MENOPAUSE

Question 1

Menopause: Definition

Answer 1

• Has occurred when a patient has not menstruated for a period of 1 year
• Most often between ages 48 and 55 years
• Not a disease state

Question 2

Menopause: Triad of phases

Answer 2

• Triad of phases
  o Climacteric:
  1.occurs approximately 10 years before menopause;
  2.ovulation becomes less frequent; 3.shortening of the menstrual cycle 4. increase in menstrual bleeding
  o Menopause
  o Post-menopause

Question 3

Menopause: Pathophysiology

Answer 3

• Menopause is the permanent cessation of menses and ovarian function
• Perimenopause is characterized by the
  1.waxing and waning of ovarian function;
  2. menstrual cycles of unpredictable duration and intensity;
  3. extended periods of estrogen deficiency;
  4. heightened FSH/LH secretion
• Follicular development and cyclical estrogen production cease during menopause
• FSH levels above 40 mIU/mL signal the approach of menopause
• Persistently high LH levels lead to continued androgen production, contributing to undesirable physical changes such as increased facial hair
• Gonadotropins in older women tend to have long half-life
• Residual oocytes and differentiating follicles have been identified in postmenopausal women and eventually become cystic in the absence of viable oocytes
• Estrogen levels fall
• Inhibin B levels also decline, closely correlating to the rise in FSH

Question 4

Menopause: Clinical Presentation

Answer 4

• Most common symptoms
  o Vasomotor symptoms: hot flashes, night sweats, and insomnia
  o Sleep disturbances
  o Mood disorders: depression, irritability, fatigue
  o Vaginal dryness or atrophy 🡪 dyspareunia; stress and urge incontinence 🡪 Kegel exercises to reduce incontinence
• Five areas of change involving sexual relations
  o Diminished sexual responsiveness
  o Dyspareunia (painful intercourse)
  o Decreased sexual activity
  o Decline in sexual desire
  o Dysfunctional male partner
• A decrease in estrogen influences peripheral blood flow responses to sensory stimulation
• Bone demineralization and resultant osteoporosis
• During climacteric, patients may lose 2%–5% of bone mass per year
• Unsteady gait and poor eyesight are significant factors equal to low bone density

Question 5

Menopause: Diagnostic Testing

Answer 5

• Pregnancy test
• FSH and LH levels are elevated
  o FSH levels greater than 40 mIU/mL consistent with complete cessation of ovarian function
• Menopausal status can also be determined by vaginal cytological examination
• Microscopic examination—parabasal cells will predominate

Question 6

Menopause: Management

Answer 6

• Vasomotor symptoms
  o Aerobic exercise: relieves hot flashes, insomnia, promotes weight loss, decreases cardiovascular risk
  o Dietary habits: high complex carbs, low fat, high in antioxidants; limit alcohol and caffeine intake
  o Stress reduction
  o Smoking cessation
  o Herbal therapies: isoflavonoid phytoestrogens and black cohosh both have estrogenic effects
• Vaginal dryness
  o Pap smear and urinalysis to rule out infection
  o Most effective treatment is topical vaginal application of an estrogen product such as the estradiol vaginal ring or estrogen vaginal cream
  o Water-soluble vaginal lubricants are alternatives to topical estrogen
  o Sitz baths, vinegar douches, and intercourse are other alternative therapies
• Psychological problems
  o Antidepressants relieve not only depressive symptoms but also hot flashes
  o Regular exercise improves cognitive function, enhances mood, and promotes daytime alertness and nocturnal sleepiness
• Postmenopausal osteoporosis
  o Bisphosphonates: first-line therapy for prevention and treatment
   Alendronate and risedronate both increase spine and hip bone mineral density; instruct patient to take on an empty stomach in the morning and remain upright for 30 minutes
  o Calcitonin: decreases bone resorption
  o Vitamin D and calcium should be taken as supplements

Question 7

Menopause: Hormone Replacement Therapy (HRT)

Answer 7

• Not a first-line treatment for menopausal symptoms
• Only to women with moderate to severe symptoms; no longer than 5 years
• Should not be used for prevention of heart disease or stroke or prevention of dementia
• Contraindicated in patients with estrogen-dependent cancer, liver disease, or pregnancy
• Different types of HRT:
  o Estrogen therapy (ET): start with lowest dose; estradiol can be given in a transdermal patch; limited to women who no longer have a uterus
  o Estrogen plus progestin therapy (EPT): continuous sequential (CS-EPT) or continuous combined (CC-EPT); many women find this method unacceptable

Question 8

Menopause: Follow up and Referral

Answer 8

• Without relief of symptoms, referral to a gynecologist is recommended
• Suspected abnormalities should also be referred to a gynecologist
• Perimenopausal or postmenopausal bleeding requires endometrial surveillance and biopsy
• Estrogen-progestin therapy usually treats DUB (Dysfunctional Uterine Bleeding)
• Depressed patients unresponsive to treatment: refer to a mental health specialist

Question 9

Menopause: Patient Education

Answer 9

• Pregnancy is still possible during perimenopause; pregnancy test essential before assuming menopause
• Patients should be counseled about birth control
• Decision about treatment is made in conjunction with the patient
• Carefully evaluate patient feelings to better understand how to assist with treatment