the facts about menopause - shawnee mission€¦ · · 2015-10-05the facts about menopause ... 3...
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The Facts About
Menopause
Amanda N. Healy, MD
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About Me
Education
University of Kansas Undergraduate
University of Kansas School of Medicine
University of Missouri- Kansas City Residency Training
Board Certified in Obstetrics and Gynecology
Women’s Clinic of Johnson County
Office locations at Menorah, Shawnee Mission and Olathe
913-491-4020
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Educational Goals
Dispel Common Myths Surrounding Menopause
Review Normal Menstrual Cycle
Discuss the Physiology of Menopause
Discuss the Common Symptoms of Menopause
Discuss Treatment Options
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Fact or Fiction?
“You can’t get pregnant during menopause”
Fiction
Oldest recorded natural conception was a 59 year
old woman
Twin pregnancy more common with increasing
age
It is possible to become pregnant until one year
has elapsed since your last period
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Fact or Fiction?
“Your sex drive goes down in menopause”
Fiction
Some women have a resurgence of their sex life
with less household demands and more time to
focus on their partner/relationship
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Fact or Fiction?
“Menopause causes weight gain”
Fiction
Baseline metabolism decreases with age, but
does not appear to be related to estrogen levels
Body composition does change with decreased
estrogen: decreased muscle mass, increased
central fat distribution
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Fact or Fiction?
“I will go through menopause at the same time
my mom did”
Fact
The age of menopause is often genetic and your
age of menopause will likely be similar to your
mother’s and older sister’s
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Fact or Fiction?
“Men don’t go through menopause”
Fact
Men continue to produce sperm throughout life,
whereas women have all the eggs they will ever
have at birth
Testosterone levels do gradually decline in men
with age (about 1% per year after age 30)
Can cause symptoms in some men: decreased
libido, reduced muscle mass, insomnia and fatigue
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Normal Menstrual Cycle
The menstrual cycle is the body’s monthly
preparation of an egg for possible pregnancy
Begins at average age of 11.5
Ends at average age of 51
Occurs every 28 days
Ovulation occurs at the mid point, cycle day 14
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Normal Menstrual Cycle
1) Pituitary gland (Brain) makes FSH (follicle stimulating hormone) tells the ovary to prepare an egg
2) The developing egg (Maturing follicle) produces estrogen to thicken uterine lining
3) Estrogen thickens uterine lining and tells the brain to release LH (luteinizing hormone) which releases the mature egg (Ovulation)
4) The follicle from which the egg is released (Corpus Luteum) produces progesterone
5) If the egg is not fertilized, progesterone levels drop and signal the uterine lining to shed (Menstruation)
6) If the egg is fertilized, pregnancy hormone (hCG) signals the corpus luteum to continue making estrogen and progesterone
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What is Perimenopause
You are born with all of the follicles you will ever have
Some follicles degenerate without every ovulating
Some follicles are lost through ovulation
As the number of follicles you have decreases, it takes
more FSH to stimulate ovulation
Because your FSH is elevated, the odds of releasing
more than one egg per cycle increases
Because the number of follicles is lower, some months
no egg is released (non-ovulatory cycle)
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What is Perimenopause?
As menopause nears, you begin to make less
estrogen
Changes in menstrual pattern
Longer/heavier cycles
Skipped periods
Hot flashes/night sweats may occur
Insomnia
Menstrual migraines (when estrogen is at it lowest point of the month, some women are prone to
migraines)
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What is Menopause?
The complete cessation of menstrual cycle for 1 year
Marks the end of reproductive years
Decreased production of ovarian estrogen
Estrogen level gets low enough that uterine lining is no longer thickened
Average age is 51
Menopause prior to 40 is a medical condition and requires treatment
Can occur with removal of ovaries at the time of surgery
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Symptoms of Menopause
Last from Months to Years
Hot Flashes/Night Sweats
Vaginal dryness and painful intercourse
Decreased libido
Urinary urgency, Urinary Tract changes
Insomnia
Weight gain
Other symptoms
Fatigue, Headache, Skin/Hair Changes, Forgetfulness, Depression/Mood Changes, Joint Pain
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Symptoms of Menopause
Hot Flashes
The most common symptom of menopause
Experienced by 75% of menopausal women
Sudden feeling of heat, especially in upper body, chest, face and neck
Last from seconds to a few minutes
Can occur more frequently at night and disrupt sleep (Night Sweats)
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Symptoms of Menopause
Vaginal Dryness
Vaginal tissue has many estrogen receptors
Before menopause, the tissue is thick, moist and has
folds (rugae) that allow for stretching during sex
Vaginal tissue thins and becomes dryer after
menopause
Can cause sexual discomfort due to dryness and tearing
of the thin tissue
More likely to get vaginal infections (discharge, odor,
itching/burning)
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Symptoms of Menopause
Decreased Libido
Multifactorial
Mood/self esteem changes associated with aging
Sexual discomfort
Underlying relationship conflict
Other health problems
One of the most common complaints at annual
exam (even in women in 20s and 30s)
1 Decreased desire Most Common
2 Decreased arousal
3 Inability to achieve orgasm
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Symptoms of Menopause
Urinary Tract Changes
Urethra (tube that carries urine out of the bladder) thins and can become irritated
Can cause urinary frequency, or Overactive Bladder (OAB)
Can increase risk of urinary tract infections
These changes may worsen previously existing Urge Incontinence (leakage with cough, laugh, sneeze, exercise)
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Symptoms of Menopause
Insomnia/Sleep Disorders
Sleep problems are reported by nearly 50% of
menopausal women
Factors that negatively influence sleep during
menopause
Hot flashes and night sweats
Nocturia (waking to urinate)
Depression/stress
Reduction in ovarian hormones
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Symptoms of Menopause
Weight Gain
Average weight gain of women in menopause 5lbs
More likely related to aging/lifestyle changes than menopause
Decreased estrogen leads to increased abdominal fat storage
Osteoporosis leads to kyphosis/loss of height
Appearance of increased waist size
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Long Term Consequences of
Menopause
Increased rate of bone loss
and Osteoporosis
Decreased mobility
Increased fracture risk
Increased fall risk
Number one cause of
Emergency Visits in
people 65+
Loss of height
Chronic back pain
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Long Term Consequences of
Menopause
Risk of Heart Disease Increases
Number 1 cause of death age 65+
Risk of Dementia Increases
These risks are not reduced with HRT
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Treatment Options
Non-medical treatments
Targeted therapy for symptom relief
Hormone Therapy
Systemic Hormone Therapy
Localized Hormone Therapy (treatment of
vulvovaginal symptoms only)
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Non Medical Treatment
Study proven Non Medical ways to treat menopause symptoms yourself
Hot Flashes/Night Sweats
Dressing in Layers
Avoiding alcohol/caffeine
Decreasing ambient temperature
Deep breathing during hot flashes
Vaginal Dryness/Pain
Vaginal Moisturizers/Lubricant
Mood/Sleep Problems
Aerobic exercise
Sleep hygiene
Decreased Libido
Aerobic exercise
Increased quality time with partner (especially trying new/adventurous things)
Sex Therapy
Osteoporosis
Aerobic and weight bearing exercise
Diet adequate in Calcium/Vit D
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Targeted Therapy
Targeted therapy is non-hormonal therapy directed at a specific symptom of menopause
Hot Flashes
Antidepressants (LexaproTM, Zoloft TM)
Clonidine
Insomnia
Sleep aids
Osteoporosis medications
Calcium/Vit D Supplementation
Bisphosphonates
SERMs
Calcitonin
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Hormone Therapy
Localized Treatment
Topical estrogen cream, pill or ring
Used for treatment of:
Vaginal atrophy
Vaginal drynes
Painful intercourse
Recurrent bladder infections
Systemic Hormone treatment does not usually relieve vaginal symptoms
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Hormone Therapy
As previously discussed, there are two female
hormones: Estrogen and
Estrogen
Thickens uterine lining
It’s decrease is responsible for most menopause
symptoms
Progesterone
Keeps uterine lining thin
Has more breast tissue receptors than estrogen
Has a minor roll in menopause symptoms
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Hormone Therapy
Women who still have their uterus require
combined estrogen and progesterone therapy
Progesterone reduces the risk of endometrial
thickening (hyperplasia), that can lead to
endometrial cancer
Women who have undergone hysterectomy
may be treated with Estrogen only
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Hormone Therapy
Women’s Health Initiative Study 2002
Raised concerns about increased risk of heart
disease, stroke, blood clots and breast cancer with
HT
Average age of women in the study was 64
Risks are not the same for
perimenopausal/menopausal women <59
Follow up studies show that risks differ depending
on age of patient and length of treatment
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Hormone TherapyBenefits and Risks of Estrogen Only
Benefits
Most effective therapy for perimenopause/menopause symptoms
Prevents bone loss and fractures
Local treatment relieves vaginal dryness
Local treatment decreases bladder infection occurrence
Decreases risk of breast cancer (with <7 years use)
Risks
Increases risk of stroke, blood clots
Increases risk of gallbladder disease
Increases risk of endometrial cancer
Does not prevent heart disease
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Hormone TherapyBenefits and Risks of Combined
Estrogen/Progesterone
Benefits
Most effective therapy for
perimenopause/menopau
se symptoms
Prevents bone loss and
fractures
Risks
Increases risk of stroke,
blood clots
Increases risk of
gallbladder disease
Increases risk of breast
cancer with >5 years use
(sooner with genetic pre-
disposition)
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Hormone Therapy
Multiple Preparations
Estrogen only and combined preparations
available in
Pill
Patch
Topical spray/cream
Vaginal cream, suppository, tablet
The particular type of estrogen or progesterone
may have different associated risks
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Hormone Therapy
ACOG and North American Menopause Society (NAMS) statement on “Bioidentical” Hormones
Plant derived hormones similar to those produced by the ovaries
Several available FDA approved forms
Oral or vaginal progesterone
Oral or transdermal Estradiol
Also used to describe “compounded” hormones obtained from compounding pharmacies
These have not been tested for effectiveness, safety, dose accuracy or absence of contaminants
Both ACOG and NAMS do not recommend use of compounded hormones
Evidence of superiority in symptom relief or safety is lacking
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Hormone TherapyNew Developments
SERM = Selective Estrogen Receptor Modulator
Act to stimulate estrogen receptors at certain tissues and inactivate receptors at other tissues
Estrogen receptors in: Brain, Breasts, Bone, Liver, Uterus, Ovaries, Vaginal tissue, Cardiovascular system
First SERM used Tamoxifen
Blocks estrogen receptors at breast
Used to reduce risk of recurrence of breast cancer in women previously diagnosed with ER positive breast cancer
Used to reduce risk of breast cancer in high risk women
Side effect Stimulates endometrial estrogen receptors (can increase risk of endometrial cancer)
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Hormone TherapyNew Developments
DuaveeTM
First FDA approved estrogen plus SERM for
treatment of menopause symptoms in women with
a uterus
SERM blocks estrogen stimulation of endometrium avoids need for progesterone
May decrease risk of breast cancer by avoiding
progesterone
NO ACOG or NAMS opinion on this new medication yet
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Hormone TherapyNew Developments
Looking Forward Could develop a SERM to
treat all menopause sx while eliminating the HRT
risks
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Hormone Therapy
American College of Obstetricians and
Gynecologists (ACOG) Statement
HRT is appropriate therapy for menopause
symptoms and osteoporosis prevention in healthy
women
Use the lowest effective dose for the shortest
amount of time possible
Is not appropriate for women with history of blood
clot, stroke, cardiovascular disease, estrogen related cancers or liver disease
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Resources
American College of Obstetricians and Gynecologists Frequently Asked Questions Menopause (FAQ047, February 2013)
American College of Obstetricians and Gynecologists Patient Education Fact Sheet Hormone Therapy (PFS003: Hormone Therapy, April 2013)
The North American Menopause Society www.menopause.org
Compounded bioidentical menopausal hormone therapy. Committee Opinion No. 532. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:411–5.
Management of menopausal symptoms. Practice Bulletin No. 141. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:202–16
Hormone therapy and heart disease. Committee Opinion No. 565. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1407–10.
Postmenopausal estrogen therapy: route of administration and risk of venous thromboembolism. Committee Opinion No. 556. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:887–90.
Estrogen Receptors/SERMs. National Cancer Institutehttp://www.cancer.gov/cancertopics/understandingcancer/estrogenreceptors/AllPage
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