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Perimenopause & Menopause

Perimenopause & Menopause. Lindsay A nderson & Sarina Scaffidi Argentina September 4, 2014. Welcome to clerkship!. Please see this 50 year old woman who complains of “irregular menses” over the past year. More information. Changes in menstrual flow? Changes in cycle length?

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Perimenopause & Menopause

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  1. Perimenopause& Menopause Lindsay Anderson & Sarina Scaffidi Argentina September 4, 2014

  2. Welcome to clerkship! Please see this 50 year old woman who complains of “irregular menses” over the past year.

  3. More information • Changes in menstrual flow? • Changes in cycle length? • Missed periods? • What does she mean by ‘irregular menses’? “My periods have been lighter for the past year, and then stopped all together 6 months ago! ”

  4. Definitions • Menopause: Permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea. • Reflection of ovarian follicle depletion, resulting in a low estrogen state • Perimenopause: Period of time surrounding menopause characterized by fluctuating hormone levels, irregular menstrual cycles, and symptom onset. • Premature ovarian failure: Loss of ovarian function before age 40 (autoimmune disorder, infection, Turner’s syndrome)

  5. What else do you want to know? • Presence of other symptoms of menopause • Severity • Impact on quality of life

  6. SIGNS & Symptoms related to Estrogen deficiency

  7. Mrs P’s Signs and symptoms Mrs. P describes mood changes, feelings of inadequacy, vaginal dryness, difficulty sleeping with episodes of warmth and sweating that awaken her.

  8. Based on history, what is the most likely diagnosis? • Perimenopause • Menopause • Primary ovarian insufficiency • Pregnancy

  9. Physical exam • General: Vitals, Weight, BMI • Cardiac/Respiratory exam • Breast exam • Abdominal exam • Pelvic exam • May see signs of vulvo-vaginal atrophy, decreased vaginal calibre O/E: Vitals - BP 120/68, HR 90, T 37.6ºC Remainder of exam is unremarkable.

  10. Investigations • Clinical diagnosis based on history and physical exam. • >45 years of age: No further investigations. • 40-45 years of age: Rule out other causes of menstrual cycle dysfunction (bHCG, prolactin, TSH). • Hormonal profile (FSH, LH, E2) may be considered once 12 months of amenorrhea have elapsed: • Increased FSH (>35 IU/L) and LH (FSH>LH) • Decreased estradiol

  11. Physiology

  12. Management • Start by having a conversation with Mrs. P about: • Impact of symptoms on quality of life (sleep, relationships and work) • Is she currently doing anything for her symptoms? • Expectations regarding treatment

  13. Lifestyle modification • First line measures to promote health and prevent disease: • Regular exercise • Good nutrition • Smoking cessation • Moderate alcohol consumption

  14. Symptom Management

  15. Hormone replacement therapy (HRT) • What is HRT? • Estrogen + Progesterone (to prevent development of endometrial hyperplasia/cancer) • Can be given orally or transdermally • KEEP DOSES LOW AND DURATION OF TREATMENT SHORT (<5 years) • Long term use for disease prevention is not recommended

  16. Hormone replacement therapy (HRT) • What are the indications? • Treatment of menopausal symptoms (vasomotor instability) • Consider if moderate-severe symptoms • What are the ABSOLUTE contraindications? ABCD • A – Acute liver disease • B – Undiagnosed vaginal bleeding • C - Cancer (breast/uterine), Cardiovascular disease • D – DVT (thromboembolic disease)

  17. Risks & Benefits of HRT

  18. Additional considerations • Low estrogen confers increased risk of: • Cardiovascular disease • Osteoporosis • Manage cardiac risk factors • Smoking cessation • 1000-1500mg elemental Ca • 800 IU Vit D • Weight bearing exercise • Bisphosphonates, SERMS

  19. Preventative care for menopausal women • Monitor BP, glucose, lipid profile, thyroid function • Regular Pap smears • Regular breast exams/mammogram • Colorectal cancer screening (FOBT) • Selective BMD testing • Prevention of falls • Annual flu shot • Safe sex practices

  20. Take home messages • Median age of presentation: 51.4 years • Physiologic changes: Loss of sensitivity of the ovaries to gonadotropin stimulation, resulting in low estrogen state • Signs and symptoms: Related to estrogen deficiency state • Investigations: Clinical diagnosis • Management: Highly individual! • Non-pharmacologic management: Lifestyle modification • Pharmacologic management: Hormonal vs. Non-hormonal

  21. Multiple choice questions • Which of the following is an absolute contraindication to the use of HRT? • Uncontrolled hypertension • Familial hyperlipidemia • Migraine headaches • Family history of estrogen dependent cancers • Acute liver disease

  22. Multiple choice questions • Which of the following is not a risk of HRT? • Stroke • Coronary heart disease • DVT/PE • Colorectal cancer • Breast cancer

  23. References • Dynamed, Medscape, Toronto Notes • SOGC Menopause Guidelines

  24. Thank you!

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