Menopause

• Menopause happens around age 51, range is 45 to 58 years of age and can take 2-8 years to transition
• Physiology of menopause

  -Decrease in number of functional ovarian follicles

  -Significant fluctuation in hormone levels

  -Ovaries less responsive to FSH

  -Ovulation, menstruation and secretion of estrogen and progesterone ceases
• Midlife body changes

  -Tooth loss, periodontal disease with decreased bone mineral density

  -Weight gain averages about 5 lbs

  -Decreased breast size

  -Ovaries and uterus atrophy

  -Hair loss, excessive growth

  -Loss of elasticity, wrinkling and loss of collagen
• Menstrual changes

  -Change in amount or duration of flow

  -Change in length of cycle

  -Skipping menstrual periods

  -Risk of unintended pregnancy
• Vasomotor symptoms

  -Hot flashes, night sweats, palpitations, irregular heartbeat, formication, anxiety & panic attacks, feelings of suffocation and exhaustion
• Vasomotor treatment options:

  Least invasive

  -Use fan/air conditioning

  -Dress in layers

  -Avoid smoking

  -Exercise

  -Avoid spicy foods

  -Relaxation breathing

  -Bio feedback

  -Hypnosis

  -Vitamins E, B12, B6 and magnesium

  -Acupuncture

  -Phyto estroegens
• Menopause hormone therapy (MHT)

  -Estrogen and progesterone for women with uterus intact
• Urogenital effects

  -vaginal dryness, vulvar & vaginal purities, increased vaginal infections (atrophic vaginitis), increased UTI, atrophic cystitis, dyspareunia, urge & stress incontinence and pelvic floor disorders
• Least invasive urogenital management:

  -OTC lubricants

  -Restrict caffeine

  -Citrus and spicy foods

  -Frequent bladder emptying

  -Soy flour

  -Flaxseed

  -Behavioral therapy

  -Kegels exercises

  -Biofeedback

  -Drink 8 glasses of water a day

  -Wipe front to back
• Psychologic symptoms

  -irritability, mood swings, depressive moods, sleep disturbance, decreased concentration, short term memory loss, difficulty coping, decreased libido, anxiety/panic attacks, decreased energy, touch aversion, agoraphobia, increased headaches, and joint/muscle pain
• Management of psychological symptoms

  Least invasive: education, exercise, relaxation techniques, psychotherapy, counseling & sleep hygiene

  Herbals: St. Johns wort, valerian, damiana and gingko baloba

  -DHEA: mood, sexual function and wellbeing

  -Melatonin (sleep)

  -MHT

  -SSRIs/antidepressants
• Osteoporosis Treatment

  Least invasive: regular weight bearing exercise, muscle strengthening exercise, avoid smoking, caffeine and alcohol use, eat a diet high in calcium rich foods and reduce fall risk in environment.

  -Calcium intake 1200 mg (over 50)

  -Calcium intake 1300 mg (9-18)

  -Calcium intake 1,000 mg (18-50)

  -Vitamin D 800 IU (over 70)

  -Vitamin D 600 IU (9-70)
• More invasive osteoporosis treatment

  -Estrogen alone for women without a uterus (Premarin)

  -Conjugated estrogen + medroxyprogesterone for women with a uterus (Premphase)

  -Biphosphates (Fosamax, Boniva, Actonel, Reclast): GI irritation, esophageal ulceration, muscles aches and pain.

  Take with water in upright position for 30 minutes after taking

  -Prolia

  -Estrogen receptor modulators (Evista)
• Preventive care heart disease

  -Least invasive: exercise, healthy diet, maintain normal body weight, no smoking, omega 3's to lower triglyceride levels

  -More invasive: antihypertensives, statins
• Estrogen:

  Benefits: beneficial effect on lipids, prevention of osteoporosis and effect on brain function.

  Possible side effects: breast tenderness, edema, bloating, headaches, nausea, weight gain, endometrial hyperplasia and CHD (1st year of use if started several years after menopause)
• Estrogen contraindications

  -Thromboembolitic disorder (DVT and PE)

  -Undiagnosed vaginal bleeding

  -Untreated estrogen dependent cancer

  -Pregnancy

  -Liver dysfunction

  -Gallbladder disease

  -High blood pressure
• Progesterone

  Benefits: protects uterine lining against effect of estrogen and inhibits growth of uterine lining

  Side effects: PMS symptoms, depression, irritability, breast tenderness, edema, constipation, somnolence, vaginal bleeding/spotting
• Recommendations for menopause hormone therapy

  -Lowest dose of MHT should be used for the shortest time possible (less than 5 years)

  -Women with uterus should take combine therapy

  -Risk of blood clots increases during the first year of treatment with MHT but then decreased over time

  -For postmenopausal women long term MHT use (3-5 years) is associated with increased risk of breast cancer