Perimenopause, Menopause and Postmenopause (2050)

What is the commonly used estrogen preparation?

-0.625mg of conjugated estrogen (Premarin) daily -may need higher dose for symptom relief

To receive the protective benefit of progesterone, a woman must take what dose?

-5-10mg of medroxyprogesterone (Provera), indicated for 12 days of each mth on a cyclical regimen OR -2.5mg if on a continuous regimen *if estrogen is to be increased for symptom relief, the progesterone should also be increased

Loss of estrogen is a significant contributor to age related changes. What are these changes?

-Critical change: greater risk for coronary artery disease and osteoporosis -Other changes: -redistribution of fat -easier weight gain -muscle and joint pain -reduced skin elasticity -changes in hair (amount, distribution) -atrophy of external genitalia and breast tissue

Describe hormone replacement therapy (HRT) - drug therapy for menopause symptoms?

-HRT was once standard in Canada for menopause symptoms HRT includes: -estrogen for women without ovaries or, -estrogen and progesterone for women with a uterus (estrogen alone may cause buildup in uterus and lead to cancer)

Menopause is a universal phase in a woman's life, however, perception of this change varies by culture:

-Hindu women may look forward to it -when elders are revered, menopause is a transition to being a 'wise woman' -NA culture, negative about aging and high value on youth, therefore menopause symptoms viewed as troublesome and need to be treated Thus, menopause is a milestone embedded in each women's personality and culture

What are the other forms of progesterone?

-Norethindrone -micronized progesterone creams, dermal patches, gels and lotions -rings placed around the cervix -subcutaneous pellets

Perimenopause is a time of erratic hormone fluctuations. What are the S&S of diminished estrogen? -vasomotor -genitourinary -psychological -skeletal -cardiovascular -dermatological

-Vasomotor: hot flashes and night sweats -Genitourinary: atrophic vaginitis, dyspareunia (secondary to poor lube), incontinence -Psychological: emotional liability, changes in sleep, decreased REM sleep -Skeletal: increased fracture rate (esp. vertebral bodies, but also humerus, distal radius, upper femur) -Cardiovascular: decreased HDLs, increased LDLs -Dermatological: reduced collagen content, changes in breast tissue

What is perimenopause?

-a normal transition -begins with change in menstrual cycles -a time of erratic hormone fluctuation -ends after cessation of menses peri= around menopause, before

The age at which menopause occurs, is not affected by what? State a few examples.

-age of menarche (first menstrual period) -physical characteristics -number of pregnancies -date of last pregnancy

What else accompanies menopause?

-cervix and vagina become pale and friable (due to alkalinity, so maybe use lubrication) -vasomotor instability (vessels become less stable) -long term consequences like increase risk of heart disease, decrease in bone density

What are the clinical manifestations of Post-menopause?

-cessation of menses -vasomotor instability -atrophy of GU tissue -stress and urge incontinence -breast tenderness

Describe what menopause is.

-cessation of menses associated with declining ovarian function -after one year of amenorrhea -starts gradually -measure FSH to see if you have menopause -visually associated with changes in menstruation (e.g. flows increased, decreased, irregular or a combination)

What accompanies /declines in menopause?

-decline in secondary sexual characteristics (still estrogen from adrenal cortex, but not enough to maintain the secondary sexual characteristics) decrease in: -breast tissue -body hair -skin elasticity -subcutaneous fat -size of ovaries and uterus

Earlier menopause is associated with what?

-genetics -autoimmune conditions -cigarette smoking -racial or ethnic factors

What are some alternative therapies for anxiety and depression (menopause symptom)?

-good nutrition, exercise, sleep -for sleep, avoid alcohol and reduce stress

What are some adverse effects of progesterone?

-greater appetite -weight gain -irritability -depression -spotting -breast tenderness

Describe nursing management of perimenopause and postmenopause.

-help women understand perimenopause changes and options for managing bothersome symptoms -foster positive image of perimenopause -teach and reassure women who have difficulty -symptoms are normal and only temporary -address misconceptions about menopause to reduce anxiety -for dry skin, moisture soaps and lotions -for stress incontinence, Kegal exercises -for atrophy in vagina and dyspareunia, water soluble lubricant -sexual capability continues -opportunity to discuss concerns

What are 3 causes of earlier menopause?

-illness -removal of uterus or both ovaries -adverse effects of radiation therapy or chemo drugs

What are the clinical manifestations of perimenopause?

-irregular menses -occasional vasomotor symptoms (hot flashes, night sweats) -atrophy of genitourinary tissue with decreased support -stress and urge incontinence -osteoporosis (decreased bone density) -mood changes

What is involved in the diagnosis of postmenopause?

-make only after other causes of women's symptoms have been ruled out -other causes of symptoms may be: depression, thyroid challenges, anemia, anxiety -get accurate history of menstrual patterns

What are some alternative therapies for hot flashes (menopause symptom)?

-measures to decrease heat production and increase heat loss e.g. cool environment, limit caffeine and alcohol, behaviour changes (e.g. relaxation) -increased air circulation at night, avoid bedding that traps heat, loose-fitting clothes, cool cloths, vitamin E

What are some adverse effects of estrogen?

-nausea -fluid retention -headache -breast enlargement

What are the events (started by changes in ovary) that result in menopause?

-regression of follicles in each ovary start with puberty and accelerates after 35 -with increasing age, fewer and fewer follicles respond to FSH -FSH stimulates dominant follicle to secrete estrogen -when follicles no longer respond to FSH, ovarian production of estrogen and progesterone declines -decreased ovarian function leads to decreased levels of estrogen and a gradual increase in FSH and LH (leutenizing hormone)= neg feedback process -reduced estrogen causes a decrease in frequency in ovulation and results in changes in reproductive organs and tissues (e.g. atrophy of vaginal tissues) -by menopause, a 10 to 20 fold increase in FSH -the increased FSH may take several years to return to premenopause -perimenopauseal women can get pregnant until menopause has occurred

What are some alternative therapies for prevent of bone loss and weight gain (menopause symptom)?

-regular exercise, which also modifies the risks for coronary artery disease (e.g. stress, obesity, inactivity and hypertension) -WEIGHT BEARING and AEROBIC exercises

State what must be considered for a woman wishing to take HRT for short-term (4-5yrs) to help with menopause symptoms.

-risk and benefits need to be considered carefully -the decision to take HRT and which ones to take, need to be thoroughly discussed -the lowest effective dose should be used -age of starting HRT may determine risk of heart disease

What other drugs are effective alternatives to HRT, in reducing hot flashes?

-selective-serotonin reuptake inhibitors (SSRIs) e.g. Paxil and Prozac -anti-hypertensive drugs (Clonidine) -anti-seizure drug (Neurontin/gabapentin)

Describe post-menopause. When does it occur ?

-time after menopause -ranges from 44 - 55 years, average is 51 years

What are biphosphonates (e.g. Alendronate, risedronate) used for in postmenopausal women?

-to decrease the risk of osteoporosis

Discuss psychological changes associated with perimenopause.

-unclear whether or not reduced estrogen causes psych changes associated with perimenopause -depression, irritability and cog problems may result from life stressors or sleep deprivation from hot flashes.

What are other treatments useful for treating menopausal symptoms?

-vaginal creams for urogenital symptoms (e.g. dryness) -transdermal (skin patch) estrogen has the advantage of bypassing the liver, but the disadvantage of causing skin irritation

What are the HALLMARKS (2) of perimenopause?

-vasomotor instability (hot flashes) and irregular menses

Describe a hot flash.

-warmth in upper chest, neck and face -profuse perspiration -lasts several seconds to 5 minutes -occurs mostly at night, disturbs sleep -causes not clearly understood (perhaps temp regulators in brain are close to where GnRH is released) -lowered estrogen associated with dilation of cutaneous vessels leading to hot flashes and sweating -sudden withdrawal of estrogen (e.g. removal of ovaries) leads to greater severity of symptoms -symptoms subside over time, with or without HRT

What triggers hot flashes?

-whatever affects body temp -e.g. hot meal, hot weather, alcohol, stress, warm clothes

State the findings for women who took estrogen plus progesterone.

Greater risk of: breast cancer, stoke, heart disease, emboli Less risk of: hip fractures, colorectal cancer

State the findings for women who took only estrogen.

Greater risk of: stroke and emboli Less risk of: fractures

What are some other alternative therapies for menopause symptoms (nutrition, herbs)?

Nutrition: -to decrease CV disease, osteoporosis, and vasomotor symptoms -daily intake of about 30kcal/kg of body weight -adequate intake of calcium and vitamin D to maintain bones -PM not on estrogen, need to take 1500mg of calcium -those taking estrogen need at least 1000mg/day -calcium supps are best absorbed with meals -diet high in complex carbs and vit B (esp B6) -Phytoestrogens (e.g. soy, tofu, chickpeas, sunflower seeds) may reduce symptoms *careful, soy may interact with warfarin Herbs: e.g. Black cohash

What are the atrophic changes associated with reduced estrogen? What are the risks related to these changes?

Vagina: thinner mucosa, disappearance of rugae, secretions reduced and more alkaline =risk of trauma and infection, dyspareunia (painful intercourse) Lower Urinary Tract: reduced bladder capacity, tone of bladder and urethra (may cause symptoms that mimic infection... dysuria, urgency, frequency)

Describe selective-estrogen receptor modulators (SERMs) use for menopause problems.

e.g. raloxifine -have some positive effects of estrogen (prevent bone loss) without neg effects of estrogen (e.g. endometrial hyperplasia) -competes with estrogen for estrogen receptor sites -decreases bone loss and cholesterol, but has minimal effects on breast and uterine tissue

What are the risks associated with earlier onset of menopause, especially those with ovaries removed with no estrogen therapy?

increased risk of : -osteoporosis -heart disease -dementia -anxiety -depression -sexual dysfunction -Parkinson-like symptoms -early death