Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Perimenopause / Postmenopause
N95.9: Unspecified menopausal and perimenopausal disorder
GENERAL CARE MEASURES
I. DEFINITION
the menopause is the landmark event of the climacteric, the 10- to 15-year period, beginning at about age 35 to 40, when women’s bodies are chang- ing and preparing for cessation of menses. a woman cannot say that she has gone through menopause until at least 1 year has passed without any menstrual period (uterine bleeding). the postmenopausal time begins when menopause is complete and menses no longer occur. For women today, the postmenopausal years may comprise as much as three-eighths of their lives or more, the age for menopause being about 50 years in the united states (mean 50.4 years). a woman who has had a hysterectomy (removal of uterus only) is not considered menopausal with cessation of menses.
II. ETIOLOGY
a. Physiologic: the gradual diminution of estrogens, resulting in cessa- tion of ovulation and thus of menstruation
B. anatomic: surgical removal of the uterus and ovaries resulting in sur- gical menopause, an abrupt end to ovulation and menstruation
III. HISTORY
a. What the patient may present with
1. Changes in character of the menstrual cycle
a. menstrual periods that are more frequent, less frequent, of lon- ger or shorter duration
b. scanty flow
c. Flooding at onset of flow
d. Gradual or abrupt cessation of menses for 1 or more months
e. irregular periods over a time frame or abrupt cessation of menstruation
2. Changes related to menopause and/or the aging process
a. Hot flashes, hot flushes
b. Vaginal dryness, atrophy of vaginal tissues
c. night sweats
d. dry skin and hair; skeletal pain or stiffness
e. Graying of hair
f. Loss of skin elasticity
g. alterations in sleep patterns
h. alterations in sexual response: longer time needed for arousal, lessened vaginal lubrication
i. mons and vulva flatten, less fatty tissue padding, thinning of pubic hair
3. recent history of gynecologic surgery: hysterectomy, oophorec- tomy, salpingectomy, dilation and curettage
B. additional information to be considered
1. menstrual history, past year
2. Contraceptive use to present
3. obstetrical history: pregnancies, abortions, stillbirths
4. Gynecologic history: surgery, endometriosis, infertility, anoma- lies, last Pap smear, any breast problems, last mammogram, sex- ually transmitted infection (sti), infections; any stress or urge incontinence
5. sexual history: dysfunction, unresponsiveness, recent changes, use of sex toys, high-risk sexual behaviors
6. Life event changes: resumption of career, retirement, caring for older family members, adult children in or out of home, divorce, separation, marriage, new sexual relationship, caring for grand- children, loss of a child
7. Lifestyle: exercise, diet, smoking, recreation, stressors, recre- ational drugs
8. medical history: chronic disease; medications (over the counter [otC], prescription); depression, anxiety
9. Family medical history
10. use of complementary therapies (botanicals, homeopathics, mas- sage, tai chi, acupuncture, Chinese medicine, aromatherapy, etc.)
11. Beliefs about menopause and expectations
12. domestic violence, elder abuse
IV. PHYSICAL EXAMINATION
a. Vital signs
1. Blood pressure
2. Pulse
3. Height
4. Weight, body mass index (Bmi)
B. General health examination
1. Head
2. neck
3. Heart
4. Lungs
5. abdomen
6. extremities, joints, spine
C. external examination for lesions, infection, atrophy, anomaly
1. urethral os
2. Clitoris
3. Labia
4. Perineum
d. Vaginal examination (speculum)
1. Walls
2. discharge
3. Lesions in the vaginal vault, noting if posthysterectomy
4. Cervix
5. Careful inspection of entire vagina
e. Bimanual examination
1. adnexa
a. tenderness
b. masses
c. Palpable ovaries, if present
2. uterus
a. size
b. mobility
c. tenderness
d. masses
3. Cystocele, rectocele, urethrocele
F. rectal examination
V. LABORATORY EXAMINATION
a. appropriate cultures, smears if suspicion of infection
B. Pap smear/human papillomavirus (HPV) screen per the american society for Colposcopy and Cervical Pathology (asCCP) guidelines
C. mammogram per american Cancer society (aCs) guidelines: annu- ally at 40 and after; may be altered with family history or personal risk factors for breast cancer and new recommendations from the aCs or national Cancer institute (nCi)
d. Consider serum follicle-stimulating hormone (FsH) level to assess for menopause if no menses for 12 months or on hormonal contraception age 50 years or older and/or desire to consider hormone therapy (Ht; FsH equal to or greater than 2–40 miu/mL); discontinue hormones for the 2 weeks prior to serum assay of FsH
e. Blood glucose and lipid levels, thyroid-stimulating hormone (tsH), 25-hydroxyvitamin d
VI. DIFFERENTIAL DIAGNOSIS
a. Carcinoma of genital tract
B. Pregnancy
C. endocrine disorders
d. decreased nutritional state; obesity, malnutrition
e. marked increase in exercise regimen
VII. TREATMENT
a. medication
1. Perimenopausal: consider low-dose oral contraceptive or other hormonal contraception after assessment for risks, desire for contra- ceptive protection; consider cycling with a progestin if intermenstrual time decreases and/or heavy bleeding/flooding characterize menses
2. Postmenopausal: consider nonhormonal or hormone (see Hormone Therapy section) interventions per clinical picture and patient’s wishes
B. General measures
1. teaching about normal menopausal symptoms, changes with aging, need for more time for arousal, use of supplemental lubri- cation (saliva, water-soluble lubricants—these come as creams, jellies, and vaginal inserts); nonhormonal agents to restore/ maintain vaginal mucosa and vaginal moisture, such as replens, Comfrey ointment, vitamin e supplement at 100 to 600 mg/d, or evening primrose oil two to four capsules/d (also helpful for hot flashes); Calendula, black cohosh (20–40 mg twice a day), changes in sexual response that accompany the removal of the uterus/ ovaries
2. teaching about self-care: diet, exercise (aerobic, weight bearing, and strengthening), prevention of osteoporosis (calcium intake 1,200–1,500 g/d, dosage will vary according to age and individual need). Vitamin d is necessary for absorption of calcium in the intes- tines; recommended dosage is 400 iu per day for adults and 600 to 800 iu for adults over age 61, and dosage may vary with exposure to sunlight. Breast self-examination; need for Pap smear as indi- cated by asCCP guidelines and pelvic examination per american College of obstetricians and Gynecologists (aCoG) guidelines; regular mammograms; contraception until 1 year without men- ses signs; and symptoms of problems: postmenopausal bleeding; prevention of vaginal infections
3. teaching about urinary health: six to eight glasses of water a day, decrease caffeine, Kegel exercises; smoking cessation
4. teaching about triggers for hot flashes—electric blanket, alcohol, spicy foods, overheating, constrictive clothing; symptom manage- ment with evening primrose oil, licorice root, phytoestrogens, sage or sarsaparilla, black cohosh (see Complementary and Alternative Therapies, Chapter 3)
5. Consider nonhormonal synthetic medication and bioflavonoid alternatives for symptom management; other botanicals, homeopathic medicines (e.g., for sleep disorders: hops, valerian tea or tincture, melatonin, exercise, relaxation techniques; for memory: ginkgo biloba [120–240 mg/d]; (see Complementary and Alternative Therapies, Chapter 3)
6. diet: low fat; avoid or decrease caffeine; zinc 15 mg/d in foods and/ or in supplements; vitamin B and C complex vitamins; fiber; phy- toestrogens (soy protein isoflavone 40–160 mg/d; lignans such as flaxseed, cereal bran; other isoflavones: chick peas, legumes, blue- grass, clover)
VIII. COMPLICATIONS/RISKS
a. Pregnancy
B. Carcinoma of reproductive tract
C. Breast cancer (risk is higher after menopausal years)
d. incapacitating menopausal symptoms: hot flashes that disrupt normal life, night sweats, sleep disturbances
e. osteoporosis
F. Possible increased risk for heart attacks, coronary heart disease (see Appendix E)
G. interactions, adverse effects of herbals, vitamins; negative interactions with prescription medications
IX. CONSULTATION/REFERRAL
a. to physician or other clinician, as appropriate for complications previously listed
B. sex therapist for prolonged or severe disruption in sexual relationship
C. Counseling: stresses of the middle years, depression
d. mammogram, sigmoidoscopy, or colonoscopy per protocol and risk
e. Bone mineral density
F. Consider consultation with homeopath, herbalist, naturopath, ayurvedic practitioner
X. FOLLOW-UP
a. Well-woman visit, Pap smear, pelvic examination as recommended by aCoG guidelines
B. mammograms and bone mineral density testing as recommended
C. as needed if problems continue or become exacerbated
See Bibliographies.
Websites: www.asccp.org/Portals/9/docs/ASCCP%20updated%20Guidelines% 20%20-%203.21.13.pdf; www.cancer.org/cancer/breastcancer/moreinformation/ breastcancerearlydectection/breast-cancer-early-dectection-ACS-recs; www.menopause
.org; www.herbalgram.org