PERIMENOPAUSE/MENOPAUSE

1. 1 PERIMENOPAUSE/MENOPAUSE Bonnie Lee Josh Stern Julie Ting

2. Objectives 2 • Describe and recognize the following regarding menopause: • Age of presentation, physiologic changes, signs and symptoms an Investigations. • Describe and recognize the following regarding menopause: • Non-pharmacologic and pharmacologic management, including effects on other organ systems. • List common signs and symptoms of menopause.

3. Case 3 • A 50 yo woman complains of irregular menses over the past year. It has now been 6 months since her last cycle. She describes mood changes, feelings of inadequacy, vaginal dryness, difficulty sleeping with episodes of warmth and sweating that awaken her. On examination, her blood pressure is 120/68, heart rate is 90 bpm, and temperature 37.6 degree Celsius. Cardiac and lung examination are unremarkable. Breast examination is normal. Examination of external genitalia is normal.

4. Is this Menopause? 4 • No

5. 5 • Perimenopause: transition period leading up to menopause, associated with fluctuations in ovarian hormone production (symptoms of both estrogen deficiency and excess within the same cycle). • symptoms of estrogen deficiency: shortened cycles → irregular cycles • symptoms of estrogen excess: breast tenderness, etc.

6. 6 • Menopause: a cessation of menses for ≥12 mo. in a woman ≥40 y.o., the result of depletion of ovarian follicles • mean age 51.4 • Premature ovarian failure: a cessation of menses for ≥12 months in a woman <40 y.o., the result of depletion of ovarian follicles.

7. Back to the case… 7 • A 50 yo woman complains of irregular menses over the past year. It has now been 6 months since her last cycle. She describes mood changes, feelings of inadequacy, vaginal dryness, difficulty sleeping with episodes of warmth and sweating that awaken her. On examination, her blood pressure is 120/68, heart rate is 90 bpm, and temperature 37.6 degree Celcius. Cardiac and lung examination are unremarkable. Breast examination is normal. Examination of external genitalia is normal.

8. Back to the case… 8 • A 50 yo woman complains of irregular menses over the past year. It has now been 6 months since her last cycle. She describes mood changes, feelings of inadequacy, vaginal dryness, difficulty sleeping with episodes of warmth and sweating that awaken her. On examination, her blood pressure is 120/68, heart rate is 90 bpm, and temperature 37.6 degree Celcius. Cardiac and lung examination are unremarkable. Breast examination is normal. Examination of external genitalia is normal.

9. Signs/Symptoms (Hx, Physical) 9 • Tissues affected by menopause are the ones with estrogen receptors • CV: • atherosclerosis, stroke • vitals, abdo circumference/BMI, cardio, resp exam • Brain: • vasomotor symptoms/hot flashes/night sweats • sleep disturbance, fatigue, poor memory and concentration • depression, irritability/emotional lability • diminished sexual drive and response

10. Signs/Symptoms (Hx, Physical) 10 • Urinary tract: • urinary frequency, urgency, & incontinence • Breasts: • atrophy • breast exam • Genital: • atrophy, dryness, increased infectious disease • abdo, PAP, pelvic exam to look for pelvic masses, vulvovaginal atrophy, decreased vaginal calibre • MSK: • myalgias & arthralgias • osteoporosis

11. DDx 11 • Hyperthyroidism • Flushing, sweating, missed periods • Pregnancy • Hyperprolactinemia • Amenorrhea • Meds (Tamoxifen, SERMs) • Blocked estrogen; mimics menopause • Carcinoid • Pheochromocytoma • Malignancy

12. Investigations 12 • Consider: • TSH • b-hCG • PRL • Ultrasound? • Biopsy? • BMD? • CLINICAL DIAGNOSIS! • FSH, LH, estradiol • Wide variation during transition period • After 12mos of amenorrhea: • FSH > 25 IU/L x 2 • Estradiol < 50 pg/mL

13. Management 13 We can treat the following: • 1. Vasomotor instability • 2. Vaginal atrophy • 3. Decreased libido • 4. Urogenital health • 5. Osteoporosis • 6. Cardiovascular disease • 7. Mood and memory

14. Management 14

15. Management 15

16. Management 16

17. HRT 17

18. Side Effects of HRT 18 • Abnormal uterine bleeding • Mastodynia – breast tenderness • Edema, bloating, heartburn, nausea • Mood changes (progesterone) • CVD: no evidence of increased CVD in newly menopausal women, use in premature ovarian failure or early menopause, don’t use in asymptomatic elderly • VTE: risk less in low doses and transdermal • Stroke/dementia: better if given earlier, use lower doses • Breast CA: estrogen alone and low dose/transdermal combo therapy have lesser impact on breast density

19. Contraindications to HRT 19 Absolute - acute liver disease - undiagnosed vaginal bleeding - known/suspected uterine cancer/breast cancer - acute vascular thrombosis or Hx of severe thrombophlebitis or thromboembolic disease - CVD Relative - pre-existing uncontrolled HTN - uterine fibroids and endometriosis - familial hyperlipidemias - migraine headaches - FHx of estrogen-dependent cancer - chronic thrombophlebitis - diabetes mellitus (with vascular disease) • gallbladder disease, hypertriglyceridemia, impaired liver function (consider transdermal estrogen) • fibrocystic disease of the breasts

20. Summary 20 • Menopause is a natural process • It is important to rule out other disease processes • Medical management of menopause is not necessary but may significantly improve patient QoL • HRT is the best available therapy for menopausal symptoms

21. 21 Questions?

22. References 22 • http://sogc.org/wp-content/uploads/2014/09/gui311CPG1409Eabstract1.pdf • Hoffman, Barbara L., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Karen D. Bradshaw, and F. Gary Cunningham. Williams Gynecology. 2nd ed. New York: McGraw-Hill Medical, 2012. Print.