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40 Cards in this Set
- Front
- Back
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Menopause
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“Menopause is defined as an age-related reduction in ovarian function with end of fertility and menstrual cycle. “
30 Million American Women All age groups “Biologic menopause if defined as the natural failure of the ovaries after age 40-45, resulting in absence of fertility and >12 months without menses.” |
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Etiology of Menopause
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The ovary is less responsive to FSH which causes pituitary to increase production. This leads to inconsistent ovulation.
Fluctuation in estrogen levels creates menstrual cycle changes, hot flashes, and sweats, sleep disturbances, fatigue, irritability, PMS, mood changes, vaginal dryness, and urinary complaints. |
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ADVERSE POSTMENOPAUSAL CHANGES
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Increased bone resorption and decreased bone formation
Rise in total cholesterol, LDL, and VLDL. HDL declines but triglycerides show no change Diminished bladder control Reduced fertility |
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POSITIVE POSTMENOPAUSAL CHANGES
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Reduction in myomas, endometriosis, adenomyosis
Gradual decrease in PMS-type symptoms Reduced fertility |
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DEMOGRAPHICS of Menopause
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Average age at perimenopause is 47 years which lasts about 3.5 years
About 95% reach menopause at 45-55 years but average is 51 years of age About 10% of women will have an abrupt cessation of menses, but 90% experience fluxuation of their cycle prior to cessation of menses. |
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RISK FACTORS FOR PREMATURE MENOPAUSE
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Turner syndrome
Autoimmune endocrinopathy Severe systemic illness Chemotherapy and radiation Possible familial components |
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ASSESSMENT of menopause
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Obtain complete medical, GYN, and menstrual history. Ask about contraceptive use, medications, and family history of menopause.
Associated symptoms Mood changes Disrupted sleep patterns Hot flashes Vaginal dryness, Vaginal bleeding not related to menses |
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PHYSICAL EXAM of menopause
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Complete physical exam including:
Breast exam Pelvic exam (ovaries become smaller and may not be detectable). Rectovaginal exam and stool for occult blood for 50 y/o and over. |
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DIFFERENTIAL DIAGNOSIS and DIAGNOSTIC TESTS
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Pregnancy (order pregnancy test)
Depression Thyroid and/or other endocrine disorders (order TSH PMS May consider ordering FSH and serum estrogen to help with diagnosis. |
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HORMONE REPLACEMENT THERAPY
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non pharmachologic
pharmacologic treatment |
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MANAGEMENT
NON Pharmacologic treatment |
exercise acupunture weight management
relaxation smoking cessation soy well balanced diet red clover avoid spicy foods black cohosh yoga limit alcohol layered clothing limit caffeine kegel vaginal lubricants |
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MANAGEMENT
NON Pharmacologic treatment cont'd |
Soy
may be helpful in the short-term (≤2 years) treatment of vasomotor symptoms. possibility interact with estrogen, use cautiously in women with estrogen-dependent cancers. if take over prolonged periods may improve lipoprotein profiles and protect against osteoporosis St. John's wort may be helpful in the short-term (≤2 years) treatment of mild to moderate depression in women. Dong quai Evening primrose oil |
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NATIONAL INSTITUTE OF HEATLH
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Black cohosh (Estroven, Remifemin)
may be helpful in the short-term (≤6 months) treatment of women with vasomotor symptoms. NIH study trialing black cohosh, soy products, red clover and vitamin E were reported to be no better than placebo for the relief of hot flashes. (Black cohosh is contraindicated in women with aspirin sensitivity because it contains salicylates.) |
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Pharmacotherapy-HT
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ACOG and the FDA recommends that hormone therapy be used at the lowest doses for the shortest duration needed to achieve treatment goals.
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Contraindications to Hormone Therapy (Beckmann et al., 2010)
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Undiagnosed abnormal genital bleeding
Known or suspected estrogen-dependent neoplasia Active deep vein thrombosis, pulmonary embolism, or a history of these conditions Active or recent arterial thromboembolic disease (stroke, myocardial infarction) Liver dysfunction or liver disease Known or suspected pregnancy Hypersensitivity to hormone therapy preparations |
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Effects of Oral Replacement*** Therapy on the Body
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HT and breast cancer
Increases risk after 5 year use Estrogen and lipids Estrogen lowers LDL Estrogen elevates HDL Estrogen may increase triglycerides ~ Progestins and lipids Elevates HDL May blunt increased lipids by estrogen |
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HT continued
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HT and heart
Enhances platelet aggregation Dilates coronary arteries (estrogen induced) Positive lipid effects HT and bones Especially beneficial first 5 years after menopause May arrest and reduce bone loss even if given later in life |
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HT continued…
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HT and Genitourinary symptoms
Relieves atrophy of genitals Relieves urinary symptoms HT and skin Increases collagen and thickness of skin HT benefits (oral) Relieves hot flushes/flashes Reduces jaw bone atrophy Decreases tooth loss Possible cognitive enhancement Possible lowing of colon cancer risk |
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Estrogen form, dose & relief
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estrogen form dose reported hot flash relief
conjugated equine 0.625mg 94% 0.4 or 0.3mg 78% oral estradiol-17B 2mg 96% 1mg 89% 0.25mg 55% transdermal estriadiol 0.05mg 96% 17B 0.25mg 86% |
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MANAGEMENT CONTINUED
PHARMOCOLOGIC TREATMENT Women with a uterus |
Estrogens, conjugated/medroxyprogesterone: 0.3/1.5 mg daily
Estradiol/norethindrone acetate transdermal: 0.05/0.14 mg patch twice weekly |
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MANAGEMENT CONTINUED
PHARMOCOLOGIC TREATMENT Women without a uterus |
Estradiol transdermal: 0.025 mg patch twice weekly
Estrogen, congugated: 0.3 mg PO daily Estrogens, esterified: 0.625 mg PO daily |
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Therapeutic Plan
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Estrogen replacement therapy (ERT)
Estrogen only Take daily Use in patients without uterus Increased estrogen effect on uterus (without the addition of progesterone) will cause uterus to hyperplasia, premalignant/malignant changes Hormone therapy (HT) Estrogen/progesterone combination Intact uterus Take daily or cyclic |
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Common Oral Estrogen Products used in HT
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Equivalent estrogen doses
Oral conjugated estrogen 0.625mg Mixture of conjugated estrogens Oral micronized estradiol 1mg Natural, emulsified estrogen Oral piperizine esterone sulfate 0.75mg Oral esterified estrogen 0.625mg Natural animal/vegetable sources |
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Common Oral Estrogen Products used in HT Continued…
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Oral estrogen
Premarin Estrace Transdermal Climara Estraderm |
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Common Oral Estrogen Products used in HT Continued…
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Estrogen may also be given
With Progestins (combination) Activella (PO) Prempro (PO) Premphase (PO) Combipatch (Patch) Vaginally (creams/rings)- Used to treat vaginal symptoms Creams Estrace Ogen Premarin Rings Estring vag ring (Q 90 days) With Testerone- enhances sexual desire Estratest |
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Common Oral Progestin Preparations
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Equivalent progestin doses
Medroxyprogesterone acetate 2.5mg daily 5-10mg X 12 days Q month (last 12 days) Norethindrone (acetate) 0.35mg daily 2.5-5mg X 12 days Q month (last 12 days) Micronized progesterone 400mg X 10 days (last 10 days of month) 200-300mg X 10 days (last 10 days of the month) 100mg daily |
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Common Oral Progestin Preparations cont'd
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Progesterone only pills
Prometrium Provera Vaginal progestin Crinone 4%, 8% |
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HT Dosing
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Start with lowest effective dose and increase according to S & S
E.g.,… Estrogen only Premarin 0.3mg daily Estrace 0.5mg daily Progesterone only Prometrium Megace Estrogen/Progesterone combinations Activella Femhrt Prempro |
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Side Effects R/T HT
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Inform practitioner if-
A Abdominal pain C Chest pain H Headaches E Eye problems S Severe leg pain Unexplained vaginal bleeding |
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Initiation of HT
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Individualized to patient
Benefits vs. risks ET/HT most beneficial if started within 5 years of perimenopausal symptoms Short term 6 months, to less than 5 years Relieve hot flushes and night sweats Long term > 5 years Prolonged, more pronounced S & S ~ET/HT if partner put on Viagra |
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HT Withdrawal
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Lower doses over time (6-12 weeks)
Oral Give same pill in lower dose daily Give ½ pill daily Same dose pill every other day, then every third day Patch Cut increments of patch off weekly |
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MEDICATION antidepressants Primary options
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ANTIDEPRESSANTS
Primary Options Venlafaxine (Effexor): 10-20 mg PO daily Desvenlafaxine (Pristiqu): 100 mg PO daily |
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MEDICATION antidepressants Secondary options
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Secondary Options
Paroxetine (Paxil): 10-25 mg PO daily Fluoxetine (Prozac): 10-20 mg orally once daily Citalopram (Celexa): 10-30 mg PO daily |
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MEDICATION
REDUCED LIBIDO |
REDUCED LIBIDO
Combination of estrogen and androgen has been reported to increase libido. Estrogens, esterified/methyltestosterone: 0.625/1.25 mg PO daily or 1.25/2.5 mg PO daily |
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MEDICATION
VULVOVAGINAL SYMPTOMS |
Estrogens, conjugated vaginal: Apply 0.5 to 2 grams once daily for three weeks then stop for one week. Repeat cycle
Estradiol Vaginal: (Intravaginal ring) 50-100 mcg/day. Ring inserted and replaced every 3 months. Estradiol Vaginal: (Intravaginal tablet) 25 mcg/day inserted once daily for 2 weeks then 2-3 weeks weekly therea |
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OSTEOPOROSIS
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Hormone therapy is an option for women who have experienced bone loss related to postmenopausal osteoporosis in an effort to prevent further bone loss.
However, HT is not approved for the treatment of osteoporosis alone (osteoporosis not related to menopause |
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SPECIAL CONSIDERATIONS
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Do not start hormone therapy in a woman who is being treated or has a history of ovarian or breast cancer with out first consulting with oncologist.
Do not use hormone therapy as a birth control method. |
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WHEN TO CONSULT
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Consult or refer for all contraindications and or questionable uses for hormone therapy.
Consult or refer for endometrial biopsy for episodes of vaginal spotting/bleeding even though this side effect of HT is common |
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FOLLOW-UP
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Follow-up 3 months after initiating hormone therapy or as often as necessary to evaluate treatment and side effects of treatment.
Review danger signs of hormone therapy such as: Vaginal bleeding, calf pain, chest pain, SOB, hemoptysis, severe HA, vision problems, breast changes, abdominal pain, jaundice. |
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COMPLICATIONS
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Postmenopausal problems include:
Cardiovascular Issues Osteoporosis Vasomotor symptoms Urogenital atrophy Incontinence Atrophic vaginitis Diminished libido |
