MENOPAUSE

  physiological (average age 51) premature ovarian failure surgical Definitions   Menopause cessation of me...

 

• physiological (average age 51)
• premature ovarian failure
• surgical
  

Definitions

 

Menopause

• cessation of menses for > 6 months
  

 

Climacteric

1. period characterized by cessation of menses
2. includes vasomotor, endocrine, somatic changes
   

Symptoms

 

1. symptoms associated with estrogen deficiency
2. vasomotor (hot flushes)
3. atrophic changes (vagina, urethra, bladder)
   • dyspareunia, vaginal itching, bleeding
   • urinary frequency, urgency, incontinence
4. skeletal (osteoporosis)
5. decreased breast size
6. skin thinning and loss of elasticity
7. sleep/wake disturbances (insomnia)
8. mood disturbances : depression, irritability, fatigue

Diagnosis

 

1. increased levels of FSH (> 40 IU/L)
2. decreased levels of estradiol

Treatment

 

1. hormone replacement treatment (doses much lower than OCP)
   • transdermal or oral
   • cyclic estrogen (Premarin) 0.625 mg OD 1-25 plus progesterone (Provera) 10 mg OD, day 14 (or 15, 16) to day 25, or
   • long cycling Premarin 0.625 mg daily plus Provera 5 mg for 14 days 3 months, or
   • continuous combined Premarin 0.625 mg plus Provera 2.5 mg daily
   • unopposed estrogen increases the risk of endometrial cancer without the addition of Provera, but Provera is not needed if previous hysterectomy
2. calcium supplement
3. physical exercise
4. evening primrose oil
   

Indications for Hormone Replacement Therapy 

 

1. relief of symptoms - see above (vasomotor, atrophy, insomnia)
2. protection against osteoporosis
3. osteoporotic risk factors
   • caucasian or oriental race
   • thin habitus
   • immobilization or physical inactivity
   • estrogen deficiency/premature menopause   
   • drugs: chronic corticosteroid therapy, chronic use of
   • heparin, anticonvulsants, or thyroid replacement
   • diet: low calcium, low vitamin D, high caffeine
   • high alcohol, or high protein
   • other factors: smoking, family history
4. cardiovascular protection
• estrogen significantly reduces risk of CAD
• decreases LDL and increases HDL
  

Side Effects of HRT

 

1. abnormal uterine bleeding - requires endometrial biopsy if  bleeding
   other than withdrawal bleeding with combined E/P therapy 
2. mastodynia (breast pain)
3. worse in progesterone phase of combined therapy
4. edema, weight gain, heartburn, nausea
5. controversy with respect to HRT and breast cancer risk
   

Contraindications of HRT

 

Absolute

1. undiagnosed vaginal bleeding
2. known or suspected cancer of breast or uterus
3. acute liver disease or chronically impaired liver function
4. acute vascular thrombosis or history of severe thrombophlebitis or thromboembolic disease

 

Relative

1. pre-existing uncontrolled hypertension
2. uterine fibroids and endometriosis
3. familial hyperlipidemias
4. migraine headaches
5. family history of estrogen-dependent cancer
6. chronic thrombophlebitis
7. diabetes mellitus
8. gallbladder disease
9. fibrocystic breasts
10. obesity
11. smoking

Selective Estrogen Receptor Modulators (SERMS)

 

1. e.g. raloxifene (Evista) 
2. mimics estrogen effects on cardiovascular system and bone
3. avoids estrogen-like action on breast and uterine tissue
4. does not relieve hot flashes (may make them worse)