FPN – Menopause

Oct 30, 2019 admin LÃO KHOA, PHỤ KHOA, SINH DỤC 0

The average age at menopause in the United States is 51 years with a normal range from 40 to 58 years of age

Menopause

Aka: Menopause, Perimenopause, Postmenopause

II. Definition

  1. Physiologic transition to cessation of Ovulation and menstruation, and reduced ovarian endocrine function

III. Symptoms: Perimenopause (lasts 3-8 years)

  1. Disturbance in menstrual pattern
    1. Shorter menstrual interval
    2. Heavier menstrual flow
  2. Hot Flashes (50-75% of women)
    1. Worse with higher BMI, Tobacco use and black race
    2. Gold (2006) Am J Public Health 96(7): 1226-35 [PubMed]
  3. Atrophic conditions (responds to Estrogen)
    1. Vaginal Mucosa (Atrophic Vaginitis)
      1. Vaginitis or vaginal Pruritus
      2. Dyspareunia
    2. Urethritis
      1. Dysuria, urgency, or Urinary Frequency
      2. Recurrent Urinary Tract Infection
  4. Neuropsychological changes
    1. Major Depression
      1. Estrogen Replacement efficacious as Antidepressant
      2. Soares (2001) Arch Gen Psychiatry 58:529-34 [PubMed]
    2. Insomnia
    3. Hippocampus changes
      1. Decreased memory
      2. Decreased learning
      3. Decreased navigation or way finding
  5. Testosterone Deficiency (worse in surgical Menopause)
    1. Decreased energy and sense of well being
    2. Decreased sexual desire, arousability, and orgasm
      1. Decreased clitoral sensitivity
      2. Decreased nipple sensitivity
    3. Thinning of pubic hair

IV. Labs

  1. Follicle Stimulating Hormone (FSH)
    1. Not necessary to confirm diagnosis
    2. May be indicated for perimenopausal women age <45
    3. FSH >25 mIU/ml confirms Perimenopause or Menopause
      1. Measure on any day if patient is not having Menses
      2. Measure on Day 3 of cycle in menstruating women
      3. Measure Day 6-7 of Oral ContraceptivePlacebo week
        1. Confirms Birth Control no longer needed
  2. Thyroid Stimulating Hormone (TSH)
    1. Consider for atypical or young presentation
    2. Vasomotor (hot flash) symptoms predominate
  3. Vaginal pH
    1. pH > 4.5 indicates Menopause
      1. Women without Vaginitis and not receiving HRT
    2. pH <4.5
      1. Can be used to monitor for adequate HRT response
    3. References
      1. Roy (2004) Am J Obstet Gynecol 190:1272-7 [PubMed]

V. Diagnosis

  1. Serum FSH level are not necessary in age over 45 years
  2. Perimenopause: Hot Flashes and irregular Menses
  3. Menopause: Hot Flashes and no Menses for 6 months

VI. Management: General Approach

  1. See Health Concerns in the Elderly
  2. See symptom management below for Menopause and Perimenopause
  3. Osteoporosis Prevention
    1. See Osteoporosis and Osteoporosis Management
    2. See Fall Prevention in the Elderly
    3. Calcium Supplementation at 1200 mg per day
    4. Vitamin D Supplementation 800-1000 IU per day
  4. Cardiovascular Disease Prevention
    1. Postmenopausal women have a higher Incidence of Angina and worse CAD outcomes than men
    2. Postmenopausal women have a higher Incidence of Heart Failure with Preserved Ejection Fraction (HFpEF)
    3. Reduce CVA, HFpEF, CAD Risk by controlling Hypertension, Atrial Fibrillation, Diabetes Mellitus, Tobacco abuse, Obesity
    4. See Cardiac Risk Management
    5. See Exercise in the Elderly
    6. Tobacco Cessation
  5. Cerebrovascular Disease Prevention
    1. Manage Hypertension
      1. See Hypertension in the Elderly
    2. Manage Atrial Fibrillation
      1. See CHADS2-VASc Score
  6. Cancer Prevention
    1. Breast Cancer Screening
    2. Cervical Cancer Screening
    3. Colorectal Cancer Screening
  7. Immunizations
    1. Influenza Vaccine annually
    2. Herpes Zoster Vaccine for 1 dose routinely at age 60 years
    3. Pneumococcal Vaccine routinely at age 65 years (Prevnar 13 and after 1 year, Pneumovax 23)
    4. Tetanus Vaccine (Tdap for at least 1 dose after age 19, then Td every 10 years)
  8. Sexual health
    1. Women are sexually active at least once weekly in >65% of cases
      1. Sherman (2005) J Women Aging 17(3): 41-55 [PubMed]
    2. Sexually Transmitted Infection occurs in at least 1% of women over age 65 years
      1. Smith (2009) Am J Public Health 99(11): 2055-62 [PubMed]
  9. Psychosocial Concerns
    1. See Depression in Older Adults
    2. See Alcohol Abuse
    3. See Intimate Partner Violence

VII. Management: Menopausal Symptom Management (and Osteoporosis Prevention)

  1. See Vasomotor Symptoms of Menopause
  2. See Atrophic Vaginitis
  3. Estrogen Replacement Therapy
    1. Weigh risks (CAD, DVT, CVA, Breast Cancer) versus benefits (Osteoporosis, Hot Flashes)
      1. Consider for women under age 60 years old or within 10 years of Last Menstrual Period
      2. After this, with advancing age, risks of CVA, MI, Dementia outweigh benefits
    2. See Cardiac Risk Management
    3. See Estrogen Replacement for a general overview of risks, benefits and protocols
      1. Estrogen Replacement is recommended only for symptom control (e.g. Hot Flushes)
      2. ACOG and AAFP do not recommend Hormone Replacement for chronic disease prevention
      3. (2013) Obstet Gynecol 121(6): 1407-10 [PubMed]
      4. Manson (2013) 310(13): 1353-68 +PMID:24084921 [PubMed]
    4. See Specific Estrogen Replacement Options
      1. Continuous Estrogen Replacement
      2. Sequential Estrogen Replacement
      3. Vaginal Estrogen
      4. Transdermal Estrogen

VIII. Management: Perimenopausal Symptom management

  1. See Vasomotor Symptoms of Menopause
  2. Agents
    1. Provera 5-10 mg for 12 days per month
      1. Prevents Endometrial Hyperplasia
    2. Oral Contraceptives (OCP)
      1. Choose continuous low Estrogen option (e.g. Lo Loestrin Fe)
    3. Levonorgestrel IUD (Mirena)
      1. Stops Menstrual Bleeding but risk of atrophy
    4. Sequential Hormone Replacement
      1. Risk of pregnancy (HRT doses are much lower than OCP doses and inadequate for Contraception)
  3. Evaluating end of Perimenopause for women on OCPs
    1. Identify when to switch to post-Menopause management
    2. Precaution
      1. Estrogen Replacement dosages are much lower than OCP doses and do NOT prevent pregnancy
      2. For women using OCPs for Contraception, transition to Estrogen Replacement should be carefully planned
    3. Protocol 1: Obtain Serum FSH on 6th day of OCPs Placebo pills
      1. Menopause suggested by FSH > 30 IU/L
    4. Protocol 2: Obtain Serum FSH and Estradiol level 2 weeks after stopping Oral Contraceptives
      1. Menopause suggested by a rise in FSH and no increase in Estradiol
      2. Castracane (1995) Contraception 52(6): 371-6 [PubMed]
    5. Protocol 3: Age based
      1. Likely safe to transition from OCP to Estrogen Replacement in mid-50s
      2. Allen (2013) CMAJ 185(7): 565-73 [PubMed]

IX. Management: Adjunctive Therapy

  1. Precaution
    1. This is controversial and not generally recommended due to potential for adverse effects
  2. Consider Androgen Replacement in Women
    1. Testosterone Replacement in Women
    2. DHEA Replacement in Women
  3. Combination Preparations
    1. E2P4T (Estrogen, Progesterone, Testosterone)
      1. Available from compounding pharmacies
    2. DHEA-S (see DHEA-S Replacement in Women)
      1. Used with the E2P4T

X. Management: Other agents

  1. See Vasomotor Symptoms of Menopause
  2. New agents
    1. Amberen (not recommended)
      1. Combination of multiple components (calcium, Magnesium, Vitamin E, Zinc, Ammonium Succinate)
      2. No evidence of benefit and expensive
      3. (2013) Presc Lett 20(2): 11

My Notes:

The Stages of Reproductive Aging Workshop STRAW+10 defines:

  • Early menopausal transition (stage –2): persistent difference of 7 days or more in the length of > = 10 consecutive cycles
  • Late menopausal transition (stage –1): amenorrhea for 60 days or longer
  • Early postmenopause (stages +1a, +1b, +1c):
  • Stage +1a lasts for 1 year after FMP and marks the end of perimenopause
  • During stages +1a and +1b, lasting approximately 2 years after the FMP, vasomotor symptoms are most likely to occur.
  • Late postmenopause (stage +2): Hormonal levels stabilize during this stage. Urogenital and vaginal symptoms typically become more prominent.
  • Induced menopause: surgical bilateral oophorectomy, radiation/chemotherapy ablation
  • Premature menopause: age of 40
  • Early menopause: menopause before age 51
  • Premature ovarian failure (POF): age 40

Figure 1: The Stages of Reproductive Aging Workshop +10 staging system for reproductive aging in women (1).

 

, the stages of the menopausal transition range from
[–2 or early menopausal transition to –1 or late menopausal
transition. The term perimenopause is similar and
often used interchangeably with menopause transition.
However, perimenopause generally encompasses at least
1 year postmenopause as well as the time leading to the FMP (Final Menstrual Period)

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