr Mona Shroff www.obgyntoday.info 13

ROUND 2 PHYSIOLOGY 14 Dr Mona Shroff www.obgyntoday.info

TEAM A What causes A menopausal woman to have 1. Hirsutism? 2. Decreased libido? What is free testosterone index ? What does it indicate 15 Dr Mona Shroff www.obgyntoday.info

Hirsutism - altered androgen : estrogen ratio Reduced libido decreased testosterone Ratio of total testosterone to SHBG. If

FSH rise(> 10 times) more compared to LH rise (3 times) due to shorter half life of LH. Menstrual irregularity 18 Dr Mona Shroff www.obgyntoday.info

TEAM C What leads to shortening of menstrual cycle in perimenopause & thereafter irregular cycles near menopause ? What is the critical threshold of follicles below which menopause occurs regardless of age 19 Dr Mona Shroff www.obgyntoday.info

Shortening in early perimenopause due to rising FSH faster follicular maturation shortened follicular phase.Later more anovulatory cycles-irregular,delayed. 1000 follicles 20 Dr Mona Shroff www.obgyntoday.info

TEAM D How do you explain the rise in fsh levels in perimenopausal transition inspite of normal to slightly raised estradiol levels? What is the average postmenopausal estrogen production rate? 21 Dr Mona Shroff www.obgyntoday.info

Reduced inhibin secretion from follicles feedback on FSH levels. 45-60 microgm/24 hrs 22 Dr Mona Shroff www.obgyntoday.info

TEAM E Mention 2 other causes of hot flushes. Name 3 drugs useful in treatment of hot flushes besides HRT. Dr Mona Shroff www.obgyntoday.info 23

Thyroid abnormalities,leukemia, Carcinoid,pheochromocytoma,pancreatic tumor. Tibolone,transdermal clonidine,gabapantene,venlafexine Dr Mona Shroff www.obgyntoday.info 24

TEAM F What does the term continuation of ovarian function postmenopausally refer to? What is the avg weight & volume of a postmenopausal ovary? Dr Mona Shroff www.obgyntoday.info 25

As the ovary fails, it continues to produce testosterone and perhaps in increased amountsfor a variable number of years. This is the so called continuation of ovarian function postmenopausally. i.e. progressive androgenisation Wt. < 10 gms Vol. < 8 cucc. Dr Mona Shroff www.obgyntoday.info 26

PHARMACOLOGY R O U 3 N D 27 Dr Mona Shroff www.obgyntoday.info

TEAM A When can a woman who is on OCPills for contraception,be shifted to HRT if necessary? 28 Dr Mona Shroff www.obgyntoday.info

When FSH on D6-D7 of pill free week is high.(>20) If in mid fifties can change directly. 29 Dr Mona Shroff www.obgyntoday.info

TEAM B NAME 4 SERMS.WHICH OF THE SERMS COMES NEAREST TO THE IDEAL SERM. 30 Dr Mona Shroff www.obgyntoday.info

- Clomiphene Tamoxifen Toremifene Droloxifene Iodoxifene Raloxifene Ormeloxifene-NEAREST TO IDEAL 31 Dr Mona Shroff www.obgyntoday.info

TEAM C The U.S. Food and Drug Administration is now requiring that a new, highlighted (boxed) warning be placed on all estrogen products for use by postmenopausal women. The warning highlights the increased risk for which diseases? 32 Dr Mona Shroff www.obgyntoday.info

stroke blood clots invasive breast cancer heart disease and heart attacks Dr Mona Shroff www.obgyntoday.info 33

TEAM D Why is the max duration for which teriparatide can be used for Rx of late postmenopausal osteoporosis? Why? 34 Dr Mona Shroff www.obgyntoday.info

In male and female rats, teriparatide caused an increased incidence of osteosarcoma that was dependent on dose and treatment duration. (In rats, osteosarcoma was seen at doses 3 to 60 times the human exposure following a 20 g dose) Long-term use (>2 years) is not recommended Transient orthostatic hypotension (infrequent) 35 Dr Mona Shroff www.obgyntoday.info

TEAM E What are the implications of progesterone challenge test in menopausal women? Dr Mona Shroff www.obgyntoday.info 36

If NEGATINE : No estrogen primed endometrium hence reassuring If POSITIVE : May have proliferative, Hyperplastic or Neoplastic endometrium Dr Mona Shroff www.obgyntoday.info 37

TEAM F What is a tissue selective estrogen complex? Dr Mona Shroff www.obgyntoday.info 38

A TSEC is the partnering of a SERM and other estrogens to achieve clinical results based on their blended tissue selective activity profiles. One option for a TSEC is the pairing of a SERM(Bazedoxifene) with CEE. Dr Mona Shroff www.obgyntoday.info 39

OSTEOPOROSIS R O U 4 N D 40 Dr Mona Shroff www.obgyntoday.info

TEAM A WHAT ARE THE CRITERIA FOR A MENOPAUSAL WOMAN TO UNDERGO BMD TESTING? Dr Mona Shroff www.obgyntoday.info 41

All women aged 65 years or older, regardless of other risk factors for osteoporosis. Postmenopausal women younger than 65 years with 1 or more risk factors for osteoporosis (other than being white, postmenopausal, and female). All postmenopausal women who have had a fragility fracture. 42 Dr Mona Shroff www.obgyntoday.info

TEAM B On BMD testing when will a woman be diagnosed as having osteopenia & osteoporosis ? Dr Mona Shroff www.obgyntoday.info 43

Normal BMD : T-score is 1.0 or above (no lower than 1.0 SD below the BMD norm for young normal women). Osteopenia : T-scores between 1.0 and 2.5 SDs (between 1.0 and 2.5 SDs below that of young normal women). Osteoporosis : T-score is 2.5 or lower (at least 2.5 SDs lower than the norm for young normal women) 44 Dr Mona Shroff www.obgyntoday.info

TEAM C What are the criteria for starting pharmacotherapy for treatment of postmenopausal bone loss? Dr Mona Shroff www.obgyntoday.info 45

T-scores below 2.0 by central DXA with no risk factors, T-scores below 1.5 by central DXA with 1 or more risk factors, Prior fragility fractures. Some authorities,including the World Health Organization, designate an intervention threshold T-score of 2.5 SDs.(if no risk factors). 46 Dr Mona Shroff www.obgyntoday.info

TEAM D Name 2 drugs each,recommen ded for primary prevention & secondary prevention of postmenopausal osteoporosis. Dr Mona Shroff www.obgyntoday.info 47

PRIMARY PREVENTION 1. HRT 2. SERMS 3. TIBOLONE 4. Biophosphonates(vertebral#) SECONDARY PREVENTION 1. Biophosphonates 2. Calcitonin (>5 yrs menopause) 3. Teriparatide 48 Dr Mona Shroff www.obgyntoday.info

TEAM E Give one example each of cortical bone & trabecular bone. Which are the most comman sites for compression vertebral fractures in menopause? Dr Mona Shroff www.obgyntoday.info 49

Cortical : all perepheral bones Trabecular : spine,pelvis,proximal femur D 12, L1-2-3 Dr Mona Shroff www.obgyntoday.info 50

TEAM F Mention 2 ways by which estrogen prevents osteoporosis? What is the simplest way to assess adequacy of estrogen therapy? Dr Mona Shroff www.obgyntoday.info 51

Maintains balance b/w osteoblastic & osteoclastic activity(decrease osteoclastic activity) Increases Vit D receptors in osteoblasts modulates Vit D activity. Aseess vaginal wall pH,if < 4.5 ; E therapy adequate Dr Mona Shroff www.obgyntoday.info 52

CANCERS R O U 5 N D 53 Dr Mona Shroff www.obgyntoday.info

TEAM A Arrange the following HRT regimens in increasing order of association with risk of endometrial cancer? 1. Estrogen only 2. Sequential E-P 3. Continuous combined 54 Dr Mona Shroff www.obgyntoday.info

1. Continuous combined 2. Sequential E-P 3. Estrogen only 55 Dr Mona Shroff www.obgyntoday.info

TEAM B Arrange the following HRT regimens in increasing order of association with risk of Breast cancer? 1. Estrogen only 2. Sequential E-P 3. Continuous combined 56 Dr Mona Shroff www.obgyntoday.info

1. Estrogen only 2. Sequential E-P 3. Continuous combined(>4 yrs) Dr Mona Shroff www.obgyntoday.info 57

TEAM C When would endometrial evaluation be called for in a woman on HRT? Dr Mona Shroff www.obgyntoday.info 58

Endometrial evaluation is called for when : (any menopausal woman not taking HRT develops uterine bleeding after more than 1 year of amenorrhea. ) any postmenopausal woman on HRT for 6 months or more with persistent uterine bleeding. and any previously amenorrheic woman on HRT who begins bleeding without apparent cause. 59 Dr Mona Shroff www.obgyntoday.info

TEAM D Name one cancer with probabale increased risk with HRT,( other than Ca breast & endometrium ) and one with probable decreased risk with HRT. 60 Dr Mona Shroff www.obgyntoday.info

Probable increased risk : Ca ovary Probable decreased risk : Ca colon Dr Mona Shroff www.obgyntoday.info 61

TEAM E When do you do mammography on a patient aged 53 yrs on combined HRT? What is the effect of raloxiphene on breast? Dr Mona Shroff www.obgyntoday.info 62

After stopping HRT for 2 wks since HRT causes increase in breast density. Raloxiphene--No change in breast density. Dr Mona Shroff www.obgyntoday.info 63

TEAM F What is the lowest dose of progesterone that is endometrium protective Sequential ? Continuous combined ? Dr Mona Shroff www.obgyntoday.info 64

Not well established but from current literature Sequential MPA : 5-10 mg/d for 12-14 d Combined MPA : 1.5 -2.5 mg/d Dr Mona Shroff www.obgyntoday.info 65

VISUAL ROUND R O U 6 N D 66 Dr Mona Shroff www.obgyntoday.info

TEAM A Dr Mona Shroff www.obgyntoday.info 67

How much progesterone does it release daily? What is the difference between LNG IUS & transdermal progesterone on endometrial hyperplasia? Dr Mona Shroff www.obgyntoday.info 68

20 micgm LNG /d Transdermal progesterone does not protect against endometrial hyperplasia. Dr Mona Shroff www.obgyntoday.info 69

TEAM B Dr Mona Shroff www.obgyntoday.info 70

The soy compounds are called genistein, daidzein, and glycitein Mention the effects of phytoestrogens on Uterus Breast bones What is EQUOL? Dr Mona Shroff www.obgyntoday.info 71

No effect on uterus & bone,protective on breast. Daidzein, an isoflavone phytoestrogen found in soy, is metabolized to equol and O- desmethylangolensin (O-DMA) by intestinal bacteria.Approximately 30%-50% of the human population produce equol-weak estrogen with modest effects on endpoints regulated by estrogen receptor alpha. Dr Mona Shroff www.obgyntoday.info 72

TEAM C Dr Mona Shroff www.obgyntoday.info 73

How much estradiol does estring release? How much estradiol does femring release? What is the difference between their use? Dr Mona Shroff www.obgyntoday.info 74

Estring : 7.5 mic gm/d Femring : 50-100 mic gm /d Femring needs progesterone for endometrial protection. Dr Mona Shroff www.obgyntoday.info 75

TEAM D Dr Mona Shroff www.obgyntoday.info 76

What does the chart represent? In the late reproductive stage (stage -3),what happens to the E2 level in the early follicular phase? Dr Mona Shroff www.obgyntoday.info 77

Stages of reproductive aging. In the late reproductive stage (stage - 3), E2 level in the early follicular phase is either normal or elevated An E2 level 80 pg/ml is often considered to be elevated. Dr Mona Shroff www.obgyntoday.info 78

TEAM E Dr Mona Shroff www.obgyntoday.info 79

Which year was it launched? Which day of year is the world menopause day celebrated? Dr Mona Shroff www.obgyntoday.info 80

The Indian Menopause Society was launched in 1995. 18 october Dr Mona Shroff www.obgyntoday.info 81

CARDIOVASCULAR & GENITOURINARY ISSUES R O U 7 N D 82 Dr Mona Shroff www.obgyntoday.info

TEAM A What were the results of the HERS 1&2 trials of HRT on CVS? 83 Dr Mona Shroff www.obgyntoday.info

HERS II trial results confirm the initial findings of HERS I increased risk of coronary events in the early years of treatment increase in thromboembolic events in the HRT group compared with placebo mainly seen in the first year of use 84 Dr Mona Shroff www.obgyntoday.info

TEAM B What is the effect of Tibolone on CVS? Dr Mona Shroff www.obgyntoday.info 85

Tibolone increases cardiac output, blood flow in capillaries, & has no effect on blood pressure. In vivo models showed prevention of atherosclerosis (Direct anti-atherogenic effect by inhibiting leukocyte adhesion molecule action) It decreases triglycerides & lipoproteins.It has transient lowering effect on HDL levels but it normalizes with long term use 86 Dr Mona Shroff www.obgyntoday.info

TEAM C Name an agent of choice for Rx of overactive bladder in a menopausal woman.(from currently available preparations) Dr Mona Shroff www.obgyntoday.info 87

Tolterodine ER 88 Dr Mona Shroff www.obgyntoday.info

TEAM D How much postvoid residual volumes indicate urinary retention in menopausal women? Dr Mona Shroff www.obgyntoday.info 89

Postvoid residual volumes greater than 200 mL indicate urinary retention in elderly women. 90 Dr Mona Shroff www.obgyntoday.info

TEAM E Name 3 drugs useful for menopausal vaginal atrophy. Dr Mona Shroff www.obgyntoday.info 91

Local low dose estradiol Oral E Tibolone Dr Mona Shroff www.obgyntoday.info 92

TEAM F Name 2 conditions where transdermal E is preferable where oral route is contraindicated. Dr Mona Shroff www.obgyntoday.info 93

Migraine Liver ds. Crohns ds Dr Mona Shroff www.obgyntoday.info 94

ROUND 8 MENTAL / PUBLIC HEALTH ISSUES & MISC. 95 Dr Mona Shroff www.obgyntoday.info

TEAM A How does HRT act on the nervous system? When & how long should it be given for benefit. 96 Dr Mona Shroff www.obgyntoday.info

Neuroprotection: It reduces the risk of Alzheimers disease by reducing b amyloid protein & cholinergic dysfunction in brain. It enhances the proliferation of neuronal cell population within the hippocampus. It regulates the synaptic neurotransmission & increases nerve growth factor. Thus it enhances neuroplasticity, memory, and cognition. It delays the onset of Parkinsons disease by its action on dopaminergic system in midbrain Start v.early in menopause & for at least 10 yrs 97 Dr Mona Shroff www.obgyntoday.info

TEAM B NAME 3 TESTS YOU WOULD ADVISE FOR A WOMAN WITH PREMATURE MENOPAUSE ? Dr Mona Shroff www.obgyntoday.info 98

LABORATORY EVALUATION OF PREMATURE OVARIAN FAILURE FSH (to establish the diagnosis of premature ovarian failure) Karyotype (

MENOPAUSE QUIZ 1 Dr Mona Shroff .

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