This document discusses menopause and aging. It begins with defining menopause and describing associated changes and symptoms. It then presents several case studies involving women experiencing menopause symptoms. It reviews hormone therapy options and risks. It also discusses the normal physiologic changes that occur with aging, including changes to body composition, cardiovascular, pulmonary, renal and other systems. It notes specific geriatric issues like cognitive function, sensory changes, incontinence, fall risks, polypharmacy and screening recommendations.

1. Menopause and Aging
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2. Objectives
Define menopause
Describe associated changes and symptoms
Treatment options for bothersome
symptoms
Review physiologic changes of aging,
specific age related problems and
screening in elderly
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3. Case #1
35 yo G1 P0101 female presents with c/o
hot flashes and amenorrhea for 12 months.
She doesn’t know why this is happening, her
sxs are worsening. She wants your help.
DDx
Tests
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4. Case #2
45 yo G2 P2002 female presents with c/o
hot flashes and irregular menses (q 3-5
mos) for the past 9 months. She doesn’t
know why this is happening, she wants your
help. By the way, she wants your help to
stop smoking also.
DDx
Tests
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5. Case #3
65 yo WF presents to start HRT. She
heard it would help protect her heart,
make her feel younger and help her
memory. She went through menopause 10
years ago and has not had any problems
except an occasional hot flash. She is 5’4”,
108 lbs. By the way, she had a wrist fx 2
yrs ago takes her Viactiv faithfully.
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6. Case #4
49 yo WF presence b/c she can’t stand her
hot flashes anymore. She can’t sleep very
well b/c she wakes up 3 times a night
drenched with sweat. She is an executive
at First National Bank. She has a history of
breast cancer 2 years ago. “Please Dr.
Ziegenbein, I need some hormones or
something.”
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7. Case #5
55 yo BF returns to discuss stopping
her HRT. She has been taking it for 5
years now with good relief of her
vasomotor sxs.
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8. Case #6
53 yo WF began continuous HRT 4
wks ago. She is now having some
vaginal spotting after being
amenorrheic for 14 months. She is
concerned.
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9. Menopause
Definition
Average Age
Related Sxs
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10. Classification System
STRAW System
Help communication
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11. Menopause Terminology:
STRAW* Staging System
*STRAW = Stages of Reproductive Aging Workshop.
†
Stages most likely to be characterized by vasomotor symptoms.
Soules MR, et al. Menopause. 2001;8:402-7.
Stages:Stages: -2-2 -1-1 +1+1 +2+2
Terminology:
Duration
of Stage:
Menstrual
Cycles:
Menopausal TransitionMenopausal Transition PostmenopausePostmenopause
EarlyEarly EarlyEarly††
LateLate††
LateLate
PerimenopausePerimenopause
VariableVariable
VariableVariable
cycle lengthcycle length
(>7 days(>7 days
differentdifferent
from normal)from normal)
≥≥2 skipped2 skipped
cycles and ancycles and an
interval ofinterval of
amenorrheaamenorrhea
((≥≥60 days)60 days)
4 yrs4 yrs
UntilUntil
demisedemise
NoneNone
00
Final Menstrual Period
1 yr1 yr
Amen.×12mos.Amen.×12mos.
aa bb
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12. Vasomotor symptoms:
Why don’t we treat every
women with hormones?
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13. WHI: HRT vs Placebo
Large prospective RCT, 2002, JAMA
16,608 postmenopausal women (50-79 y.o.)
Ave age at enrollment = 63 yrs
Two arms:
Estrogen + Progestin (Prempro 0.625/2.5), n=8506
Placebo, n=8102
Outcomes measured:
Primary : Coronary heart disease (CHD) and invasive breast
cancer
Secondary : stroke, pulmonary embolism, DVT, endometrial
CA, colorectal CA, hip and vertebral fractures and death from
other causes
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14. HRT Arm: Stopped Early @ 5.2 yrs
Invasive Breast Cancer = 38 vs 30/10,000
person yrs (HR 1.26)
CHD = 37 vs 30/10,000 (HR 1.29)
Stroke = 29 vs 21/10,000 (HR 1.41)
Venous Thromboembolic disease = 34 vs
16/10,000 (HR 2.11)
Colorectal cancer = 10 vs 16/10,000 (HR 0.63)
Hip fracture = 10 vs 15/10,000 (HR 0.66)
Vertebral fracture = 9 vs 15/10,000 (HR 0.66)
No change in endometrial and lung cancer
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15. WHI: Estrogen Only vs Placebo
WHI 2004: JAMA
10,739 postmenopausal women
s/p hysterectomy (50-79 y.o.)
Ave. age @ enrollment = 63.6 y.o.
Two arms:
Estrogen (Premarin 0.625 mg), n=5310
Placebo, n=5429
Outcomes:
Primary: CHD and invasive breast cancer
Secondary: stroke, pulmonary embolism, DVT, colorectal
cancer, hip/vertebral fractures and death from other
causes
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16. Outcomes
Ave. follow up 6.8 years (Hazard Ratio)
Invasive breast Cancer = 26 vs 33/10,000
person yrs (0.77)
CHD = 49 vs 54/10,000 (0.91)
Venous Thromboembolic disease = 28 vs
21/10,000 (1.33)
Stroke = 44 vs 32/10,000 (1.39)
Fatal = 4 vs 4/10,000 (1.13)
Nonfatal = 32 vs 23/10,000 (1.39)
Colorectal cancer = 17 vs 16/10,000 (1.08)
Hip fracture = 11 vs 17/10,000 (0.61)
Vertebral fracture = 11 vs 17/10,000 (0.62)
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17. Clinical Event
Hazard Ratio, 95% confidence interval
HERS E+P WHI E+P WHI E alone
CHD Events 0.99 (0.80-1.22) 1.29 (1.02-1.63) 0.91 (0.75-1.12)
Stroke 1.23 (0.89-1.70) 1.41 (1.07-1.85) 1.39 (1.10-1.77)
Pulm. Embolism 2.79 (0.89-8.75) 2.13 (1.39-3.25) 1.34 (0.87-2.06)
Breast Cancer 1.30 (0.77-2.19) 1.26 (1.00-1.59) 0.77 (0.59-1.01)
Colon Cancer 0.69 (0.32-1.49) 0.63 (0.43-0.92) 1.08 (0.75-1.55)
Hip Fracture 1.10 (0.49-2.50) 0.66 (0.45-0.98) 0.61 (0.41-0.91)
Death 1.08 (0.84-1.38) 0.98 (0.82-1.18) 1.04 (0.88-1.22)
Global Index - 1.15 (1.03-1.28) 1.01 (0.89-1.70)
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18. Menopausal Complaints:
Treatments
Hormones vs non-hormones vs herbals
Efficacy
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19. Hormones Contraindicated
Breast CA
Endometrial CA
Undiagnosed vaginal bleeding
CHD
Venous thrombosis
Stroke
Pregnancy
What is not here, that is a CI on OCP’s?
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20. Normal Physiologic Changes
of Aging
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21. Demographics
34 million elderly now
69 million in 2030
Gerontology
Health in the aged
Absence of ds
Maintain function and comfort
Presence of satisfactory support systemsBrought to you by

22. Body Composition and
Homeostasis
Decrease muscle mass
Increase body fat
Changes volume of distribution
Impaired baroreceptor
Orthostatic hypotension
Impaired thermoregulation Brought to you by

23. Cardiovascular
Decrease LV compliance
Increased reliance on atria
More LVH
Stiffer arteries
Decreased beta-adrenergic
responsiveness
Decreased max. HR with exerciseBrought to you by

24. Pulmonary
Decreased elastic recoil, airways collapse
earlier
Decreased forced vital capacity, functional
residual capacity, residual volume, FEV1
Decreased ventilatory response and
chemoreceptor function
Increased hypoxia and hypercapnia
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25. Renal
Decreased mass, # of glomeruli
Increased glomerulosclerosis
GFR slowly decreases
CrCl maintains
Decreased Na+ rentention, decreased
responsiveness to AVP; less concentration
of urine
Decreased thirst and drink response
Increased dehydration Brought to you by

26. Endocrine
Decreased glucose tolerance
Independent of obesity and inactivity
FG decreases 1 mg/dL/decade
Increased insulin resistance
Decreased GH, IGF-1
Give elderly men GH, increases lean body
mass
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27. Immunologic
Decreased T-cell activity
Decreased Ab response to foreign
antigen
Increased autoantibodies
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28. Specific Geriatric Issues
Other assessments to
be made.
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29. Cognitive Function
Normal decline
Dementia
Alzheimer’s
Vascular
Others
Depression
Medications
EtOH
MMSE Brought to you by

30. Sensory
Visual
Auditory
Balance
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31. Incontinence
Types
Risk factors
Assess
Tests
Treatment
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32. Types of Incontinence
Urge
Stress
Functional
Overflow
Mixed
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33. Fall Risks
Intrinsic
Person oriented issues…
Mobility
“Get up and go” test
Extrinsic
Environment
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34. Polypharmacy
Medication List
Drug-drug interactions
Altered pharmacokinetics,
pharmacodynamics
Herbals
OTC
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35. Osteoporosis
Screening
Risk Factors
Treatments
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36. Others
Abuse
Sexuality
Vaccinations
Financial
Support System
Driving
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37. Screening
Thyroid
Cancer
Sxs
Pap
Mammogram
Colonoscopy
Lipids
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38. Questions???
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