1. Menopause Jeannie Harper, PhD, RN

2. Definition Menopause: Complete cessation of menses where the woman has not had bleeding or spotting for 1 year Surgical Menopause: hysterectomy or bilateral oophorectomy

3. Menopause usually occurs in late 40’s to early 50’s with 51-52 being the median age Perimenopause occurs around age 39-51 and lasts 4-5 years Cigarette smoking and history of short periods can decrease the age of onset

4. Perimenopausal Changes Irregular menstrual cycles, anovulation, lighter or heavier bleeding, longer periods, spotting Higher levels of FSH but decreased response Decreased amounts of estrogen; can cause atrophy of the vagina and urethra Dyspareunia (painful intercourse) from decreased lubrication and thinner vaginal walls Urinary frequency, dysuria, uterine prolapse & stress incontinence

5. Perimenopausal changes cont’d Hot flashes/Vasomotor instability Result of fluctuating estrogen Most common symptom Most common 2 yrs postmenopause, but some may experience before and 10 yrs or more after Aggravated by warm or crowded rooms, alcohol, hot drinks, spicy food, stress and closeness to heat source Can have night sweats interfering with sleep

6. Perimenopausal changes cont’d Mood and behavior response: No evidence that menopause affects mental health Can cause insomnia leading to fatigue and depressed mood May have varying emotions r/t loss of childbearing, aging, physical abilities and energy Coping affected by perception of event, support system, and coping mechanisms

7. Osteoporosis Decreased bone mass, and increased fractures The decrease in estrogen causes slow thinning of the bones and a reduction in calcium absorbed into the intestine Affects approximately 50% of women in the US

8. Osteoporosis risks Increased risk with Caucasian or Asian, small boned and thin Inadequate calcium intake in adolescents into the 30’s and 40’s Excessive caffeine intake Vit D deficiency Smoking and excessive alcohol intake Greater phosphorous than calcium intake with soft drinks Steroid therapy, hyperthyroidism, and diabetes

9. Signs of Osteoporosis First sign usually loss of height Back pain may be present Dowager’s hump Fractured hip: often preceding a fall Bone density screening recommended for high risk women at 60 and all women over 65

10. Prevention Teach: Weight bearing excercises Weight management Calcium and Vit D supplementation Adults 50 and over need 1200mg Ca and 800-1000mg Vit D; younger than 50 1000mg Ca and 400-800 Vit D Annual bone mineral density test Avoid excessive alcohol and smoking

11. Osteoporosis Treatment & Prevention Calcitonin (treat) HRT (prevention) Estrogen agonist and antagonist (treat and prevent) Parathyroid hormone (treat) Bisphosphonates (prevent and treat)

12. Cardiovascular Disease Risk increases after menopause Heart disease leading cause of death among US women

13. CAD Risk Factors Obesity Smoking and excessive alcohol use High cholesterol and blood pressure Diabetes Family history Aging and post-menopause: estrogen decreases LDL and increases HDL Controversy exists on whether HT has a cardioprotective effect

14. Menopausal Hormone Therapy(MHT) ERT or ET- estrogen replacement therapy HRT or HT- estrogen and progestin used Therapy treats discomforts such as hot flashes and vaginal and urinary atrophy

15. ET use in the past Considered the fountain of youth in the 1960’s Prescribed for many off label uses i.e. wrinkles, aches and pains, Alzheimer’s, depression, heart attack In 1990’s research found evidence of HT cardioprotective benefit; current research questions this benefit for healthy women and also found an increased risk of stroke

16. Current research Used for urinary tract health with localized vaginal ET Reduces post-menopausal osteoporotic hip, spinal, and nonspinal fractures American Heart Assoc does not recommend ET & EPT for 1 ° or 2° prevention of CVD ET can increase risk of endometrial cancer in post-menopausal women Conflicting evidence of increased risk of ovarian and breast cancer Increased risk of ischemic stroke

17. To use or not to use MHT Do the benefits outweigh the risks?- short term use and low risk of CVD Should be taken at the lowest dose for the shortest time Recurrence of symptoms after discontinuation Women with history of or high risk of breast cancer should not take MHT EHT is associated with gallbladder disease

18. Side affects and risks Estrogen- headaches, N/V, bloating, ankle & feet swelling, weight gain, breast soreness, brown spots on skin, eye irritation, and depression Risks: blood clots, heart attack, stroke, and invasive breast cancer in older women with a uterus

19. Treatment Guidelines Estrogen preparations: Oral tablets: most common Topical creams Transdermal patches: applied 1-2 times a week to a hairless area of skin, trunk or upper arms and rotate sites Transdermal gels and sprays: applied daily Suppositories Vaginal ring

20. Non-hormonal Prescription Therapy SSRI’s/SNRI’s Paroxetine Venlafaxine Fluoxetine Gabapentin Clonidine

21. Alternative Therapies Homeopathy Accupuncture Herbs- understand mechanism of action, side affects, and contraindications: dong quai, ginseng Botanical Therapies: Soy, red clover, black cohosh, vit E, Comfort measures for hot flashes

22. Care Managment Counseling on what to expect, what they need to know, why it happens, and treatments Informed Consent for MHT, weight bearing exercise, and calcium supplements Sexual counseling Nutrition Exercise Medications