Menopause 101: Signs & Symptoms Patricia T. Alpert, DrPH, APN, FAANP

Objectives At the end of the session the participants will be able to: Define menopause Identify the signs & symptoms of menopause Identify action steps to take during menopause

At the end of the session the participants will be able to:

Define menopause

Identify the signs & symptoms of menopause

Identify action steps to take during menopause

Menopause Quiz Most women experience menopause by age 50. True False Women can experience menopausal symptoms even though they still are having periods. True False

Most women experience menopause by age 50.

True False

Women can experience menopausal symptoms even though they still are having periods.

True False

Menopause Quiz As a women approaches menopause, she will probably experience hot flashes. True False It’s normal to experience some spotting or bleeding after menopause. True False

As a women approaches menopause, she will probably experience hot flashes.

True False

It’s normal to experience some spotting or bleeding after menopause.

True False

Menopause Quiz Women experience increase rate of bone loss after menopause. True False Urinary problems in women become more common after menopause. True False

Women experience increase rate of bone loss after menopause.

True False

Urinary problems in women become more common after menopause.

True False

Menopause Quiz It takes longer to become sexually aroused after menopause. True False Sleep disturbances are common in the years leading up to menopause, but improves once menopause occurs. True False

It takes longer to become sexually aroused after menopause.

True False

Sleep disturbances are common in the years leading up to menopause, but improves once menopause occurs.

True False

Menopause Quiz If a woman experiences an abrupt onset of menopause, her symptoms are typically more severe. True False Menopause symptoms require medical treatment. True False Mayo Clinic. Retrieved on 10/15/07 from: mayoclinic.com

If a woman experiences an abrupt onset of menopause, her symptoms are typically more severe.

True False

Menopause symptoms require medical treatment.

True False

Mayo Clinic. Retrieved on 10/15/07 from: mayoclinic.com

Menopause: What is It? A combination of 2 Greek words Month Termination Literally means: “the end of the monthlies, or Meno = Menstruation Pause = Ceases

A combination of 2 Greek words

Month

Termination

Literally means: “the end of the monthlies, or

Meno = Menstruation

Pause = Ceases

Menopause Defined—con’t Is universal, irreversible & natural Defined as: the permanent cessation of menstruation due to loss of ovarian follicular activity Clinically: twelve consecutive months of amenorrhea without other causes

Is universal, irreversible & natural

Defined as:

the permanent cessation of menstruation due to loss of ovarian follicular activity

Clinically: twelve consecutive months of amenorrhea without other causes

Menopause Defined Premenopause Reproductive years Perimenopause Vasomotor symptoms & irregular periods Postmenopause Begins 12 months after final menses

Premenopause

Reproductive years

Perimenopause

Vasomotor symptoms & irregular periods

Postmenopause

Begins 12 months after final menses

Stages of Reproductive Aging Stage -5 early reproductive years Stage -4 peak reproductive years Stage -3 late reproductive years Stage -2 early menopause Stage -1 late transition Stage +1 early postmenopause Stage +2 late postmenopause (Stages of Reproductive Aging Workshop [STRAW], Medicine, 2001)

Stage -5 early reproductive years

Stage -4 peak reproductive years

Stage -3 late reproductive years

Stage -2 early menopause

Stage -1 late transition

Stage +1 early postmenopause

Stage +2 late postmenopause

(Stages of Reproductive Aging Workshop [STRAW], Medicine, 2001)

Historical Perspective Earliest known reference scarce Artistotle referred to age of menopause begins at age 40 A French physician coined the word menopause in 1821 Medical interest  in mid 19 th century 1930’s described as a deficiency disease

Earliest known reference scarce

Artistotle referred to age of menopause begins at age 40

A French physician coined the word menopause in 1821

Medical interest  in mid 19 th century

1930’s described as a deficiency disease

Historical Perspective Synthetic estrogens developed in 1938 1970’s medicalization of menopause complete 1970’s: International Menopause Society established 1976 first International Congress on Menopause held in Paris

Synthetic estrogens developed in 1938

1970’s medicalization of menopause complete

1970’s: International Menopause Society established

1976 first International Congress on Menopause held in Paris

Historical Perspective Symptoms differ in different areas West – hot flashes Japan – shoulder pain India – poor vision Greater use of HRT in the West Viewed negatively in the West Welcomed in countries like India

Symptoms differ in different areas

West – hot flashes

Japan – shoulder pain

India – poor vision

Greater use of HRT in the West

Viewed negatively in the West

Welcomed in countries like India

Epidemiology  number of middle-aged and older women Due to  longevity (age 77.8)  numbers living longer in hypoestrogenic state Up to one-third of life cycle Approximate age 50-51 Unchanged since antiquity

 number of middle-aged and older women

Due to  longevity (age 77.8)

 numbers living longer in hypoestrogenic state

Up to one-third of life cycle

Approximate age 50-51

Unchanged since antiquity

Epidemiology Normal range 49-55 years of age Average age in US 51 years Can occur as early as 35 Can occur as late as 60’s Approximately 1% Menopause before age 40

Normal range 49-55 years of age

Average age in US 51 years

Can occur as early as 35

Can occur as late as 60’s

Approximately 1%

Menopause before age 40

Physiology During Reproductive Years During reproductive years ovaries controlled by pituitary glands FSH & LH Leads to production of Estrogen Progesterone Testosterone

During reproductive years ovaries controlled by pituitary glands

FSH & LH

Leads to production of

Estrogen

Progesterone

Testosterone

Estrogens Estradiol** Important estrogen in menopause Receptors on multiple organs Estrone Estriol

Estradiol**

Important estrogen in menopause

Receptors on multiple organs

Estrone

Estriol

Physiology in Aging Loss of ovarian sensitivity to gonadotropin stimulation Oocytes undergo atresia Throughout life cycle Decline 20-25 years after menarche Variable menstrual cycle length

Loss of ovarian sensitivity to gonadotropin stimulation

Oocytes undergo atresia

Throughout life cycle

Decline 20-25 years after menarche

Variable menstrual cycle length

Changing Endocrinology with Aging FSH levels during the follicular phase  progressively Estradiol  slightly until follicular exhaustion Inhibin B  (related to  primordial follicles) At final menses FSH levels 10-15 times higher

FSH levels during the follicular phase  progressively

Estradiol  slightly until follicular exhaustion

Inhibin B  (related to  primordial follicles)

At final menses FSH levels 10-15 times higher

Changing Endocrinology—con’t At final menses estradiol level at 50% less than during reproductive years Continues to  Reaches nadir 2-3 years later Marked hormonal instability Major change at final menses  FSH &  estradiol

At final menses estradiol level at 50% less than during reproductive years

Continues to 

Reaches nadir 2-3 years later

Marked hormonal instability

Major change at final menses  FSH &  estradiol

Changing Endocrinology—con’t Changing circulating androgens controversial  free androgen levels during menopause transition (Burger, Dudley, Cui et al., J Clin Endocrinol Metab, 2000) Postmenopause--ovary primarily androgen-secreting organ Testosterone from ovarian interstitial cells

Changing circulating androgens controversial

 free androgen levels during menopause transition (Burger, Dudley, Cui et al., J Clin Endocrinol Metab, 2000)

Postmenopause--ovary primarily androgen-secreting organ

Testosterone from ovarian interstitial cells

Changing Endocrinology—con’t Oophorectomy results  of 50% circulating testosterone Other major androgen DHEA  from adrenal cortex Not related to menopausal transition

Oophorectomy results  of 50% circulating testosterone

Other major androgen DHEA  from adrenal cortex

Not related to menopausal transition

Changing Endocrinology--Postmanopause Beside  FSH & LH and  estradiol & progesterone Well preserved testosterone levels  DHEA Major estrogen circulating is estrone Primary estrogen in postmenopause Primarily from adipose tissue

Beside  FSH & LH and  estradiol & progesterone

Well preserved testosterone levels

 DHEA

Major estrogen circulating is estrone

Primary estrogen in postmenopause

Primarily from adipose tissue

Aging Physiology--Summary Fewer ova = Less estrogens Endometrium builds up but follicles cannot fully mature  Anovulation  No corpus luteum  No progesterone & no stable uterine lining  Irregular menstruation

Fewer ova = Less estrogens

Endometrium builds up but follicles cannot fully mature

 Anovulation

 No corpus luteum

 No progesterone & no stable uterine

lining

 Irregular menstruation

Estrogen & Testosterone Levels

Early Menopause Defined as menopause < 40 years of age Affects about 1% of women Due to: Physical conditions Surgically Other risk

Defined as menopause < 40 years of age

Affects about 1% of women

Due to:

Physical conditions

Surgically

Other risk

Physical Factors for Early Menopause Ovarian insensitivity syndrome (autoimmune) Genetic disorders (mosaic) Low body weight Poor nutrition/chronic infection Polycystic ovaries

Ovarian insensitivity syndrome (autoimmune)

Genetic disorders (mosaic)

Low body weight

Poor nutrition/chronic infection

Polycystic ovaries

Surgical Menopause Bilateral oophorectomy Unilateral oophorectomy When remaining ovary fails Hysterectomy alone does not mark beginning of menopause But cannot mark beginning of menopause due to cessation of periods

Bilateral oophorectomy

Unilateral oophorectomy

When remaining ovary fails

Hysterectomy alone does not mark beginning of menopause

But cannot mark beginning of menopause due to cessation of periods

Other Risk Factors Chemotherapy Induce menopause During treatment or within 3-6 months Radiation therapy Premature ovarian failure* Often no cause identified

Chemotherapy

Induce menopause

During treatment or within 3-6 months

Radiation therapy

Premature ovarian failure*

Often no cause identified

Perimenopause The period prior to beginning menopause Length ranges: ~4 years average Many begin to experience symptoms Many in their 40’s Some never notice symptoms

The period prior to beginning menopause

Length ranges: ~4 years average

Many begin to experience symptoms

Many in their 40’s

Some never notice symptoms

Symptoms Begin During Perimenopause Hot flashes Night sweats Coldness Irregular periods Heavy or light Shorter or longer Difficulty sleeping Getting to sleep Staying asleep Mood changes Depression Anxiety Heart palpitations Dry skin and/or hair loss Loss or  sexual desire Incontinence

Hot flashes

Night sweats

Coldness

Irregular periods

Heavy or light

Shorter or longer

Difficulty sleeping

Getting to sleep

Staying asleep

Mood changes

Depression

Anxiety

Heart palpitations

Dry skin and/or hair loss

Loss or  sexual desire

Incontinence

Symptoms Correlated with Menopause According to USDHHS Vasomotor & vaginal dryness most consistently associated Sleep disturbance—mixed findings Mood—majority of studies show no association Cognitive disturbances—no evidence

According to USDHHS

Vasomotor & vaginal dryness most consistently associated

Sleep disturbance—mixed findings

Mood—majority of studies show no association

Cognitive disturbances—no evidence

Symptoms Correlated—con’t Somatic complaints—most studies show no association Urinary complaints—mixed findings Sexual dysfunction—mixed findings Reduced quality of life—conflicting findings (DHHS, 2005, http://www.ahrq.gov/clinic/tp/menopstp.htm)

Somatic complaints—most studies show no association

Urinary complaints—mixed findings

Sexual dysfunction—mixed findings

Reduced quality of life—conflicting findings

(DHHS, 2005, http://www.ahrq.gov/clinic/tp/menopstp.htm)

Hot Flashes The second most common symptom (Neugarter & Kraines, 1965, Psychom Med) Second only to irregular periods 75%-85% of women report hot flashes 20% continue into their 60s and 70s Hot flashes & sweats (night sweats) classic Involves pulses of dopamine & GnRH Down setting of the thermoregulatory centers

The second most common symptom (Neugarter & Kraines, 1965, Psychom Med)

Second only to irregular periods

75%-85% of women report hot flashes

20% continue into their 60s and 70s

Hot flashes & sweats (night sweats) classic

Involves pulses of dopamine & GnRH

Down setting of the thermoregulatory centers

Hot Flash

 Particularly characteristic In late perimenopause & early Menopause  Short-lived (3-5 minutes) Sensation of heat in upper body, face & neck  Sweating may be present  heart rate  peripheral blood flow  skin temperature

Urogenital Changes Urethral tissue become thin Causes dysuria, incontinence &  frequency Changes in vulva & vagina occur Vaginal atrophy Cervical atrophy Burning Vaginal dryness UTIs Vulvae pruritus

Urethral tissue become thin

Causes dysuria, incontinence &  frequency

Changes in vulva & vagina occur

Vaginal atrophy

Cervical atrophy Burning

Vaginal dryness UTIs

Vulvae pruritus

Sleep Disturbance more difficulty sleeping during the transition May be due to vasomotor symptoms Up to 40% - 60% experience problems A slight  from premenopausal women

more difficulty sleeping during the transition

May be due to vasomotor symptoms

Up to 40% - 60% experience problems

A slight  from premenopausal women

Mood Symptoms The symptoms most often reported Depression Anxiety According to DHHS meta-analysis shows no relationship

The symptoms most often reported

Depression

Anxiety

According to DHHS meta-analysis shows no relationship

Decreased Libido Reports  desire (Deed et al., 2007l; Am J Obstet Gynecol) Related to several factors Disturbed sleep—43% Night sweats—1.9 episodes/night Depression—18% (moderate to severe)

Reports  desire (Deed et al., 2007l; Am J Obstet Gynecol)

Related to several factors

Disturbed sleep—43%

Night sweats—1.9 episodes/night

Depression—18% (moderate to severe)

Cultural Differences Prevalence of VMS varies by culture VMS more common in West (30%-75%) & Europe (20%-30%) In Asian countries prevalence is 5%-20% Some groups in India report no VMS (Obermeyer, 2000, Menopause)

Prevalence of VMS varies by culture

VMS more common in West (30%-75%) & Europe (20%-30%)

In Asian countries prevalence is 5%-20%

Some groups in India report no VMS (Obermeyer, 2000, Menopause)

Cultural Differences Studies found lower estrogen in Asians compared to Whites (Randolph et al. 2003 &2004, J Clin Endocrinol Metab) Less reports of VMS by Asians Mayan women have similar estrogen levels as U.S. women (Beyene et al, 2001, Am J Hum Biol) Mayan women report less VMS VMS  prevalence in those living in regions with > seasonality (Sievert et al, 2005, Am J Phys Anthropol)

Studies found lower estrogen in Asians compared to Whites (Randolph et al. 2003 &2004, J Clin Endocrinol Metab)

Less reports of VMS by Asians

Mayan women have similar estrogen levels as U.S. women (Beyene et al, 2001, Am J Hum Biol)

Mayan women report less VMS

VMS  prevalence in those living in regions with > seasonality (Sievert et al, 2005, Am J Phys Anthropol)

Cultural Differences More VMS in Blacks due to lower cold & heat tolerances compared to Whites (Walsh et al, 1989, Am J Phys Med Rehabil; Gold et al. 2006, Am J Public Health) Heavier women  VMS More estrone production More insulation Lower estradiol than thinner women Hispanic & Blacks heaiver than Asians

More VMS in Blacks due to lower cold & heat tolerances compared to Whites (Walsh et al, 1989, Am J Phys Med Rehabil; Gold et al. 2006, Am J Public Health)

Heavier women  VMS

More estrone production

More insulation

Lower estradiol than thinner women

Hispanic & Blacks heaiver than Asians

Cultural Differences due to Lifestyle Behaviors Possibly associated to estrogen concentration & fluctuation Smokers report VMS more often Those exposed to second-hand smoke also Alkaloid components of smoke, e.g., nicotine Lower rates in Hispanics & Asians

Possibly associated to estrogen concentration & fluctuation

Smokers report VMS more often

Those exposed to second-hand smoke also

Alkaloid components of smoke, e.g., nicotine

Lower rates in Hispanics & Asians

Culture & Lifestyle Behavior—con’t Role of physical activity Consumption of: Daily alcohol associated with VMS Consumption lower in Asians & Hispanics Phytoestrogen consumption Isoflavones & lignans similar to estradiol Have weak estrogenic activity Consumed more often in Asian women

Role of physical activity

Consumption of:

Daily alcohol associated with VMS

Consumption lower in Asians & Hispanics

Phytoestrogen consumption

Isoflavones & lignans similar to estradiol

Have weak estrogenic activity

Consumed more often in Asian women

Cultural & Lifestyle—con’t Hysterectomy Highest rates in Blacks Lower rates in Hispanics & Asians Socioeconomic status Hispanics & Blacks generally lower than Whites Stress Highest in Hispanics

Hysterectomy

Highest rates in Blacks

Lower rates in Hispanics & Asians

Socioeconomic status

Hispanics & Blacks generally lower than Whites

Stress

Highest in Hispanics

Diagnosis No one specific test FSH level is mid-range based on history dx perimenopause Dx menopause Age (50 years) Amenorrhea 3-11 months Cycle irregularity last 12 months

No one specific test

FSH level is mid-range based on history dx perimenopause

Dx menopause

Age (50 years)

Amenorrhea 3-11 months

Cycle irregularity last 12 months

Menopause & Diabetes Menopause affects sugar levels in diabetics Can magnify menopause symptoms Fatigue Mood changes Hot flashes

Menopause affects sugar levels in diabetics

Can magnify menopause symptoms

Fatigue

Mood changes

Hot flashes

Menopause & Hypothyroidism 20% of menopausal of women have hypothyroidism Thyroid problems can mimic menopausal symptoms: Weight gain Fatigue Cold intolerance Elevated cholesterol

20% of menopausal of women have hypothyroidism

Thyroid problems can mimic menopausal symptoms:

Weight gain

Fatigue

Cold intolerance

Elevated cholesterol

What Can Women Do? Physical activity Helpful but HT more effective Healthy diet Phytoestrogens Calcium and vitamin D Lighter clothing or dress in layers

Physical activity

Helpful but HT more effective

Healthy diet

Phytoestrogens

Calcium and vitamin D

Lighter clothing or dress in layers

Clinical Consequences of Hormone Changes Bone Loss Consequence of  estradiol Occurs particularly during late perimenopause & early menopause 30% of US women 60-69 years have osteoporosis  to 50% between 70-79 years

Bone Loss

Consequence of  estradiol

Occurs particularly during late perimenopause & early menopause

30% of US women 60-69 years have osteoporosis

 to 50% between 70-79 years

Clinical Consequences of Hormone Changes—con’t Landmark study (Linsay, et al., 1976, Lancet) Surgical menopause (with bilateral oophorectomy) Not on replacement estrogen therapy 1% to 2% per year loss of bone mineral density

Landmark study (Linsay, et al., 1976, Lancet)

Surgical menopause (with bilateral oophorectomy)

Not on replacement estrogen therapy

1% to 2% per year loss of bone mineral density

Clinical Consequences of Hormone Changes Cardiovascular Risk Once taught to be related to menopause Longitudinal studies cast doubt Suggest small change in HDL around menopause Previous reported changes in TC, LDL may be due to aging Associated with cardiovascular events not evident

Cardiovascular Risk

Once taught to be related to menopause

Longitudinal studies cast doubt

Suggest small change in HDL around menopause

Previous reported changes in TC, LDL may be due to aging

Associated with cardiovascular events not evident