Download Menopause Slides 013113

Managing Menopause
01/31/13
Objectives
By the end of this lecture, participants will be able to:
• Define menopause and perimenopause
• Review common symptoms
• Discuss treatment options
• Provide appropriate patient education
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Definitions
• Menopause: permanent cessation of menstruation
resulting from loss of ovarian function
– Clinical diagnosis: absence of menses for >12 months in
women over age 45
• Perimenopause: 2-8 years preceding menopause and 1
year after final menstrual period
• Premature menopause: menopause occurring before
age 40
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Perimenopause Symptoms & Treatment
• Menopause symptoms often start in the perimenopausal
period
• Usually involves irregular menses and hot flashes
• Treatment options
– Low-dose oral contraceptives can regulate periods and reduce
hot flashes and vaginal dryness. For nonsmokers, continue to
~age 50-51, then discontinue when patient is likely to be in
menopause
– Mirena IUD may help with heavy bleeding
– Cyclic progesterone can regulate menstruation
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Menopause Symptoms
• Average age of onset 51 years
• Common symptoms
– Menstrual changes
– Vasomotor symptoms (hot flashes, night sweats)
– Urogenital atrophy
• Severity can vary by ethnicity
– African American women have more severe hot flashes than
Caucasian women
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Menstrual Changes
• ~90% of women experience 4-8 years of menstrual
changes before menopause
• Changes in:
– Flow
– Duration
– Cycle length
• Often have anovulatory cycles
• Potential for pregnancy still exists
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Vasomotor Symptoms
• Commonly described as feelings of intense heat
– May cause neck and face to flush; sweating and chills are
common
– Hot flashes vary in intensity; typically last 30 sec to 10 min
• 75% of women report vasomotor flushes
– Many experience them for ~10 years
– 15% report severe flushes for >15 years
• Greatest frequency is 2-4 years after menopause
• Risk factors include surgical menopause, decreased BMI, and
cigarette smoking
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Urogenital Atrophy
• Vaginal dryness/irritation +/- discharge
• Dyspareunia (painful intercourse)
• Urinary symptoms
– Frequency
– Painful intercourse
– Incontinence
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Other Menopause-Related Symptoms
• Changes in libido
• Poor concentration
• Irritability
• Memory lapses/loss
• Mood swings
• Headaches
• Anxiety
• Depression
• Feeling of dread
• Hair loss
• Insomnia
• Facial hair
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“Your body knows more about menopause
than your doctor does!”
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Hormone Replacement Therapy
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Hormone Replacement Therapy (HRT)
• Initially prescribed for vasomotor symptoms in 1960s
• “Instead of being condemned to witness the death of
their own womanhood, they will remain fully
feminine—physically and emotionally—for as long as
they live…Menopause is curable.”
- Dr. Robert A Wilson -
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HRT History
HRT for
vasomotor
symptoms;
expands to
remaining
“feminine
forever”
HRT use
declines as
endometrial Ca
linked to
unopposed
estrogen
use
HRT use
increases
when
discovered
adding
progestin is
protective,
& prevents
osteoporosis
HRT use
expands, ?
prevent
CAD/CVA
Women and
providers are
confused…
(HERS, NHS
published)
Are
hormones
good or
bad?
WHI results published;
HRT use drops drastically
1960
“Fountain
of youth”
1970
“Poison”
1980
“Good
medicine”
1990
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2002
“POISON”
2011
What we thought we knew…
• Estrogen therapy seemed logical based on the
hypothesis that
– Menopause is associated with:
• Decreased estrogen
• Accelerated cardiovascular disease
– Thus, replacing estrogen will have a cardio protective effect
• For many years, HRT was prescribed based on this
hypothesis and observational trials
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Women’s Health Initiative (WHI)
• Prospective study of estrogen + progesterone (Prempro)
or estrogen alone on risks for coronary heart disease,
breast cancer, and hip fracture
• Women with severe menopausal symptoms were
excluded
• Risk of CHD, stroke, DVT/PE, and breast cancer increased
with estrogen + progesterone
• Risk of stroke and DVT/PE increased with estrogen alone
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WHI Findings: Other Menopausal Symptoms
• No beneficial effect of hormone replacement therapy
on cognitive function in older post-menopausal
women when given for up to 5 years
– Women on HRT in midlife (early menopause) may have
protection against cognitive impairment
– HRT in late menopause seems to have deleterious effects
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Current Indications for HRT
• Vasomotor symptoms related to menopause
• Vaginal or vulvar atrophy
• Not recommended to start if >10 yrs after menopause
• For short-term use only (max 5 yrs?)
Individualized decision should be made by provider
and patient based on risks for CVD, breast cancer,
osteoporosis, and quality of life
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Nursing Role
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CASE 1
Karen, a 47-year-old woman,
calls the PACT complaining of
severe and frequent hot
flashes.
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Nursing Goals
1. Attempt to identify if symptomology is possibly due to
a condition other than menopause
– Rule out possible acute conditions first: cardiac, infection,
hypogylcemia, medication reaction, respiratory, etc… then
determine if related to hormones
2. Prioritize urgency
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Possible Triage Questions
• Have you taken your temperature?
• Do you have a new or worsening cough, urinary tract symptoms, or abdominal
pain?
• Do you become weak with your hot flashes?
• Do you notice shortness of breath with activity in general?
• Have you measured your blood pressure lately?
• Do you have chest pain with the hot flashes?
• Do you have pain in your arm or jaw with the hot flashes?
• Do you have difficulty breathing with your hot flashes?
• Have you ever had a heart attack or chest pain?
• Do you have diabetes? Have you been diagnosed with hypoglycemia?
• Do your hot flashes occur within one hour of eating?
• Describe your menstrual cycles. Have you noticed any changes?
• What medications (Rx and OTC including herbs) are you taking?
• Do you feel more anxious or depressed when your hot flashes occur?
• Have your hot flashes been getting worse over the past 2 months?
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CASE 2
Sophie, a 51-year-old woman, presents to the primary
care clinic for a well woman exam. While you are
talking to her, you notice that her face becomes flushed
and she is sweating profusely.
What questions would you ask?
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Clarifying Questions
•
•
•
•
•
When did the hot flashes start?
How often do they occur, when do they occur, how long do they last?
What makes your hot flashes worse?
What have you done to relieve the symptoms? Does it work?
Are you experiencing other symptoms?
– Vaginal bleeding
– Night sweats and/or insomnia
– Memory problems
– Urinary incontinence
– Problems with sexual activity
– Weight gain
– Depression or anxiety
• What medications (Rx and OTC including herbs) are you taking?
• Do you smoke?
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Case 2, continued
As a result of your questions, you find out that Sophie
experiences severe and frequent hot flashes that are
affecting her job. Her last menstrual period was 18
months ago, although last month she had some spotting
that lasted one week. She also mentioned that she
smokes 1 pack per day.
What do you tell Sophie about smoking and menopause?
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Smoking and Menopause
• Women who smoke >10 cigarettes/day are 40% more
likely to go into menopause early than nonsmokers
– Early menopause can to lead to heart disease, strokes, and
osteoporosis
• Women who smoke have more severe hot flashes and
sleeping difficulties
• Women who smoke are 35% more likely to break a hip
after menopause than nonsmokers. Former smokers
have a 15% greater risk of hip fracture.
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Treating Menopausal Symptoms
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CASE 3
Marge, a 58-year-old menopausal female calls
and asks if it’s ok to take Black Cohosh for her
hot flashes. She says that it helped her friend.
Her last visit was 3 months ago. Her BP was
130/80, and her lab work was normal. Both her
mother and grandmother had breast cancer.
Marge wants to know what else she can do in
addition to taking Black Cohosh. She states:
“My co-workers are constantly making remarks
about how soaked I get. It’s embarrassing.”
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Hot Flashes: Hormone Replacement Therapy (HRT)
HRT is reasonable for women who feel that benefits of symptom
relief outweigh risks
• All routes of systemic therapy are equally effective
− Transdermal estrogen has lower risk of blood clots than oral route
• Use the lowest effective dose of estrogen
− 0.625 mg per day oral, 0.5mg transdermal, or lower
• For women with a uterus, progesterone must be added
• Bioidentical hormones
− Typically refer to custom-compounded formulations
− No rigorous testing, so safety/efficacy are unknown
− Similar risks/side effects as traditional HRT
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Hot Flashes: Medication Alternatives to Estrogen
Therapy
Progestin methods
MPA 400mg
Megace 20 - 80mg
Venlafaxine 37.5 - 150 mg
Desvenlafaxine 100 & 150mg
Fluoxetine 20 mg
Paroxetine 10 - 25 mg
Gabapentin 300 - 2,400 mg
Clonidine 0.1 - 0.2mg
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Hot Flashes: Herbal/Vitamin Remedies
Efficacy
Vitamin E
No effect
Black cohosh
Mixed results
Evening primrose oil
No effect
Ginseng
No effect
Comment
Wild yam (“natural progesterone”) No effect
Phytoestrogens (isoflavones)
Mixed results
Soy, red clover
Phytoestrogens (lignans)
Mixed results
Crushed flaxseed
Chasteberry
No effect
Dong quai
No effect
Licorice root
No effect
Note that many herbs are estrogenic and the risks are unclear
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Hot Flashes: Mind-Body Therapies
Efficacy
Comment
Paced respiration
May be effective
Small randomized trial
Acupuncture
Mixed results
Yoga
May be effective
Exercise
Mixed results
Homeopathy/magnet therapy
No effect
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Small pilots and 1
randomized trial
Hot Flashes: Lifestyle Changes
Many women decide to treat menopausal symptoms
through lifestyle changes
• Identify triggers and avoid them if possible
– Triggers to consider include spicy foods, alcohol, caffeine,
stress, or being in a hot place
• Dress in layers and remove clothes when flashes occur
• Use fans at home or in the workplace
• Losing weight might help decrease flash frequency
Reference: http://womenshealth.gov/menopause/symptom-relief-treatment/
retrieved 7/6/2012
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Vaginal and Urinary Symptoms
• Women often have both vaginal and urinary symptoms
due to the drop in estrogen which affects the vaginal
and urethral tissues
–
–
–
–
–
–
Vaginal dryness +/- thin watery discharge
Pruritus
Dysparunia (painful intercourse)
Painful urination
Urinary urgency/incontinence
Frequent urinary tract infections
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Vaginal Atrophy
Clinical diagnosis
• Appearance of external genitalia and vaginal mucosa
– Loss of labial/vulvar fullness
– Pale urethral/vaginal epithelium
– Decreased vaginal secretions
• pH >4.5
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Treatment Comparisons:
Estrogen Cream vs. Moisturizer vs. Lubricant
Vaginal Moisturizer vs. Vaginal Lubricant
• Replens vaginal moisturizer
- Improves vaginal epithelium
• Vaginal lubricants (e.g., Astroglide)
- Make intercourse more comfortable
- No long-term benefit to vaginal epithelium
Intravaginal estrogen cream vs. Replens
• Equivalent improvements in vaginal epithelium
• Equivalent improvement of vaginal itching, irritation, dysparunia
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Vaginal Atrophy: Estrogen Cream
Advantages
• Relieves atrophy and may improve sexual function
• Low dose is effective
• Not necessary to oppose with progesterone
– Be sure to tell women to report any vaginal bleeding which
should be thoroughly evaluated
• All preparations are equally effective
Disadvantages
• Not appropriate for women with a history of breast cancer
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Vaginal Estrogen Comparison
Creams
Estring*
Vagifem Tablet*
Frequency
Daily for 2 wks,
then 2x a wk
Replace every 3
months
Daily for 2 weeks,
then 2x a week
Safety
No reports of
endometrial Ca
No endometrial
No reports of
proliferation at 1 yr endometrial Ca
Comments
Can achieve
systemic
estrogen levels
No rise in serum
estrogen
No systemic or
endometrial
absorption
Hormone Products for Postmenopausal Use in the United States and Canada. Compiled by
The North American Menopause Society, ©2009. http://www.menopause.org/htcharts.pdf
*Not on VA Formulary
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Resources
• North American Menopause Society (NAMS). Information on menopause and
educational materials. http://www.menopause.org/edumaterials.aspx
• PubMed Health. Fact sheet:menopause.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004974/
• womenshealth.gov. Menopause and menopause treatments fact sheet.
http://www.womenshealth.gov/publications/our-publications/factsheet/menopause-treatment.cfm
• womenshealth.gov. Menopause symptom relief and treatment.
http://www.womenshealth.gov/menopause/symptom-relief-treatment/
• NHLBI. Facts about menopausal hormone therapy.
http://www.nhlbi.nih.gov/health/women/pht_facts.pdf
• National Institute on Aging. Hormones and menopause: tips from the National
Institute on Aging. http://www.nia.nih.gov/sites/default/files/TipSheet_
HormonesAndMenopause_0.pdf
• National Cancer Institute. Menopausal hormone therapy and cancer.
http://www.cancer.gov/cancertopics/factsheet/Risk/menopausal-hormones
• National Center for Complimentary and Alternative Medicine. Herbs at a glance.
http://nccam.nih.gov/health/herbsataglance.htm
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Additional Information
• Bozkurt B. Where do we currently stand with advice on hormone replacement
therapy for women? Methodist Debakey Cardiovasc . 2010;6(4):21-5. Review.
• Goodman et al. American Association of Clinical Endocrinologists medical
guidelines for clinical practice for the diagnosis and treatment of menopause.
Endocr Pract 2011;17(6):949-54.
• International Menopause Society. Recommendations.
http://www.imsociety.org/ims_recommendations.php
• Loprinzi et al. Newer antidepressants and gabapentin for hot flashes. J Clin
Oncol 2009; 27:2831-7.
• Nelson et al. Nonhormonal therapies for menopausal hot flashes: systematic
review and meta-analysis. JAMA 2006;295:2057-71.
• Rossouw et al. Risks and benefits of estrogen plus progestin in healthy
postmenopausal women: principal results from the WHI randomized controlled
trial. JAMA 2002;288:321-33.
• Shifren & Schiff. Role of hormone therapy in the management of menopause.
Obstet Gynecol 2010;115:839-55.
• Tao et al. Knowledge, perceptions and information about hormone therapy (HT)
among menopausal women. PLoS One 2011;6(9):e24661. Review.
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Author
Author:
Rachel Bonnema, MD, MS
Omaha VA Medical Center, Omaha, NE
WH Nurse Reviewers: Barbara Robinson, RN
Katrina Goldby, RN, BSN, JD
Susan Johnson-Molina, RN, BSN, MAOM
Connie LaRosa, RN, MSA, CPHQ
Barbara Polak, RN, MSN
Mary Ann Reale, MS, RN
Lisa Roybal, MSN, WHNP
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