Menopause Chapter 12 Women’s health – Flashcards
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hormone replacement treatment is currently found to be linked to
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cervical cancer
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Estrogen study findings
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- does not increase or decrease heart disease or breast cancer; - does help prevent osteoporosis-related hip fractures; - helps protect spine and small bones against osteoporosis; *** not approved for tx of osteoporosis;
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Natural menopause
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the point in time of cessation of menstruation for at least 12 consecutive months; - usually occurs between 40-58 with avg of 52 years; - if smoker may occur 1 year sooner;
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Natural menopause occurs in response to
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- normal hypothalamic- pituitary axis changes; - family history; - there is some genetic determinants of when it will occur;
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Perimenopause
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2-8 years prior to LMP; and for 12 months of initial amenorrhea following menopause;
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What is common during perimenopause and why
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anovulation - due to few follicles develop and are less responsive to FSH; - ovaries produce less estradiol, progesterone, and androgens;
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Irregular menstrual cycles during perimenopause
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- longer or shorter cycles; - heavier or lighter flow; - periods of amenorrhea; - worsening of premenstrual symptoms;
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what causes menstruation to cease during menopause
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- ovarian follicle production stops; - estrogen and progesterone levels low; - FSH and LH high;
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Early menopause
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- first 5 years following menopause when hormonal fluctuations often continue to occur;
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Premature menopause
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< 40 years; - usually follows same pattern as natural menopause;
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Late menopause
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- 6 years after LMP and until death; - increasing GU symptoms due to reduced estrogen levels;
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Measuring hormone levels during late menopause
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- can be difficulty to interpret and usually not recommended because they can change every day;
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Symptoms associated with perimenopause and menopause
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- acne; - irregular menses; - arthralgia; - irritability/mood d/o; - asthenia; - mastalgia; - decreased libido; - myalgia; - decreased vaginal lubrication; - depression; - nervousness/anxiety; - dizziness; - night sweats; - dry eyes; - nocturia; - dry/thinning hair; - odor; - dyspareunia; - palpitations; - dysuria; - paresthesia; - fatigue; - poor concentration; - forgetfulness; - recurrent cystitis; - formication; - recurrent vaginitis; - headache; - skin dryness/atrophy; - hairsuitism/virilization; - hot flashes/flushing; - sleep disturbance/insomnia; - stress urinary incontinence; - urinary frequency; - urinary urgency; - vaginal atrophy; - vaginal/vulvar burning/irritation/pruritis;
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Estrogen after menopause
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- Estradiol (E2); - Estriol (E3); - Estrone (E1);
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Estradiol (E2)
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- most potent; - main estrogen during reproductive years; - low amounts in postmenopausal years; - peripheral conversion of androstenedione;
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Estriol (E3)
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- secreted by placenta and synthesized from androgens; - produced by fetus during pregnancy; - present in non-pregnant women in small amounts as by-product of estradiol and estrone;
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Estrone (E1)
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- weakest estrogen; - primary estrogen present postmenopause, children and men; - produced by adipose conversion of androsteniedione secreted by adrenals and small percent by ovaries, and by metabolism of estradiol;
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Other hormones after menopause
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- Corticostromal and hilar cells of the stromal tissue are steroidogenic and produce significant levels of both androstenedione and testosterone for many years after menopause; - Androstenedione are approximately have the level after menopause; - testosterone remain constant; - high FSH and LH;
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Obesity and menopause
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- higher amounts of body fat may experience menopause later as adipose tissue converts androstenedione to estrogen;
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What are causes of menopause
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- surgical excision of both ovaries; - change in ovarian function due to medications or radiation; - primary ovarian insufficiency; - idiopathic; - caused by disease;
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Primary ovarian insufficiency
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women < 40; - not always permanent; - can be associated with autoimmune and genetic disorders;
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Temporary menopause
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- can be idiopathic; - caused by disease; - caused by medications;
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Induced or premature menopause
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- have early loss of fertility and more severe symptoms; - risk for cardiovascular disease; - risk of osteoporosis; - risk of cognitive impairment with aging;
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Diagnosing menopause
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- retrospective diagnosis; - serial FSH not recommend because variable: levels > 40 ort indicative; - anti-mullerian hormone (AMH): limited use for those seeking fertility assessments; - Labs: CBC, fasting glucose, TSH, prolactin
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Anti-mullerian hormone (AMH)
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- marker of ovarian reserve; - primarily used for fertility assessment; - AMH reflects # of follicles; - levels drop to an undetectable point approximately 5 years before menopause;
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Differential diagnosis of menopause
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- aneima: fatigue, cognitive changes; - anovulation: amenorrhea; - arrhythmias: fatigue, palpitations; - arthritis: joint aches/pain; - depression: fatigue, moodiness, anxiety, sleep disturbances, insomnia; - diabetes: fatigue, hot flashes/heat intolerance; - hyperprolactinemia: menstrual cycle changes; - HTN: headaches; - hyperthyroidism: sleep disturbance, insomnia, nervousness, irritability, heat intolerance; - hypothyroidism: fatigue, dry skin, cognitive problems; - infections: vasomotor symptoms, dyspareunia, cystitis symptoms, vaginitis;' - pregnancy, SAB, uterine fibroids, uterine polyps, endometriosis, adenomnyosis, ovarian cysts, ovarian tumors: menstrual changes, menorrhagia; - vulvar dystrophy: vaginal atrophy, dyspareunia;
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Presentation of menopause
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- unique and personal to each woman; - some find it severe; - some find it a non-event
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Hot flashes
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intense heat sensation with or without profuse sweating that occurs with LH surge; - when at night it is termed night sweats
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hot flushes
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similar to hot flashes but include flushing in face and chest d/t peripheral vascular dilation
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Usual pattern for hot flashes
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- type and severity worsen gradually; - peak about 2 yrs after LMP;
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length of experiencing hot flashes
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- most women will have on avg of 5 yrs after menopause; - some may have up to 10 years after menopause; - overweight women are more likely to experience;
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Sleep disturbance with menopause
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- associated with somatic, mood, and cognitive symptoms, performance deficits
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Sleep disturbance with menopause may lead to
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- inability to concentrate; - lethargy; - fatigue; - difficulty performing tasks; - lack of motivation; - also linked to cardiac disease and depression;
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Vaginal atrophy and menopause
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- vaginal dryness and dyspareunia; - predisposes to UTIs;
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Sexual function and aging
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- longer time to achieve vaginal lubrication; - production of fewer secretions; - reduced vaginal elasticity; - reduced pigmentation; - reduced rogation; - decreased # of superficial epithelial cells; - increased petechiae and vaginal bleeding d/t minor trauma such as sex; - reduced lactobacilli which increases pH and increases risk for infections; - atrophy of adipose and collagen tissue in vulva;
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What women are more likely to experience more severe symptoms
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those with higher level of perceived stress and negative attitudes toward menopause and aging
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Changes in neuroendocrine system during menopause causes
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hot flashes
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Changes in skin during menopause causes
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- dryness; - pruritis; - wrinkles; - facial hair; - dry mouth; - dry eyes; - rogue whiskers
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Changes in skeletal system during menopause causes
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- osteoporosis
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Changes in vocal cords during menopause causes
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deeper voice
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Changes in breasts during menopause causes
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smaller; softer; droopier;
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Changes in heart during menopause causes
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CAD; increased lipids
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Changes in vulvovaginal during menopause causes
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atrophy; dyspareunia; vaginitis
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Changes in uterus during menopause causes
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prolapse
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Changes in bladder during menopause causes
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stress incontinence; increased risk for UTIs
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Initial stage of menopausal transition
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referred to as early transition; - avg age is 47; - intermittent lengthening of cycle: 40-50 days; - Early FSH levels high but variable; - change in bleeding pattern;
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With menopause what is an indication for further diagnostics
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- vaginal bleeding more frequent than every 21 days;- - bleeding heavy or lasting > 7 days; - unresolved menopausal symptoms; - persistent irregular bleeding; - bleeding 1 year post menopause; - bleeding 6-12 months after amenorrhea; *** may indicate need for pelvic US and or endometrial bx
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final stage of menopausal transition
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referred to as late transition; - dramatic fluctuations in FSH and estradiol; - amenorrhea and decreased bleeding;
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symptoms during Perimenopause
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fluctuating hormones; - anovulatory cycles; - ertaic bleeding; - exaggerated or prolonged PMS; - vasomotor symptoms; - vaginal dryness; - urinary incontinence; - amenorrhea; - weight gain or redistribution of weight; - need 200-400 cal less/day;
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Why is exercise important during perimenopausal period
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- weight management; - emotional well being; - bone density;
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What is the earliest findings for menopausal transition
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- decreased length of cycles; ** most common is vasomotor symptoms; - GU atrophy; - symptoms can begin up to 10 years prior
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Menopause
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up to 12 months of amenorrhea; - FSH levels are 70-100; - difficult to predict/estimate LMP; - influenced by smoking: can be 1-3 years earlier; - influenced by genetics: more likely to have early menopause if mother did; - Influenced by BMI since estrogen is stored in fat;
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Postmenopausal
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Bone loss highest 1 year before through 2 years after LMP; - increased risk of CVD and stroke; - increased risk for dementia; - body composition and skin changes; - loss of balance;
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Overweight and obesity
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Increased weight is not associated with hormonal changes but rater natural part of aging;
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Weight gain postmenopausal
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- women gain an avg of 5 # at midlife due to decreased musle mass and decreased activity; - Recommends: - optimal BMI 18.5-24.9; - waist circumference of < 35; - loosing weight usually requires both reduction of calories and increasing exercise;
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Fat distribution changes midlife
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- from hips to thighs to waist; - increased waist circumference has link with cardiovascular disease and Diabetes
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Complications associated with midlife
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- osteoarthritis; - cholecystic disease; - urinary incontinence; - breast cancer; - endometrial cancer; - colorectal cancer; - greater frequency of hot flashes, night sweats; - greater frequency of stiffness in back, shoulders, neck;
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Cardiovascular disease in midlife
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- #1 cause of mortality in both sexes in the US; - refers to Hypertension, valvular heart disease,angina, MIs; strokes, arrhythmias, CHF, PAD, aortic disease, arterial and venous thrombosis, PEs, and congenital heart defects;
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what group is at greatest risk of cardiovascular disease
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African American
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Major risk factors of cardiovascular disease
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- age; - smoking; - sedentary lifestyle; - family history of premature CVD; - preexisting hypertension; - dyslipidemia; - DM; - increased following menopause;
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Menopause and cholesterol
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- increased LDL; - increased VLDL; - LDL oxidation is enhanced; - HDL may decrease slightly;
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Menopause and elasticity
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- decreased elasticity in vascular system related to decreased estrogen and progestin;
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Menopause procoagulation factors
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- production of fibrinogen and factor VII; - increase of some fibrinolytics: - plasminogen; - antithrombin III
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Diabetes Mellitus risk factors
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- overweight/obese: BMI > 25; - abdominal adiposity: waist circumference > 35; - sedentary lifestyle; - insulin resistance; - history of gestation diabetes; - history of PCOS; - family history of DM; - hypertension; - dyslipidemia; - increased with age; - affects minotiry women
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Prediabetes
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- impaired fasting glucose: 100-125; - impaired glucose tolerance: 2 hour- 75 gm glucose load > 140-190;
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Complications of diabetes
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- increased risk for cardiovascular disease; - increased risk of cerebrovascular disease; - infections; - foot ulcers; - PVD; - peripheral neuropathy; - nephropathy; - retinopathy;
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Management of diabetes after menopause
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- more difficult to manage; - not due to hormonal changes; - due to weight gain and change in body composition; - increased insulin resistance;
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Medications for treatment of diabetes after menopause
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- Metformin first line therapeutic options; - Glucose control, statin > or = age 40; - stop smoking; - BP control; - decrease risks of cardiovascular disease and complications;
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Risks of cancer at midlife
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- increases with age; - 77% after age 55;
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Osteoporosis at midlife
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- most common bone disease in humans characterized by: - low bone mass; - deterioration of bone tissue; - disruption of bone architecture; - reduced bone strength with increased risk for fractures;
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Primary osteoporosis
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- associated with aging; - affects women much more than men; - estrogen loss first year after menopause: bone loss is rapid but slows to 1% each year;
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Secondary osteoporosis
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iatrogenic due to medications: - corticosteroids; - anticonvulsants; - methotrexate; Disease processes: - hyperthyroidism; - chronic liver disease; - GI disease related to malabsorption; **can affect women of any age;
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Idiopathic osteoporosis
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- low bone density and fracture in young adults when no other cause is identified;
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Modifiable risk factors of Osteoporosis
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- excessive thinness: BMI < 21; - hypogonadal states: anorexia, athletic amenorrhea, premature menopause, androgen insensitivity, hyperprolactinemia, Turners syndrome, Klinefelters syndrome; - nulliparity; - cigarettes smoking; - excessive alcohol or caffeine; - sedentary activity level; - frequent falls; - inadequate calcium or vitamin D intake; - medications; - chronic disease
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Medications that can cause osteoporosis
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- thyroid hormone; - corticosteroids; - anticonvulsants; - aluminum-containing antacids; - lithium; - methotrexate; - gonadotropin-releasing hormone; - cholestyramine; - heparin; - warfarin; - Depo-provera; - premenopausal tamoxifen; - SSRIs; - proton pump inhibitors;
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Chronic diseases that are linked to osteoporosis
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- endocrine disorders; - gastrointestinal disorders; - bone disorders; - chronic liver disease; - seizure disorders; - prolonged immobility; - eating disorders; - chronic renal failure; - frailty;
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Nonmodifiable risk factors of osteoporosis
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- advanced age; - female; - Caucasian and Asian then Hispanic and AA; - personal history of fracture during adult; - family history of osteoporosis; - first degree relative with history of fracture; - genetic diseases: CF, ehlers-Danlos, osteogenesis imperfecta, porphyria, Gauchers disease, hemochromatosis, Marfans, homocystinuria; - hematologic disorders: hemophilia, sickle cell, multiple myeloma, thalassemia, leukemia, lymphomas; - rheumatologic and autoimmune ( Lupus, RA, ankylosing spondylitis;
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Bone mineral density (BMD);
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- tested via dual energy x-ray called DXA scan; - central BMD at spine/hip and vital for diagnosis and management; - quantitative CT can be used to perform spine measurements - usually with arthritis
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Quantitiative CT is less likely to reflect
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osteocytes
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T-score in bone mineral density
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- # of standard deviations that pt's BMD is > or 50 and postmenopausal women;
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T-score for osteopenia
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1.0 to - 2.5;
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T-score indicating osteoporosis
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< -2.5
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Z-score for Bone mineral density
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- compared BMD of same sex, age, ethnicity for reference; - recommended for premenopausal women, children, and men < 50;
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Z-score of < -2.0
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below expected range for age;
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Z-score of >-2.0
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within expected range for age
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Prevention of osteoporosis for perimenopausal and postmenopausal women
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- adequate intake of Calcium = 1200 mg/day; - adequate intake of Vitamin D = 800-1000 U/day > 50 y.o. - weight bearing and resistance exercise; - fall prevention; - avoid tobacco; - moderate alcohol intake ( < 2 drinks/day);
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Management of osteoporosis
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- recommended for women with T-scores of < -2.5 and for those with hip and vertebral fractures;
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WHO recommends use of what tool for osteoporosis
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- FRAX tool: to identify those who would realize a cost effective benefit from initiating medication treatment; - If hip fx > or = 3% or major osteoporotic fracture > or = 20% then medication tx is recommended;
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repeat BMD testing for osteoporosis
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- every 2 years after treatment is initiated to monitor effects of therapy;
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Alendronate (Fosamax)
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Prevention: 5 mg every day or 35 mg weekly; Treatment: 10 mg daily or 70 mg weekly;
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Aendronate (Fosamax) considerations
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caution with upper GI disease; - clinical association with: - dysphagia; - esophagitis; - ulceration; - take first think in the morning on an empty stomach with 8 oz of water; - remain upright and take no other food or drink for at least 30 minutes;
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Risendronate (Actonel)
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- prevention: 5 mg daily or 35 mg weekly or 150 mg monthly; - Treatment: 5 mg daily or 35 mg weekly or Ateliva 150 mg monthly;
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Risendronate (Actonel) considerations
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caution with upper GI disease; - clinical association with: - dysphagia; - esophagitis; - ulceration; - take first think in the morning on an empty stomach with 8 oz of water; - remain upright and take no other food or drink for at least 30 minutes;
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Ibandronate (boniva)
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prevention or treatment 150 mg monthly; treatment: 3 mg IV every 3 months;
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Ibandronate (boniva) considerations
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caution with upper GI disease; - clinical association with: - dysphagia; - esophagitis; - ulceration; - take first think in the morning on an empty stomach with 8 oz of water; - remain upright and take no other food or drink for at least 60 minutes; - IV inj administered over 15-30 seconds;
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Zoledronic acid (reclast)
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prevention: 5 mg IV every 2 years; Treatment: 5 mg IV 1 x year
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Zoledronic acid (reclast) considerations
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- IV infusion administered over no less than 15 minutes;
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Calcitonin (Miacalcin, fortical);
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Treatment: 200 U intranasal spray daily or 100 U SQ daily or every other day;
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Calcitonin (Miacalcin, fortical) considerations
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- usually administered as nasal spray; - has an analgesic effect on osteoporotic fractures;
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Estrogen for treatment of osteoporosis
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- Prevention: doses and routes vary
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Estrogen for treatment of osteoporosis considerations
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also effective in alleviating most symptoms of menopause; - comes in pill or patch;
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Raloxifene (Evista
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prevention or treatment 60 mg daily
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Raloxifene (EVista) considerations
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- may cause hot flashes; - not recommended if pt is taking ET or EPT;
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Teriparatide (Forteo)
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treatment 20 mcg sq daily
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Teriparatide (forteo) considerations
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reserved for use after failure of first line agents
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DEnosumab (Prolia)
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treatment 60 mg SQ every 6 months;
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Denosumab (Prolia) considerations
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reserved for use after failure of first line agent;
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Thyroid disease in midlife
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- affects women more than men; - increased risk with age;
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symptoms of thyroid disease that mimic menopausal transition
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- menstrual cycle changes/irregularities; - disruption of sleep; - fatigue; - mood swings; - heat intolerance; - palpitations;
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Screening of thyroid disease
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- both men and women > 35 screened every 5 years; - measure TSH;
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Depression
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- many women report depression, anxiety, stress, or decreased sense of well-being during menopausal transition
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Risks of depression
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- increased midlife due to stresses and hormonal fluctuations; - history of depression; - postpartum depression; - PMS:
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Triggers for hot flashes
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- hot drinks; - spicy foods; - caffeine; - ETOH;
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Dietary changes to manage menopause
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- increase water intake to replace sensible loss from sweating; - cold water seems to relieve dry skin and may decrease discomfort; - recommend 6- 8 oz glasses each day- small or no improvement of hot flashes;
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Vitamin and supplements for menopause symptoms
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- Vitamin E: small or no improvements for hot flashes; - Vitamin D recommended;
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Vaginal lubricants and moisturizers for menopause
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- 25-50% will experience vulvovaginal atrophy due to decreased estrogen levels;
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Genitourinary syndrome of menopause
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- vulvovaginal dryness, burning, or irritation; - inadequate lubrication; - pain with sex; - urinary urgency; - dysuria; - UTIs;
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Genitourinary syndrome of menopause mild symptom treatment
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- respond well to vaginal lubricants and moisturizers - should be initial treatment; - moisturizers provide longer relief: supports a normal pH; - petroleum jelly : avoid- can injure vaginal tissue, are not easily removed, and may increase risk of BV; - Fragrance: avoid- can cause vaginitis or irritation;
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Douching
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- not effective for moisturizing; - will remove normal flora; - increases risk for infection;
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smoking during menopause
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increases: - cardiovascular risk; - rate of bone loss; - earlier menopause; - increased presence of vasomotor symptoms;
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Stress management with menopause
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- associated with increased severity and frequency of hot flashes; - increases sleep distrubance; - decreased libido; - paced respiration has been linked to reduce hot flashes
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Sleep and menopause
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- use light blankets, cotton sleepwear or moisture wicking pajamas, well-ventilated room; - avoid caffeine, alcohol, or nicotine; - exercise enhances sleep quality, reduces sleep latency, and increases amount of time in deep sleep; - don't exercise right before bed;
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mental function and menopause
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- stay as mentally and physically active as possible; - increase omega-3 fatty acids; - no smoking; - consume ETOH in moderation; - reduce hyptertension, diabetes, hyperlipidemia protects from dementia;
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Pharmacologic treatment of moderate to severe menopausal symptoms
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- impact on quality of life is how defined now; - hormonal therapy most effective for menopause related vasomotor symptoms
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Pharmacologic treatment of mild to moderate menopausal symptoms
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- lifestyle changes alone or in combo with nonprescription remedies;
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Hormonal therapy for menopause
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- used for vasomotor symptoms; - use in first 10 years has not been shown to increase risk of cardiovascular disease;
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Estrogen therapy for menopause
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- exclusively for women with hysterectomy because unopposed estrogen increases risk of endometrial hyperplasia;
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Estrogen- progestogen therapy: sequential regimen
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- estrogen taken daily with progestogen added in cyclin fashion usually 1-12 days of the month; - most women will have withdrawal bleeding;
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Estrogen- progestogen therapy: continuous regimen
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estrogen and progestogen taken daily; - can avoid withdrawl bleeding;
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Estrogen- progesterogen therapy: pulsed combination therapy
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- progestogen taken for 2 days followed by a day off in repeating pattern;
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Estrogen- progesterogen therapy: cyclic
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estrogen is taken daily for 21 days; then progestogen added for days 12-21;
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Side effects of cyclic Estrogen- progesterogen therapy:
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- withdrawl bleeding between days 22-28 ( no HT taken); - menopause usually rebound when estrogen not taken - few womens choose this option
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Estrogen preparations for menopause
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- Systemic: - oral; - transdermal patch; - creams; - sprays; - gels; - Local: - creams; - tablets; - rings;
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Vaginal ring for menopause
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- releases 0.5 or 0.1 mg/day of estradiol acetate over 3 months and is the only local treatment that has been proven effective for hot flashes; - slightly more systemic absorption; - women with history of BRCA should avoid;
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Estrogen therapy for menopause absolute contraindications
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- known or suspected BRCA/ estrogen-dependent neoplasia; - history of uterine or ovarian cancer; - history of heart disease or stroke; - history of biliary tract disorders; - undiagnosed genital bleeding; - history of thrombophlebitis or thromboembolic disorders;
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Estrogen therapy for menopause adverse effects
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- uterine bleeding; - breast tenderness; - nausea; - abdominal bloating; - fluid retention in extremities; - headache; - dizziness; - hair loss;
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Progestogens for treatment of menopause
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MPA; - micronized progestogen; - norgestimate; - norethindrone acetate;
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Progestogens for treatment of menopause absolute contraindications
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- active thrombophlebitis or thromboembolic disorders; - liver dysfunction or disease; - known or suspected BRCA, undiagnosed abnormal vaginal bleeding; - pregnancy;
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combined Progestogens/estrogen for treatment of menopause adverse effects
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- mood changes; - possible increased uterine bleeding; - sleepiness; - sluggish; - abdominal pain; - acne; - breast pain; - rearely increased thirst and difficulty sleeping;
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Estrogen-Bazedoxifene therapy
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- taken daily and continuous; - breakthrough bleeding early during therapy but tends to wane; - good for intact uterus; ***BZA protects against endometrial hypertropy and malignancy;
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Estrogen-androgen therapy
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- theorized to improve loss of libido in postmenopausal women but not enough evidence and not approved by FDA; - S/E: alopecia, acne, deepening of voice, hirsuitism;
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Natural vs bioidentical hormones
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- natural refers to components that originate from plant, animal, or mineral sources;
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Forms of estrogen
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- estrone; - estriol; - 17 beta estradiol
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Forms of progestogen
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- micronized form
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Progesterone creams
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- FDA regulations not enforced; - OTC creams such as phytogest, pro-gest, endocreme, and Pro-dermex; - one study suggests improved vasomotor effects;
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Side effects of hormone therapy
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- fluid retention: - bloating: - breast tenderness; - headaches; - mood changes; - nausea;
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Treatment for hormone therapy s/e: fluid retention
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- decrease salt intake; - maintain adequate water intake; - exercise; - herbal diuretics; - mild rx diuretics;
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Treatment for hormone therapy s/e: bloating
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- change to low dose transdermal estrogen; - decrease progestogen dose; - try micronized progestogen;
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Treatment for hormone therapy s/e: breast tenderness
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- decrease estrogen dose; - change estrogens; - decrease salt intake; - change the progestogen; - decrease the caffeine and chocolate comsumption;
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Treatment for hormone therapy s/e: headaches
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- change to transdermal estrogen; - decrease estrogen and/or progetogen dose; - change to cc-EPT regimen; - ensure adequate water; - decrease salt, caffeine, etoh;
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Treatment for hormone therapy s/e: mood changes
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- decreased progestogen dose; - change to CC-EPT regimen; - ensure adequate water; - decreased salt, caffeine, etoh;
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Treatment for hormone therapy s/e: nausea
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- take with meals; - change in estrogen; - change to transdermal estrogen; - decrease estrogen or progestogen dose;
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Nonhormonal treatments for vasomotor symptoms of menopause
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- Venlafaxine ( effexor); - fluoxetine (prozac); - paroxetine (paxil); - Gabapentin ( neurontin); - Clnidine (catapres); - Methyldopa (aldomet) and belladonna; - ergotamine; - phenobarbital
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Use of Venlafaxine (effexor) for menopause vasomotor symptoms
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* dose: 37.5-75 mg/day and can up titrate; * comments: response is immediate; * S/E: N/V, dry mouth, decreased appetite; * contraindication: MAOIs, taper when DC.
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Use of FLuoxetine (prozac) for menopause vasomotor symptoms
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- Dose: 20 mg/day and up-titrate; - Comments: response is immediate; - contraindication: concommitant use of MAOIs, thioridazine; - Caution with: warfarin; taper when DC
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Use of Paroxetine (paxil) for menopause vasomotor symptoms
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- dose: 10-25 mg/day; - comments: response is immediate; - S/E: asthenia, sweating, nausea, somnolence, anorgasmia, decreased libido, weight gain, blurred vision; - contraindications: use of MAOIs, thioridazine, caustion with warfarin; taper when d/c;
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Use of Gabapentin for menopause vasomotor symptoms
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- dose: initial 200-300 mg/day at bedtime but can increase; - S/E: somnolence, dizziness, ataxia, fatigue, weight gain; - contraindications: avoid antacids within 2 hours of use; taper when DC
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Use of clonidine (catapres) for menopause vasomotor symptoms
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- dose: 0.5-1 mg BID; - Comments: available as patch; less effective then antidepressant or gabapentin; - S/E: dry mouth, drowsiness, dizziness, weakness, constipation, rash, myalgias, urticaria, insomnia, nausea, agitation, orthostatic hypotension, impotence, arrhythmia;
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Black cohosh
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- dose: 20-40 mg BID; - indication: vasomotor symptoms; - comments: benefit simialr to estrogen for vasomotor symptoms; - safety: for < 6 months not established; S/E: can potentiate antihypertensives, GI upsets, headache, dizziness, hypotension, painful extremities, failure;
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Plan of care and pt education for hormonal therapy for menopause
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- initiate low dose (0.3 mg CEE, 0.25- 5 mg of 17 beta estradiol patch;2-6 weeks - vasomotor s/s usually begin to resolve in 2-6 weeks; - S/E: doesn't cause weight gain, but may cause fluid retention; - follow-up in 6-8 weeks to evaluate progress; - Vasomotor symptoms lasts 7.6 years on average but may experience for 14 years; - D/C treatment - symptoms may reoccur when tapered or stopped; -
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Chaste tree berry
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- indication: menstrual irregularity; - comments: more popular in europe; - approved in Germany for pMS, mastalgia, menopause; - S/E: headaches, GI
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Dong quai
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- dose: 2 caps BID to TID; - indication: gynecologic conditions; - comments: widely used in asia; **research has found no benefit for menopause; - S/E: red face, hot flashes, sweating, irritability, insomnia; - contraindications: use of anticoagulants;
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Evening primrose oil
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- dose: 3-4 gms/day in divided dose; - indications: vasomotor symptoms, mastalgia; - Comments: data shows no benefit; - s/e: risk for seizures, lowers seizure threshold, thrombosis, inflammation, immunosuppression, diarrhea, nausea;
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Ginkgo
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- dose: 40-80 mg TID; - indication: memory changes; - comments: insufficieny researcy for safety; - S/E: GI, headache, hypotension, brain bleeds with chronic use;
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Ginseng
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dose: 1-2 gm root daily; - indication: general tonic improved mood and fatigue; - Comments: NO BENEFIT for menopause; - S/E: uterine bleeding, myalgia, rash nervousness, dizziness, insomnia, hypertension; - Contraindicated: BRCA, MAOIs, stimulants, anticoags; may potentiate digoxin;
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Kava
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- dose: 150-300 mg root daily; - indication: anxiety, insomnia, vasomotor symptoms; - comments: effective for anxiety; banned in many countries d/t hepatotoxicity; - Contraindications: depression; - S/E: GI, impaired reflexes and motor function, weight loss, hepatotoxicity, rash;
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Licorice root
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Dose: - mg of root equivalent daily; - indication: expectorant, anti-inflammatory, antiviral, antibacterial, menopause-related symptoms; - Comments: no data to support for vasomotor sx; - S/E: aldosteronism, cardiac arrhythmias, cardiac arrest; - Contraindication: hepatic and renal disease, DM, HTN, arrhythmia, hypokalemia, hypertonus, pregnancy, diuretics;
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Passion flower
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- dose: 3-10 grains daily; - indication: sleep disturbances; - comments: mixed results in sleep improvement, and menopausal sleep disturbance
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St. Johns wort
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- dose: 300 mg TID; - indication: depression, irritability, vasomotor sx; - Comments: effective for depression, some studies shows help hot flashes, often combined with black cohosh; - interferes with metabolism of many medications: C450 system.. estrogen, digoxin, theophylline; decreases INR levels; - Contraindications: antidepressants, MAOIs, immunosuppressants; - S/E: GI, constipation, cramping, photosensitivity, rash, dry mouth, fatigue, dizziness, restlessness, insomnia
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Valerian root
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- dose: 300-600 mg before bed; - indication: insomnia, anxiety; - Comments: research showed improvement in sleep and depression/mood scales; - S/E: headache, uneasiness, excitability, arrhythmias, morning sedation, GI upset, cardiac function disorder;
