Natelaine E Fripp MD Clinical Assistant Professor Dept of Family amp Community Medicine University of Maryland School of Medicine Learning Objectives Define menopause Identify the stages of menopause ID: 1042884
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1. Menopause: Understanding the Cause, Symptoms, and TreatmentNatelaine E. Fripp, MDClinical Assistant ProfessorDept. of Family & Community MedicineUniversity of Maryland School of Medicine
2. Learning ObjectivesDefine menopause Identify the stages of menopause Discuss what triggers the onset of menopauseIdentify the most common symptoms of menopauseIdentify complications of menopauseReview potential treatment options to relieve symptoms
3. Stages of MenopauseVerywell Health/ Emily Roberts
4. PremenopauseTime between the first period and perimenopauseTypically, age 30 and under. Might have shifts in hormone levelsLittle to no symptoms
5. Perimenopause“Around Menopause”transitions to menopauseAge 40’s to 50’s but can start earlierMay last 10 yearsOvaries decrease production of estrogen and progesterone.
6. PerimenopauseSymptoms: Irregular periods, weight gain, changes in mood, sweats and flushes, headaches, vaginal dryness, breast tenderness, acnePregnancy is still possible
7. MenopauseClassic definition: 12 consecutive months with no periodsOvaries stop or greatly slow down the production of reproductive hormones estrogen and progesterone and stop releasing eggs Marks the end of fertility
8. PostmenopauseBody is adjusting to lower hormone levelsTypically age 55Menopausal symptoms might go away or become milderIncrease risk of health conditionsEx. Heart disease and osteoporosis
9. Menopause
10. Menopause factoidsAristotle defined the age of menopause as 40 yearsTerm menopause was coined in 1821 by a French physician1970’s: Menopausal societies began to emergeEstrogen deficiency related to menopauseBull Indian Inst Hist Med Hyderabad.2002 Jul-Dec;32(2):121-35.
11. Menopause factoidsSymptoms reported differ across the globeUS: hot flushJapan: shoulder painIndia: low visionBull Indian Inst Hist Med Hyderabad.2002 Jul-Dec;32(2):121-35.
12. Menopause factoidsWomen in the West harbor negative views of menopauseFeeling oldLooking like my motherDrying up1800’s menopause had positive viewPeriod of rest
13. What triggers menopause?Natural causesAge related decline in ovarian reserveLeads to reduction in estrogen and progesterone levelsSurgical removal of ovaries (oophorectomy)Causes abrupt onset of menopauseSymptoms can be more severe
14. What triggers menopauseChemotherapy and radiationHormone therapyEx Lupron used for endometriosis and bleeding from fibroidsOften temporary
15. What triggers menopause?Ovarian insufficiencyOccurs in 1% women by age 40 (MayoClinic)Early menopausePremature ovarian failureOften treated with HRT (OCPs) until the natural age of menopause is reached
16. What triggers menopause?Family historyAutoimmune disordersPersonal reproductive historyChromosomal abnormalitiesUnhealthy lifestyle habits
17. Is there a test for this?Testing is not neededSometimes it is doneFollicle stimulating hormone (FSH) increasedLuteinizing hormone (LH) increasedEstrogen (estradiol) decreasedThyroid stimulating hormone (TSH) increasedHypothyroid can mimic menopause
18. Symptoms
19. Symptoms related to MenopauseEstrogen and progesterone hormones affect many functions in a woman’s body other than menstruation and fertilitycirculatory system, urogenital system, nervous system, skeletal system, memory, sexuality, skin, vision, and teeth.Women will live a third of their lives after menopauseBe aware of the symptoms, systemic effects, and available treatment options associated with estrogen loss.
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21. SymptomsHot flushesMost commonly reported symptomLoss of hormones restricts the body’s ability to regulate temperature Night sweatsSecond most commonVaginal drynessLost lubrication and elasticity, painful intercourse, vaginal infections
22. SymptomsSleep disturbanceInsomnia, early awakeningMood changesIrritability, anxiety, depressionUrinary problems incontinence, urinary frequency/urgencyBreast changesTenderness, smaller sizeFatty tissue on mammograms
23. SymptomsDecreased libidoFatigueHair dryness, loss, alopeciaTooth decayBleeding and receding gums Burning mouthDizziness Weight gainChange in taste and smellLoss of confidenceRecurrent UTIFeeling coldBloating and water retentionAcnePoor concentrationJoint pain, muscle tensionBrian fogHeadachesMemory changesPalpitationsTingling to extremitiesTrouble breathingDry eyesChange in skin texture
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25. Two common complicationsOsteoporosisIncreased bone lossdecreased bone density Cardiovascular Diseasethe most common cause of death in womenrate of CVD increases steadily reaching parity with men by age 70Cholesterol changes:increased LDL “bad” cholesteroldecreased HDL “good” cholesterolComplications of Menopause
26. Treatment
27. TreatmentVasomotor symptoms (hot flushes)70% women reportMore common with higher BMI, cigarette use, minoritiesSymptoms last an average of 7 yearsLost ability to thermoregulateEstrogen lossThermoregulatory center in hypothalamusMost common indication for treatmentAm Fam Physician. 2016;94(11):884-889
28. TreatmentVasomotor symptoms affect: SleepConcentrationEnergyMoodWork Sexual activitySocial activities
29. TreatmentVasomotor symptomsHormone therapy (HT or HRT) is standard of careUses one or more hormones to treat symptoms of menopauseEstrogen, progestin/progesterone, or bothSometimes testosterone
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31. HRT history1800’s treatments were mostly herbalCannabis Opium1920’s estrogen compounds were isolated and oral estrogen was made available
32. HRT history1942 Premarin hit the market as the first estrogen productAyerst successfully marketed Premarin as a cure for a non-disease“Cure” for menopausemarketed to men to make a woman pleasant to live with1970’s evidence emerged that unopposed estrogen can increase the risk of endometrial cancerhttps://www.theguardian.com/world/2022/jan/18/she-will-not-become-dull-and-unattractive-the-charming-history-of-menopause-and-hrt
33. HRT historyPremarin was repackaged as estrogen-progesterone therapy – Prempro2002 WHI stopped the HRT arm of the study stating women with a uterus had higher rate of CAD and breast cancerResults had lasting effectsResults were found to be misreportedhttps://www.theguardian.com/world/2022/jan/18/she-will-not-become-dull-and-unattractive-the-charming-history-of-menopause-and-hrt
34. HRT history84% decline in prescription writing in the last 2 decadesHRT prescriptions were down. Doctors feared prescribing. Women were on their own.Menopausal education was taken out of some medical schools.2017 authors of WHI paper published a correctionhttps://www.theguardian.com/world/2022/jan/18/she-will-not-become-dull-and-unattractive-the-charming-history-of-menopause-and-hrt
35. Uses for HRTHRT helps to relieve Hot Flashes, Vaginal Dryness, Fatigue, Thinning Hair, Loss of Muscle Strength and Insomnia
36. Types of HRTEstrogen and progestinFor women who still have a uterusEstrogen onlyFor women who do not have a uterus
37. Types of HRTEstrogenNasal sprayPillsSkin gel and spraySkin patchesVaginal creamsProgesterone/ProgestinPillsSkin patchesVaginal creamsVaginal suppositoriesIntrauterine devices
38. How HRT is takenCyclicEstrogen for 25 daysAdd progestin during days 10-14No hormones days 26-30Might have monthly bleedingCombined Take estrogen and progestin together every dayMight stop bleeding
39. How HRT is takenStart low dose and increase as neededGive about 3 months to see effectsAdjust if necessary
40. Contraindications to HRTPregnancy or breastfeedingLiver diseaseUnexplained vaginal bleedingHistory of certain cancersOvarian, breast, endometrialHistory of DVT, PE, or clotting disorders
41. HRT Side EffectsReturn of periods Irregular vaginal bleeding/spotting Headache Nausea Breast tenderness Bloating (progesterone) Weight gain (progesterone): generally only 2-3 pounds can be “blamed” on the hormones: the rest is decreased metabolism associated with menopause, increased caloric intake and/or decreased exercise. May exacerbate depression (progesterone) Enlargement of uterine fibroids Exacerbation of endometriosis Fluid retention (may exacerbate asthma, epilepsy, migraine, heart disease, kidney disease) Spotty darkening of the skin
42. When to stop HRTWhen menopausal symptoms endTaper down the doseSymptoms might return
43. Other Treatment OptionsLifestyleMind body techniquesPrescription medicationsDietary supplementsAcupuncture
44. Treatment OptionsLifestyleCooling techniquesClothing: layers, breathable, sleevelessFans, cold packs, dual control blanketsAvoid triggersAlcohol, caffeine, spicy food, hot food or liquidExercise and YogaWeight loss
45. Treatment OptionsMind body techniquesCognitive behavioral therapyMindfulnessHypnosis
46. Treatment optionsPrescription medicationsParoxetine (Paxil) 7.5 mg FDA approvedFezolenatant (Veozah) 45mg FDA approvedSSRIs and SNRIsEx. escitalopram (Lexapro), citalopram (Celexa) venlafaxine (Effexor), duloxetine (Cymbalta)
47. Treatment OptionsPrescription medicationsGabapentinOxybutynin
48. Dietary Supplements Phytoestrogens 3 types: isoflavones, lignans, and coumestans. Isoflavones “weak” estrogen receptor modulatorsmimic the role of estrogen. they can mimic the good actions and the not so good- they can also function to block the action of estrogen at some sites unclear if safe for women at risk for breast cancer or its recurrence. Recommended dose 6.5 g of soy per serving for a total of 25 g per day.
49. PhytoestrogensSoy contains 3 isoflavones: preventive benefits in cardiovascular diseasereduce the frequency of hot flashes and to reduce the incidence of osteoporosis. Six studies have shown that soy isoflavones can reduce the frequency of hot flashes.
50. Dietary SupplementsBlack cohoshPhytoestrogenic herbalMost studies show it is effective in reducing frequency and intensity of hot flashes, improvement in “global” menopausal symptoms, and in vaginal lubricationRed Clovecontains four isoflavones, including genistein, the most active component of soy. The most popular dietary supplement derived from red clover is Promensil ™.
51. Dietary SupplementsPromensilClinical trials with Promensil did survey women to test their level of satisfaction; 93% of users said they wanted to continue taking it. 500 mg Promensil tablet contains 40 mg of plant estrogens. This is the equivalent of one cup of soy milk and four cups of chickpeas.
52. Dietary SupplementsGinkgo bilobaUsed as a mood elevator or to improve memory and other cognitive functions. Can cause bleeding problems in several individuals, with or without other medicines. Speak with your physician if you plan to take this herb, especially if you are taking medicines for bleeding or clotting problems or for arthritis.
53. Dietary SupplementsWild yam source of “natural progesterone”contains diosgenin, which is not converted to active hormones in the bodyNO effects on estrogen or progesterone receptors. Vaginal Lubricantsnumerous non-prescription vaginal lubricants on the market K-Y Jelly ™ and Vagisil ™Never use a water insoluble preparation in the vagina, e.g. Vaseline ™.
54. Take Home PointsMenopause is part of the transition from childbearing years to nonchild bearing yearsStages: premenopause, perimenopause, menopause, postmenopauseSymptoms are numerousIncreases risk for osteoporosis and heart disease70% of women report vasomotor symptoms HRT remains standard of careSeveral options for treatment are now available
55. Now you know! Let’s talk about it…questions?
56. ResourcesManaging Menopausal Symptom: Common Questions and Answers. Am Fam Physician. 2023;108(1):28-39 Bull Indian Inst Hist Med Hyderabad.2002 Jul-Dec;32(2):121-35.Hormone Therapy and Other Treatments for Symptoms of Menopause. Am Fam Physician. 2016;94(11):884-889Menopause. The Journal o the North American Menopause Society. Vol 30. No 6. pp 573-590.2023https://www.mayoclinic.org/diseases-conditions/menopause/symptoms-causes/syc-20353397www.pennmedicine.org/updates/blogs/womens-health/2016/december/the-change-before-the-change#:~:text=Premenopause%20is%20the%20time%20between,the%20National%20Institute%20on%20Aging.https://www.theguardian.com/world/2022/jan/18/she-will-not-become-dull-and-unattractive-the-charming-history-of-menopause-and-hrtThe Rise and Fall of Hormone Replacement Therapy. From the lecture series : The Skeptics’s Guide to health, mediciane and them edia. March 4, 2019 Health And Fitness, Medicine and Disease
57. The End