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  1. 1. Menopause
  2. 2. Overview of Presentation <ul><li>Definition </li></ul><ul><li>Etiology/Endocrinology </li></ul><ul><li>Epidemiology </li></ul><ul><li>Clinical Manifestations </li></ul><ul><li>Diagnosis </li></ul><ul><li>Therapies </li></ul>
  3. 3. Etiology/Endocrinology <ul><li>Menopause occurs due to programmed loss of ovarian follicles </li></ul><ul><li>During perimenopause inhibin B falls due to decline in follicular number and FSH rises, estradiol preserved, low progesterone </li></ul><ul><li>In late menopausal transition, FSH and estradiol fluctuate </li></ul><ul><li>After menopause, ovary no longer secretes estradiol, however produces androgens under the stimulation of LH </li></ul>
  4. 4. Definition <ul><li>Stages of Reproductive Aging Workshop ( STRAW) Staging System 2001 </li></ul><ul><li>Menopausal transition: a) Variation in menstrual cycle ( > 7 d different from normal) and ≥2 skipped cycles and >=60 d amenorrhea; b)  FSH </li></ul><ul><li>Perimenopause: Starts at the time of the menopausal transition ( see above) and ends 12 months after last menstrual period </li></ul><ul><li>Menopause: 12 months of amenorrhea after final menses </li></ul><ul><li>Postmenopause: Stage 1 is the first 5 years after menopause – women have bone loss and hot flashes. Stage 2 is 5 yrs after the last menstrual period until death. </li></ul>
  5. 5. Epidemiology <ul><li>Average age of menopause is app. 51.4 years; menopause prior to age 40 is premature ovarian failure </li></ul><ul><li>Age of menopause reduced in smokers </li></ul><ul><li>Ethnicity and race may influence menopause, earlier age among Hispanic women and later in Japanese-American women when c/w Caucasian </li></ul><ul><li>Important to assess family history of early menopause </li></ul>
  6. 6. Clinical Manifestations <ul><li>Irregular bleeding patterns - if heavy bleeding should perform endometrial surveillance given period of unopposed estrogen exposure </li></ul><ul><li>Hot flashes - Etiology unknown. Thermoregulatory dysfunction. Self limited to 1-5 yrs. Variable among cultures – 75% US women complain of hot flashes, 20% seek therapy. </li></ul><ul><li>Sleep disturbance – Hot flashes can arouse from sleep and primary sleep disorders more common </li></ul>
  7. 7. Clinical Manifestations-2 <ul><li>Vaginal dryness – Estrogen deficiency leads to thinning of epithelium - > vaginal atrophy ( loss of rugae, pale, pH inc to > 6.0) </li></ul><ul><li>Sexual dysfunction – decrease in blood flow to vagina/vulva -> decreased lubrication; dyspareunia </li></ul><ul><li>Urinary sx – low estrogen results in atrophy of urethral epithelium and predispose to stress/urge urinary incontinence </li></ul>
  8. 8. Clinical Manifestations -3 <ul><li>Depression – Overall studies support an association between menopause and mood changes such as irritability/nervousness; controversial if related to true depression </li></ul><ul><li>Bone loss – secondary to estrogen def </li></ul><ul><li>Breast pain – Common in early menopausal transition </li></ul><ul><li>Skin changes – estrogen def -> reduced collagen content of the skin/bones </li></ul>
  9. 9. Therapies <ul><li>Tx moderate/severe vasomotor sx only </li></ul><ul><li>Estrogen – most effective; po or transdermal; if women has uterus give in conjunction with progesterone; short term therapy; taper to end </li></ul><ul><li>Behavioral changes – keeping temp cool, regular exercise, relaxation therapy </li></ul><ul><li>SSRIs – One of first choices if not taking HRT. RCT’s have shown benefit </li></ul><ul><li>Gabapentin - suggested for nocturnal hot flashes </li></ul>
  10. 10. Therapies -2 <ul><li>Progestins – Megestrol acetate, norethindrone acetate, high dose DMPA shown to be effective </li></ul><ul><li>Clonidine – effective in some trials; try transdermal; may be good in women with HTN </li></ul><ul><li>Phytoestrogens – NO more effective than placebo; concern is that they are SERMS </li></ul><ul><li>Herbal/Black Cohosh – No more effective than placebo; may have estrogenic effect on breast </li></ul>