Menopause
Jill C. Cash, Rhonda Arthur, and Anne Moore
Definition
A.Physiologic or natural menopause is the cessation of menses for 12 consecutive months due to the loss of ovarian follicular activity. Natural or physiologic menopause is a retrospective diagnosis recognized 12 months after the final menses. Natural menopause is generally experienced in women between 45 and 55 years of age.
B.Natural menopause before the age of 40 is considered premature.
C.Premature ovarian failure (POF) is the full or intermittent loss of ovarian function before the age of 40. POF is thought to be caused by genetics, autoimmune disorders, or surgical or chemical interventions.
D.Induced menopause is the abrupt cessation of menses related to chemical or surgical interventions.
E.Perimenopause is caused by fluctuations in ovarian function in the years preceding menopause. The average onset is usually in a woman’s 40s but may occur earlier. Due to fluctuations in ovarian function, pregnancy may still occur and unintended pregnancy should be avoided. Perimenopausal symptoms often last several years, with the average duration being 5 years.
Incidence
A.Currently, 30 million American women are menopausal, with another 6 million to become menopausal in the next 10 years. Two million women enter menopause each year—6,000 every day.
Pathogenesis
A.Physiologic menopause is due to failure of ovarian follicular development and ovarian hormone depletion. The major endocrine changes include the decreasing negative feedback on the hypothalamic-pituitary system with increasing follicle-stimulating hormone (FSH) and luteinizing hormone (LH). When the ovaries cease to produce estrogen, they become unable to respond to FSH, resulting in the cessation of ovulation and menstruation.
Common Symptoms
A.Insomnia.
B.Absence of menses.
C.Urogenital atrophy:
1.Vaginal dryness.
2.Dyspareunia.
3.Dysuria/frequency.
D.Vasomotor symptoms such as hot flashes/night sweats.
E.All postmenopausal spotting/bleeding should be evaluated for pathologic causes.
Subjective Data
A.Determine onset, duration, and course of presenting symptoms.
B.Obtain complete medical history, including medications, and assess for risk of osteoporosis, cardiovascular disease, and breast and endometrial cancer.
C.Obtain complete gynecologic history, including menarche, interval and duration of menstrual cycles, history of dysmenorrhea, and pregnancy history. Question the patient regarding sexual history and contraceptive use (condoms, pills, diaphragm, intrauterine devices [IUDs]).
D.What is the patient’s current menstrual pattern? Is pregnancy a possibility?
E.Review associated symptoms (hot flashes, insomnia, genitourinary symptoms), onset, timing, duration, and impact on daily life.
F.Assess for mood swings and dysphoria.
Physical Examination
A.Check blood pressure (BP), pulse, and respirations.
B.Observe general overall appearance and obtain height, weight, and body mass index (BMI).
C.Auscultate heart, lungs, and abdomen.
D.Percuss the abdomen for organomegaly.
E.Palpate:
1.Palpate thyroid gland.
2.Perform clinical breast exam, including supra/infraclavicular and axillary lymph node assessment.
3.Palpate groin for lymphadenopathy.
4.Palpate the abdomen for masses.
F.Pelvic examination:
1.Inspect external genitalia for fissures, lesions (external genital warts, genital ulcers), and atrophy.
2.Palpate for tenderness, cysts, lesions; milk
the urethra for discharge.
3.Speculum examination:
a.Inspect vagina for presence of discharge (amount, color, odor), rugae, foreign bodies, signs of trauma, inflammation.
b.Inspect cervix for presence of inflammation, friability, discharge.
c.Perform vaginal/cervical cultures and Pap test as indicated.
4.Bimanual examination if indicated (pain, bleeding):
a.Check cervical motion tenderness (CMT); evaluate the size, contour, mobility, and tenderness of uterus. An enlarged or irregular uterus requires additional evaluation. Over time it is normal for the postmenopausal uterus to decrease in size.
b.Palpate the adnexa for tenderness and masses. Ovaries should not be palpable in postmenopausal women and require further evaluation if masses or ovaries are appreciated.
5.Rectovaginal examination, with stool for occult blood in women age 50 and older.
Diagnostic Tests
A.No laboratory tests are diagnostic for menopause.
B.Consider thyroid-stimulating hormone (TSH).
C.Consider qualitative beta human chorionic gonadotropin (HCG), if amenorrhea is sudden.
D.Complete blood count (CBC) if excessive vaginal bleeding.
E.Obtain Pap smear as indicated.
F.Endometrial biopsy as indicated for postmenopausal spotting or bleeding.
G.Transvaginal ultrasonography for enlarged or irregular uterus or inadequate exam due to body habitus.
H.Additional screening as indicated, such as mammogram, hemoccult, cholesterol, and bone mineral density (BMD).
Differential Diagnoses
A.Menopause.
B.Perimenopause.
C.Anemia.
D.Leukemia or other cancer.
E.Menstrual irregularity for any cause of secondary amenorrhea.
F.Pregnancy.
G.Psychosomatic illness.
H.Thyroid disorders.
Plan
A.Patient education:
1.Provide reassurance as to the cause of the absence of menses.
2.Discuss common symptoms of menopause.
3.Provide education regarding healthy lifestyle changes: regular exercise, weight control, smoking cessation, limiting use of drugs and alcohol, and stress reduction.
4.Encourage a healthy diet rich in vitamin D and calcium:
a.Supplement diet with calcium to achieve 1,000 mg a day for women age 19 to 50; 1,200 mg a day for women 50 years of age and older.
b.Vitamin D supplements to achieve:
i.600 IU/d until the age of 70.
ii.800 IU/d for 71 years of age and older.
5.Encourage vaginal lubricants as needed for vaginal dryness, including water-soluble options and coconut oil. See section Genitourinary Symptoms of Menopause.
6.Avoid warm environments, caffeine, alcohol, spicy food, and emotional upset; these may trigger hot flashes.
7.Encourage sleep hygiene and adequate rest.
8.Discuss the risks and benefits of exogenous hormone therapy (HT).
9.Assess and manage women at increased risk for osteoporosis according to current osteoporosis guidelines.
10.Assess and treat cardiac risk factors, including hypertension and dyslipidemia as indicated.
11.
See Section III: Patient Teaching Guide Menopause.
B.Pharmaceutical therapy:
1.Hormone therapy (HT):
a.Estrogen therapy (ET) and estrogen plus progestogen therapy (i.e., HT) may be a strategy for management of menopausal symptoms. All women should be counseled regarding the indications, risk, and benefits of HT. HT is indicated for treatment of vasomotor symptoms: hot flashes and night sweats, and vulvovaginal atrophy and painful intercourse. Use of exogenous ET prevents bone loss when used for symptom management but is not indicated for treatment of osteoporosis. It may be used as a strategy for women with osteopenia if other pharmacologic methods are insufficient or inadequate (see Osteoporosis/Kyphosis/Fracture
section of Chapter 22).
Risks of HT include an increased risk of venous thromboembolism (VTE), and breast cancer. Longterm unopposed ET increases the risk of endometrial cancer; that is why all women using ET must be prescribed a progestogen concomitantly. Potential areas of concern with the use of HT include gallbladder disease and cardiovascular events. ET should not be prescribed for women with a history of significant cardiovascular disease warranting procedures such as coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA). The provider should carefully screen and educate the patient prior to initiating HT (see Table 17.4).
b.Postmenopausal women without an intact uterus generally are not prescribed progesterone and are treated with estrogen alone.
c.Oral HT may be given either sequentially or continuously. The sequential regimen is given daily, with progesterone given 12 to 14 days of the month. It is common to have withdrawal bleeding with this regimen. An alternative to this is the continuous regimen, in which both estrogen and progesterone are taken daily.
2.Transdermal estrogen: patches, creams, sprays, lotions. Generally considered safer than oral medications with respect to VTE risk, as the first-pass metabolism effect is avoided and lower doses can achieve a therapeutic effect (see Table 17.5).
3.Transvaginal estrogen (see Table 17.6).
4.Absolute contraindications to use of ET also apply to use of oral and topical estrogen (breast cancer, active liver disease, and/or history of recent thromboembolic event). Vaginal estrogen creams are minimally systemically absorbed. Screening for endometrial hyperplasia and/or use of a progestogen episodically should be considered on an individual basis.
5.Absolute contraindications to ET:
a.Acute liver disease.
b.Cerebral vascular or coronary artery disease, myocardial infarction (MI), or stroke.
c.History of or active thrombophlebitis or thromboembolic disorders.
d.History of uterine or ovarian cancer.
e.Known or suspected cancer of the breast.
f.Known or suspected estrogen-dependent neoplasm.
g.Pregnancy.
h.Undiagnosed, abnormal vaginal bleeding.
6.Relative contraindications to ET:
a.Active gallbladder disease.
b.Familial hyperlipidemia.
7.Absolute contraindications to progesterone therapy:
a.Active thrombophlebitis or thromboembolic disorders.
b.Acute liver disease.
c.Known or suspected cancer of the breast.
d.Pregnancy.
TABLE 17.4 Hormone Therapy