Download Menopause: What every medical student should know

MENOPAUSE: What every
medical student should know
Sherry K Nordstrom, MD
Asst Prof of OB/GYN, UIC College of
Medicine
Learning Objectives
• Understand pathophysiology of normal and
premature menopause
• Know major symptoms of menopause
• Learn about various treatment options for
menopausal symptoms
Definitions
• Menopause - the cessation of menses for at
least one year due to loss of ovarian activity
• Perimenopause - the time surrounding
menopause when symptoms usually occur
• Postmenopause - the lifespan of a woman
after cessation of menses
Characteristics
• Average age at menopause is 51
range 48-55
• Average age at perimenopause (based on
irregular menses) is 47.6
mean duration of 4 years
• Average duration of postmenopause is
>30 years
• Smokers have menopause 2-3 years earlier
than nonsmokers
Pathophysiology of Ovulation
• FSH (Follicle Stimulating Hormone) tells
the ovary to recruit eggs
• Estrogen is made by the developing eggs
• LH (Luteinizing hormone) peaks at
midcycle (with estrogen and FSH) resulting
in ovulation
• Post-ovulation, the corpus luteum makes
progesterone until lack of pregnancy results
in lowered progesterone and menses
Pathophysiology of
perimenopause
• Anovulation more common in 40s as
ovaries less responsive to FSH
• FSH levels increase to try to bribe ovaries
into responding
• Estrogen levels decrease as fewer follicles
are recruited
• Progesterone levels fluctuate as corpus
luteum produces varying amounts
Pathophysiology of Menopause
• Fewer and fewer follicles are recruited until
no follicles develop at all
• FSH and LH levels become persistantly
elevated
• Estrodiol levels stabilize at 10-20 pg/ml
• Testosterone levels stable, but ovarian
production increases - androstenedione
decreases by half so have relative androgen
deficiency
Task
• Break into small groups
• List 5 symptoms of
menopause/perimenopause besides hot
flashes
• List one treatment for each symptom
Clinical Presentation
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Irregular cycles
Hot flashes
Vaginal dryness or irritation
Emotional lability
Memory lapses
Decreased libido
Facial hair/acne
Palpitations
10 WAYS TO KNOW IF YOU HAVE
"ESTROGEN
ISSUES"
1. Everyone around you has an attitude problem.
2. You're adding chocolate chips to your cheese omelet.
3.The dryer has shrunk every last pair of your jeans.
4. Your husband is suddenly agreeing to everything you say.
5. You're using your cellular phone to dial up every bumper sticker
that says "How's my driving-call 1-800-***!
6
. Everyone's head looks like an invitation to batting practice.
7. You're convinced there's a God and he's male.
8. You can't believe they don't make a tampon bigger than Super Plus.
9. You're sure that everyone is scheming to drive you crazy.
10. The ibuprofen bottle is empty and you bought it yesterday.
Irregular Cycles
• 90% of women have irreg cycles prior to
cessation of menses
• Cycle length shortens, as short as 21 days,
followed by skipped periods
• Occasionally see longer cycle length
• Flow may be lighter or heavier
When to Worry
• If bleeding closer than every 21 days
• If bleeding lasts longer than 10 days
• If bleeding heavy enough to soak a maxipad
in 1 hour or less for several hours in a row
• If any of the above, the patient needs further
evaluation
What to do:
• EMB (endometrial biopsy)
• D&C (rare now)
• Ultrasound evaluation of uterus with
possible saline infused sonohysterogram
(SIS)
• Hormonal treatments such as progesterone,
GnRH agonists or OCPs
• Surgical treatments such as endometrial
ablation or hysterectomy
Hot Flashes
• Also called hot flushes or vasomotor events
• Sudden onset of feeling of intense heat with
reddening of face/chest/head skin followed
by profuse perspiration
• Lasts a few seconds - several minutes
• Present in 85% of women, last >5 years
postmenopause in 25-50%
Hot Flashes
• Frequency is variable - from one per week
to several per hour - changes as woman
goes through menopause
• Cause sleep disturbances - may be the
etiology of emotional lability in menopause
• Triggered by stress
• Embarrassing - happens when women at
peak of careers, causes feeling of loss of
control
Hot Flashes - Etiology
• Primarily related to estrogen deficiency but
not the whole answer
• Estrogen replacement reduces flash
frequency and severity, but may not
eliminate them
• Seen in women on OCPs, some medical or
psychiatric conditions
Hot Flashes - Treatment
• Estrogen replacement - most effective
• Wear layered clothing, keep cool
• Progesterone replacement - effective alone,
can be used orally or transdermally
• Botanical remedies - black cohosh, red
clover, soy products with phytoestrogens
being studied - minimal success
• Clonidine, SSRI’s, Gabapentin with some
success
Vaginal Dryness
• Woman often describes dryness or irritation
• Due to atrophy of mucosal surfaces
• Causes vaginitis, pruritus, dyspareunia,
stenosis of vaginal opening and
incontinence
• Symptoms vary with sexual activity, size of
vaginal opening prior to menopause, patient
tolerance. Many patients with atrophic
appearing vaginas are asymptomatic
Vaginal Dryness - Treatment
• Lubrication - KY jelly, Astroglide, Vaginal
moisturizers (Replens)
• Estrogen replacement - topical or oral
• Encourage maintenance of sexual activity can improve blood flow to area and
maintain vaginal caliber, reducing
symptoms
Emotional Lability
• Extremely variable symptom - depression
most common, also see mania
• Possibly related to sleep disturbances
• Psychiatry literature feels symptoms
combination of hormonal changes and life
stressors often occuring at the same time
(children leaving home, aging parents, etc)
• Estrogen replacement may help
• Treat in conjunction with psychologist
Memory Lapses
• Well documented decrease in short term
memory and concentration
• Generally transient, improves after
completion of menopause
• May not return to premenopausal baseline
• Some data suggest estrogen helps return
memory to baseline and may offer
protection from Alzheimer’s Disease later
in life - jury still out.
Decreased libido
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Makes evolutionary sense
Problematic for relationships
Almost always multifactorial
Can measure testosterone levels and replace
testosterone
• Estrogen also can help
Medical Risks Related to
Menopause
• Osteoporosis risk increases - lose 2% of
bone/year
• Cardiovascular disease risk doubles
• Alzheimer’s Disease - 70% of women
without HRT have AD by age 90
Women have 2-3x risk of men
Diagnosis of Perimenopause
• Clinical symptoms in appropriate age group
• Lab tests not necessary in all women, but
can help in unsure cases
• FSH, LH, estrogen levels. Remember all
these fluctuate in perimenopause so all may
be normal but pt still perimenopausal.
Diagnosis of Menopause
• No menses for > 12 months in appropriate
age group
• Always see elevated FSH (>25) but don’t
always need to test if obvious.
• Premature menopause - women < 40 years,
occurs in 1% of population. Must have
elevated FSH to diagnose.
Treatment of Menopause
• No medical “treatment” is required for most
women
• Need to understand pts views on symptom
control and preventative medicine
• Good opportunity for education regarding
healthy lifestyles, weight loss, exercise
Supportive Care
• Educate - Woman needs to know which
symptoms are normal, which are cause for
concern
• Address individual symptoms such as hot
flashes or vag dryness
• Offer health screening - pap, mammo, chol,
TSH, colonscopy, etc.
• Provide education about diet, exercise,
smoking cessation
Complementary Medicines
• Many (approx 70%) use alternative
treatments for menopausal symptoms - ask
• Patients may worry HRT not “natural”
• Lots of research ongoing in this area
• Herbal supplements not regulated by FDA
so dose, strength not reliable. Risks not
well studied
Types of Complementary
Medications
• Soy - contains phytoestrogens, may provide
hot flash and vaginal atrophy relief
• Black Cohosh - hot flashes –
• Red clover - hot flashes
• Gingko baloba - memory loss/mood swings
• Wild yam creams - progesterone but not
bioavailable for humans so useless
• St John’s wort - depression/mood swings
Hormone Replacement Therapy
• Replacement of estrogen to physiologic
premenopausal levels
• Women with hysterectomies need only
estrogen
• Women with uteri need progesterone as
well to decrease risk of endometrial
hyperplasia and carcinoma present with
unopposed estrogen use
Estrogen
• Many forms available
• Synthetic and “natural” sources
• #1 selling estrogen is Premarin (Pregnant
MARe urINe) which is conjugated
estrogens at .625mg - best studied form
• Can be taken orally, vaginally,
intramuscularly or transdermally
Estrogen
• Monitor effectiveness based on pt
symptoms and side effects
• Can use timed blood or salivary estrogen
levels to help monitor
• FSH levels not helpful
• Use lowest dose that provides relief - .3mg
Premarin still offers osteoporosis protection
Estrogen Side Effects
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Irregular vaginal bleeding
Breast tenderness
Nausea
Headaches including migraines
Weight gain
Most resolve or reduce with continued use
Often cause discontinuation - must warn
patients
Progestins
• Reduces risk of endometrial cancer back to
baseline in estrogen users
• Can reduce hot flashes, osteoporosis on own
• Synthetic and natural types available synthetics have many side effects
Progestins - side effects
• Synthetics:
Weight gain, breast tenderness,
depression, irritability, bloating, headaches
• Generally more severe than estrogen side
effects
• Naturals:
Drowsiness, breast tenderness, bloating
• Usually milder than synthetics
HRT regimens
• If hysterectomy - estrogen alone
Common doses Premarin .625mg or
0.3mg daily, Estrace 1mg or 2mg daily
• If have uterus - use combined HRT
(estrogen and progestin)
2 types are sequential or continuous
combined
Sequential HRT
• Use estrogen daily and use progestin for
part of month
• Most common Premarin .625mg qd with
Medroxyprogesterone (Provera) 10mg or
5mg for 10-14 days of the month
• 80-90% will get a withdrawal bleed
monthly
• Progestin side effects generally worse with
intermittent use and relatively high dose
Continuous Combined HRT
• Estrogen and progestin daily
• Most common Premarin .625mg with
Provera 2.5mg daily
• 40-60% have breakthrough bleeding in first
6 months, 20% lasts > 1 year
• Generally lower side effects related to lower
progestin dose
Continuous Combined HRT
• Amenorrhea desirable for women
• If not achieving, can change progestin type
or dose
• Amenorrhea more common if pt further
from natural cessation of menses
Benefits of HRT
• Reduces hot flashes, vaginal dryness,
osteoporosis (fracture risk), and colon
cancer risk (WHI study)
• May improve short term memory issues,
may improve emotional lability
Risks of HRT
• Combined HRT increases risk of breast
cancer, heart attack, stroke, DVT (WHI
study)
• Estrogen alone increases DVT, slight
increase in stroke
• If uterus present and take estrogen alone,
increases risk of endometrial cancer (1-2%),
7% develop hyperplasia
• Lowers seizure threshold in some patients
Breast Cancer Risk
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1/9 women who live to 85 develop breast
cancer
RR with combined HRT 1.25-1.33 (WHI
and others)
RR with estrogen alone 0.8 (WHI)
Increases with prolonged use of combined
HRT
Counterintuitively, mortality among HRT
users with breast cancer is less RR 0.82
Breast Cancer Risk
• Need to discuss with patient
• Women with strong family histories should
probably avoid HRT
• Look at overall risks for each patient - heart
disease, osteoporosis, colon cancer,
Alzheimer’s Disease as well as pts
individual symptoms related to menopause
Women with Breast Cancer
• Some have very symptomatic menopause
• Some choose to use HRT, many try herbal
remedies - data not great to say herbal
remedies safer, but phytoestrogens appear
lower risk
• Remember cancers can have Estrogen and
Progesterone receptors
• Requires extensive discussion between the
patient, her gynecologist and her oncologist
Why use HRT in the post-WHI
era?
• Reduces menopausal symptoms better than
any other treatment available
• Prevents some future diseases - osteoporosis
and colon cancer
• May prevent other diseases - Alzheimer’s
Disease
Why do many patients and
doctors avoid HRT?
• Increased risk breast cancer, DVTs, heart
attacks and strokes (Combined HRT).
• Side effects - wt gain, bloating, breast
tnederness, irregular bleeding, etc
• Doesn’t completely eliminate menopausal
symptoms
Individualize Therapy
• Each patient and physician has to weigh the
risks and benefits for the individual before
undertaking HRT
• Have frequent f/u visits after initiating HRT
to assess side effects and concerns
• Reevaluate decision to continue or not on an
annual basis
Remember
• Menopause will happen to every woman if
she lives long enough
• Symptoms of menopause extremely
variable in severity
• Good opportunity for lifestyle
education/modification and screening for
diseases
• May not require any treatment