Transcript MENOPAUSE QUIZ

MENOPAUSE QUIZ
1
Dr Mona Shroff
www.obgyntoday.info
2
 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
Dr Mona Shroff
www.obgyntoday.info
3
R
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D
Dr Mona Shroff
HISTORY / FAMOUS
PERSONALITIES
www.obgyntoday.info
TEAM A
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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.
Dr Mona Shroff
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ALOIS ALZHEIMER
5
Dr Mona Shroff
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TEAM B
6
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.
Dr Mona Shroff
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FULLER ALBRIGHT
7
Dr Mona Shroff
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TEAM C
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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
Dr Mona Shroff
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PROFESSOR HERBERT FLEISCH
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Dr Mona Shroff
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TEAM D
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•Associate Dean for Ethics,
David Geffen School of
Medicine at UCLA
•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.
•Proposed the “estrogen window”
hypothesis for carcinogenesis of
breast carcinoma.
Dr Mona Shroff
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PROF. S.G. KORENMAN
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Dr Mona Shroff
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TEAM E
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American biochemist. He received the
Nobel Prize in Physiology or Medicine
in 1943
In 1929-1930 he succeeded in
isolating oestrone, a feat
independently accomplished at about
the same time by Butenandt in
Germany.
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
Dr Mona Shroff
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EDWARD DOISY
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Dr Mona Shroff
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ROUND 2
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PHYSIOLOGY
Dr Mona Shroff
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TEAM A
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 What causes A menopausal woman to
have
1.
Hirsutism?
2.
Decreased libido?

What is free testosterone index ?
What does it indicate
Dr Mona Shroff
www.obgyntoday.info
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 Hirsutism - altered androgen : estrogen
ratio
Reduced libido – decreased
testosterone
 Ratio of total testosterone to SHBG.
If <25% of premenopausal value:
indicates androgen insufficiency
Dr Mona Shroff
www.obgyntoday.info
TEAM B
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Out of LH & FSH what
rises more in menopause &
why?
What is the only marker of
perimenopausal transition?
Dr Mona Shroff
www.obgyntoday.info
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 FSH rise(> 10 times) more
compared to LH rise (3 times)
due to shorter half life of LH .
 Menstrual irregularity
Dr Mona Shroff
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TEAM C
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 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
Dr Mona Shroff
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 Shortening in early perimenopause
due to rising FSH –faster follicular
maturation – shortened follicular
phase.Later more anovulatory
cycles-irregular,delayed.
 1000 follicles
Dr Mona Shroff
www.obgyntoday.info
TEAM D
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 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?
Dr Mona Shroff
www.obgyntoday.info
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 Reduced
inhibin secretion from
follicles – feedback on FSH
levels.
 45-60 microgm/24 hrs
Dr Mona Shroff
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TEAM E
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 Mention 2 other
causes of hot
flushes.
 Name 3 drugs
useful in
treatment of hot
flushes besides
HRT.
Dr Mona Shroff
www.obgyntoday.info
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 Thyroid abnormalities,leukemia,
Carcinoid,pheochromocytoma,pancreatic
tumor.
 Tibolone,transdermal
clonidine,gabapantene,venlafexine
Dr Mona Shroff
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TEAM F
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 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
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 As the ovary fails, it continues to produce
testosterone and perhaps in increased
amounts…for 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
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R
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Dr Mona Shroff
PHARMACOLOGY
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TEAM A
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 When can a woman who is on
OCPills for contraception,be
shifted to HRT if necessary?
Dr Mona Shroff
www.obgyntoday.info
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 When FSH on D6-D7 of pill
free week is high.(>20)
 If in mid fifties can change
directly.
Dr Mona Shroff
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TEAM B
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NAME 4 SERMS .WHICH
OF THE SERMS COMES
NEAREST TO THE IDEAL
SERM.
Dr Mona Shroff
www.obgyntoday.info
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 Clomiphene
 Tamoxifen
 Toremifene
 Droloxifene
 Iodoxifene
 Raloxifene
 Ormeloxifene-NEAREST TO IDEAL
Dr Mona Shroff
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TEAM C
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 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?
Dr Mona Shroff
www.obgyntoday.info
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 stroke
 blood clots
 invasive breast
cancer
 heart disease
and heart
attacks
Dr Mona Shroff
www.obgyntoday.info
TEAM D
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 Why is the max duration for
which teriparatide can be used
for Rx of late postmenopausal
osteoporosis?
 Why?
Dr Mona Shroff
www.obgyntoday.info
35
 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 µg
dose)
 Long-term use (>2 years) is not recommended
 Transient orthostatic hypotension (infrequent)
Dr Mona Shroff
www.obgyntoday.info
TEAM E
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 What are the implications of
progesterone challenge test in
menopausal women?
Dr Mona Shroff
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37
 If NEGATINE : No estrogen
primed endometrium hence
reassuring
 If POSITIVE : May have
proliferative , Hyperplastic or
Neoplastic endometrium
Dr Mona Shroff
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TEAM F
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What is a tissue selective
estrogen complex?
Dr Mona Shroff
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 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
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R
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D
Dr Mona Shroff
4
OSTEOPOROSIS
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TEAM A
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 WHAT ARE
THE CRITERIA
FOR A
MENOPAUSAL
WOMAN TO
UNDERGO BMD
TESTING?
Dr Mona Shroff
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42
 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.
Dr Mona Shroff
www.obgyntoday.info
TEAM B
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 On BMD testing
when will a
woman be
diagnosed as
having
osteopenia &
osteoporosis?
Dr Mona Shroff
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44
 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)
Dr Mona Shroff
www.obgyntoday.info
TEAM C
 What are the
45
criteria for
starting
pharmacotherapy
for treatment of
postmenopausal
bone loss?
Dr Mona Shroff
www.obgyntoday.info
46
 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).
Dr Mona Shroff
www.obgyntoday.info
TEAM D
 Name 2 drugs
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each,recommen
ded for primary
prevention &
secondary
prevention of
postmenopausal
osteoporosis.
Dr Mona Shroff
www.obgyntoday.info
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 PRIMARY PREVENTION
1. HRT
2. SERMS
3. TIBOLONE
4. Biophosphonates(vertebral#)
SECONDARY PREVENTION
1. Biophosphonates
2. Calcitonin (>5 yrs menopause)
3. Teriparatide

Dr Mona Shroff
www.obgyntoday.info
TEAM E
 Give one example
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each of cortical
bone & trabecular
bone.
 Which are the most
comman sites for
compression
vertebral fractures
in menopause?
Dr Mona Shroff
www.obgyntoday.info
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 Cortical : all perepheral bones
Trabecular : spine,pelvis,proximal
femur
 D 12, L1-2-3
Dr Mona Shroff
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TEAM F
 Mention 2 ways by
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which estrogen
prevents
osteoporosis?
 What is the
simplest way to
assess adequacy of
estrogen therapy?
Dr Mona Shroff
www.obgyntoday.info
52
 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
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R
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Dr Mona Shroff
CANCERS
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TEAM A
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 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
Dr Mona Shroff
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1. Continuous combined
2. Sequential E-P
3. Estrogen only
Dr Mona Shroff
www.obgyntoday.info
TEAM B
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 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
Dr Mona Shroff
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1. Estrogen only
2. Sequential
E-P
3. Continuous
combined(>4
yrs)
Dr Mona Shroff
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TEAM C
 When would
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endometrial
evaluation be
called for in a
woman on
HRT?
Dr Mona Shroff
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59
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.
Dr Mona Shroff
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TEAM D
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 Name one cancer with
probabale increased risk
with HRT,( other than Ca
breast & endometrium ) and one
with probable decreased risk
with HRT.
Dr Mona Shroff
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 Probable
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increased risk
: Ca ovary
 Probable
decreased risk
: Ca colon
Dr Mona Shroff
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TEAM E
 When do you do
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mammography on a
patient aged 53 yrs
on combined HRT?
 What is the effect
of raloxiphene on
breast?
Dr Mona Shroff
www.obgyntoday.info
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 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
TEAM F
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 What is the lowest dose of
progesterone that is endometrium
protective
Sequential ?
Continuous combined ?
Dr Mona Shroff
www.obgyntoday.info
65
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
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R
O
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N
D
Dr Mona Shroff
VISUAL ROUND
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TEAM A
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Dr Mona Shroff
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 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
69
 20 micgm LNG /d
 Transdermal progesterone does not
protect against endometrial
hyperplasia.
Dr Mona Shroff
www.obgyntoday.info
TEAM B
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Dr Mona Shroff
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71
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
72
 No effect on uterus & bone ,protective on
breast.
 Daidzein, an isoflavone phytoestrogen found in
soy, is metabolized to equol and Odesmethylangolensin (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
TEAM C
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Dr Mona Shroff
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 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
75
 Estring : 7.5 mic gm/d
 Femring : 50-100 mic gm /d
 Femring needs progesterone for
endometrial protection.
Dr Mona Shroff
www.obgyntoday.info
TEAM D
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Dr Mona Shroff
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77
• 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
78
 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
TEAM E
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Dr Mona Shroff
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 Which year was it launched?
 Which day of year is the world
menopause day celebrated?
Dr Mona Shroff
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81
 The Indian Menopause Society was
launched in 1995.
 18 october
Dr Mona Shroff
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R
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N
D
Dr Mona Shroff
CARDIOVASCULAR &
GENITOURINARY ISSUES
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TEAM A
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 What were the results of the
HERS 1&2 trials of HRT on
CVS?
Dr Mona Shroff
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84
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
Dr Mona Shroff
www.obgyntoday.info
TEAM B
85
 What is the
effect of
Tibolone on
CVS?
Dr Mona Shroff
www.obgyntoday.info
86
 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
Dr Mona Shroff
www.obgyntoday.info
TEAM C
 Name an agent of
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choice for Rx of
overactive
bladder in a
menopausal
woman.(from
currently
available
preparations)
Dr Mona Shroff
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88
 Tolterodine ER
Dr Mona Shroff
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TEAM D
 How
much
postvoid
residual volumes
indicate urinary
retention in
menopausal
women?
Dr Mona Shroff
89
www.obgyntoday.info
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 Postvoid residual volumes
greater than 200 mL indicate
urinary retention in elderly
women.
Dr Mona Shroff
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TEAM E
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Name 3 drugs useful for
menopausal vaginal atrophy .
Dr Mona Shroff
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92
 Local low dose estradiol
 Oral E
 Tibolone
Dr Mona Shroff
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TEAM F
93
Name 2 conditions where
transdermal E is preferable
where oral route is
contraindicated.
Dr Mona Shroff
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94
Migraine
Liver ds.
Crohns ds
Dr Mona Shroff
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ROUND 8
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MENTAL / PUBLIC
HEALTH ISSUES & MISC.
Dr Mona Shroff
www.obgyntoday.info
TEAM A
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 How does HRT act on the
nervous system?
 When & how long should it be
given for benefit.
Dr Mona Shroff
www.obgyntoday.info
97
 Neuroprotection:
It reduces the risk of Alzheimer’s 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 Parkinson’s disease by its
action on dopaminergic system in midbrain
 Start v.early in menopause & for at least 10 yrs

Dr Mona Shroff
www.obgyntoday.info
TEAM B
98
NAME 3
TESTS YOU
WOULD
ADVISE FOR A
WOMAN WITH
PREMATURE
MENOPAUSE?
Dr Mona Shroff
www.obgyntoday.info
LABORATORY EVALUATION OF PREMATURE
OVARIAN FAILURE
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
 FSH (to establish the diagnosis of premature ovarian







failure)
Karyotype (<30 yr of age or sexual infantilism)
Cortisol after ACTH stimulation, antiadrenal
antibodies (adrenal insufficiency)
TSH, antithyroid antibodies (hypothyroidism)
Glucose (fasting and 2 hr after 75-g glucose load,
diabetes mellitus)
Calcium and phosphorus (hypoparathyroidism)
Sedimentation rate, complete blood count with
differential, antinuclear antibody, rheumatoid factor
(autoimmune disease)
Pregnenolone (to evaluate 17-hydroxylase deficiency
in sexually infantile women)
Dr Mona Shroff
www.obgyntoday.info
TEAM C
100
 Name 2 syndromes associated with
premature menopause.
 When would you start HRT in these
cases?
Dr Mona Shroff
www.obgyntoday.info
101
 Turners syndrome : late HRT
 Swyers syndrome : early HRT
Dr Mona Shroff
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TEAM D
102
 Which gene mutation has been
identified with premature
menopause & blepharophimosis
(drooping eyelids)?
 What does the word
“menopause” & “climacteric”
mean?
Dr Mona Shroff
www.obgyntoday.info
103
 FOX L 2 GENE MUTATION
 Men = month, pauses = stop
 Climacteric = ladder
(GREEK)
Dr Mona Shroff
www.obgyntoday.info
TEAM E
104
 What is the
average age
of menopause
in Western
countries & in
India?
Dr Mona Shroff
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105
 Avg age of menopause in India
is 48 as compared to west
where it is 51.
Dr Mona Shroff
www.obgyntoday.info
TEAM F
 What is a
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rectangular
society ?
 Which countries
have a near
perfect
rectangular
societies
Dr Mona Shroff
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107
 A society in which nearly all
individuals survive to an advanced
age & then succumb over a narrow
age range nearing 85 yrs
 SWEDEN & SWITZERLAND
Dr Mona Shroff
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THANK YOU
108
Dr Mona Shroff
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