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MENOPAUSE

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					MENOPAUSE
Turning the Corner…
    Issues on Menopause
Menopause is:

• Normal part of being a woman

• Time when a woman’s monthly
  period stops
Causes of Menopause:

• Your body makes fewer hormones

  – estrogen

  – progesterone
It occurs:

• Over 3 to 5 years

• Complete when a woman has not had
  a period for 12 months in a row
Age:
• Every woman is different

• Start around age 50

• Some earlier 40’s, even 30’s
Types of Menopause:
• Natural - most women  slowly over
  a few years

• Induced - immediate after removal of
  or damage to the ovaries
Perimenopause:
    “around menopause”
• Time immediately prior to natural
  menopause (about 6 years>)

• Changes of approaching menopause
  being

• The year after menopause
Changes of Approaching
Menopause
• Bladder Control Problems - urine leakage
• Feeling Sad or Cranky
• Weight Gain
• Aches in your bones
• Forgetfulness
• Irregular Periods - missed periods bleeding
  between, more or less bleeding
• Hot Flashes - heat in the face and upper
  body causes sweating. Occurs at night
• Dry Vagina - itching; painful sex
Contraception
• Pregnancy still possible until
  menopause is reached

• Birth control pill
Hot Flashes
• A sudden warm feeling in the face or
  upper body, blushing, increased
  pulse, perspiration, a cold chill
  usually follows
• Triggers:
   – warm environment
   – stress
   – hot drinks
   – alcohol
Urogenital Conditions
• Dryness and/or irritation of the
  vagina

• Itching and/or irritation of the vulva

• Urinary urgency

• Leaking urine when coughing or
  sneezing
Tips for Urinary Conditions
• Keep urination diary for one week,
  ad day-by-day account of the
  following info:
   – Type and amount of fluid intake
     and time of day
   – Amount of urine and time of day
   – Any urge sensed before urination
   – Amount of urine leaked, plus the
     time of day and type of activity
Sexuality Changes
• Diminished response

• Decreased desire

• Dyspareunia (painful intercourse)

• Declining frequency of sexual
  activity
Confirming Menopause

• FSH level 30 - 40 MIU/ml

• Medical History
Contact Healthcare Provider
if you notice the following:

• Very heavy periods (“gushing”)
• Periods that last 2 or more days
  longer
• Periods come more often than 3
  weeks
• Spotting between periods
• Bleeding after intercourse
Possible Causes of
Reproductive Abnormal
Uterine Bleeding
•   Hormonal imbalance
•   Birth control producers
•   Pregnancy
•   Fibroids
•   Uterine lining abnormalities
•   Cancer
In the U.S., a female at birth
has a 23% lifetime risk of
dying from heart disease,
compared to 4% for breast
cancer
Cardiovascular Disease
“Heart Disease”
• # 1 killer of women

• Diseased blood vessels in the heart
  are called coronary heart disease

• Diseased blood vessels outside the
  heart can lead to stroke and high
  blood pressure
Heart Disease Risk Factors
• Advancing age         • Diabetes
• Being black           • Drinking more than
• Having a close          three alcoholic
  relative who had a      beverages daily
  heart attack or       • Stress
  stroke before age     • Being more than
  60                      30% over ideal
• Cigarette smoking       weight
• Physical inactivity   • Being past
• High blood              menopause
  pressure                (especially if
                          reached before age
Osteoporosis
• Disease characterized by:

  –  bone density

  –  risk of fracture

  – preventable and treatable
    Osteoporosis Risk Factors
•   Advancing age         •   Heavy alcohol intake
•   Being white           •   Vitamin D deficiency
•   Being female          •   Amenorrhea during
•   having family             reproductive years
    member with it            for longer than 6
                              months
•   Being small-boned
    and/or thin           •   Use of “bone-
                              robbing” Rx’s such as
•   Having an inadequate      steroids and anti-
    diet (especially Ca)      seizure drugs
•   Little or no exercise •   Thyroid disease
•   Smoking cigarettes •      Being past
What can I do to feel better?
•   Do not smoke
•   Exercise regularly
•   Eat a healthy diet
•   Reduce stress
•   Stay cool during hot flashes
•   Ease vaginal dryness
•   Improve bladder control
•   Talk to family and friends
•   Ask for help
•   Learn new ways to relax
•   Make time for yourself
•   Laugh a lot
•   Stay healthy
Treatment Options
• No treatment at all

• Non-prescription remedies

• Prescription therapies

• Complementary
Non-prescription Remedies
• Vaginal remedies:
  – K-Y jelly; Replens
• Vitamins:
  – Vitamin E - hot flashes, lower risk
    of heart attack
  – Vitamin B - relieve dry skin and
    hair. Beware of toxic effects
  – Folate - preventing heart disease
Non-prescription:
Vitamins/Minerals
Selected vitamin/mineral supplement doses
recommended for women by the National
Academy of Sciences
 N utrient          Recommended daily allowance
 Vitamins
  Vitamin A            3,300 IU
  Vitamin C
    nonsmoking women   75 mg
    women who smoke    110 mg
  Vitamin D
    Age 50-70          400 IU
    Age 70+            600 IU
  Vitamin E
    natural source     22 IU
    synthetic source   33 IU
  Folate               400 mcg
  Vitamin B6           1.5 mg
  Vitamin B12          2.4 mcg
 Minerals
  Calcium – age 50+    1,200 mg
  Magnesium            320 mg
  Phosphorous          700 mg
Prescription Therapies

• ET - Estrogen Therapy

• HT - Hormone Therapy (Estrogen
  plus Progesterone)
HT and Progestogen
• Women with a uterus - progesterone

• Counteracts the increased risk of
  uterine cancer from taking ET alone
HT - Now What?
Women’s Health Initiative (WHI) trial
• part of the National Institute of
  Health
• 8 year study
• hoping to prove that long term HT
  protects against heart disease
• study halted after 5 years (July,
  2002)
Study Results:

• increase   in risk of heart attacks and
  strokes
• increase   in blood clots in legs and
  lungs
• increase   in gallbladder disease
• increase   in breast cancer
The study found that if 10,000 women
  taking the hormone combination for
  one year were compared to 10,000
  women not taking the hormone
  combination, the following results
  would occur:
• 8 more of the HT users will develop
  invasive breast cancer
• 7 more of the HT users will have a
  heart attack or other coronary events
• 8 more of the HT users will have a
  stroke
But there was some good news among
  women receiving the combination
  hormone therapy as compared to the
  placebo group:
• 6 fewer of the HT users will have
  colorectal cancers
• 5 fewer of the HT users will have hip
  fractures
“As with any prescribed medication, it
 is very important to be aware of the
 risks and benefits associated with
 hormone therapy. Each individual is
 unique and may respond differently
 to the treatment. Please visit with
 your healthcare provider regarding
 these issues and the latest available
 information about hormone therapy.”
Women Who Should Not Use
ET
• Breast cancer
• Abnormal uterine bleeding of an
  unknown cause
• Increased triglyceride level
• History of blood clotting disorders
• History of liver disease
ET Types
• Premarin
• Estatab
• Ogen
• 17 beta-estradiol (patches, tablets,
  creams)
• Custom-made formulations - not
  FDA approved
Forms of ET
• Systemic - tablets, skin patches,
  injections

• Local - vaginal creams, ring (Estring)
    Side Effects of ET
• Vaginal bleeding
• Breast tenderness
• Nausea
• Fluid retention
• Changes in shape of the eye (contact
  lens intolerance)
• Headaches
• Depression
• Reduced tolerance to sugar and
  carbohydrates
Concerns about ET and Cancer
Risk
• Taking estrogen alone for 5 or 7 years can
  triple the risk of endometrial (uterine)
  cancer. Taking progestogen makes the
  risk decrease to the level of taking no
  hormones at all.
• Relationship between ET & breast cancer
  is controversial
   – 40% increased risk if taken for greater
     than 5 years
   – Increased risk possible if progestogen
     or testosterone is added to ET
Progestogen
•   Oral
•   Injection
•   Gels
•   Creams
•   Patch
Androgens
• Major impact on motivational and
  libidinal aspects of sexual behavior
• Estratest and Estratest HS - oral
  tablets for the treatment of moderate
  to severe vasomotor symptoms.
• Side effects:
   – masculinizing
   – agitation
   – depression
Dealing with HT Side
Effects Strategy
 Side Effect
Headaches    Restrict salt intake, reduce dose of
             oral estrogen, change to an everyday
             continuous dosage schedule, and
             switch to an estrogen patch
Depression   Restrict salt intake, change form
             continuous to cyclic progestin, stop
             ERT/HT to see if hormones are the
             cause
N ausea      Take estrogen tablets at bedtime or
             with meals, switch to an estrogen
             patch
SERMs
Selective Estrogen Receptor Modulators
“Designer Estrogens”
• Provides the benefit of estrogen on
  bone without adverse effect on the
  uterus or breast
• Decreased total and LDL cholesterol
• Increased incidence of hot flashes
• Same risk for venous thrombosis as
  ET/HT
SERMs - “designer
estrogens”
• Tamoxifen (Nolvadex oral
  tablets)approved for breast cancer
• Raloxifene (Evista) oral tablets,
  osteoporosis treatment
   – does not affect endometrium or
     breast
   –  total cholesterol and LDL
   –  incidence of hot flashes
 Complementary Therapies -
 Alternative Treatments

CAM Therapies
1.) Mind-Body: yoga, tai chi
2.) Alternative Medical System: acupuncture,
  oriental medicine, naturopathy
3.) Lifestyle and Disease Prevention:
  nutritional intervention
Complementary Therapies -
Alternative Treatments
4.) Biologically Based Therapies: herbs,
  vitamins, minerals, chelated products
5.) Manipulative and Body Based Systems:
  chiropractic medicine, massage, acupressure
6.) Biofield: therapeutic touch, reiki
7.) Bioelectromagnetics: magnet therapy
 Complimentary
• Acupuncture - stimulation of anatomical
  locations on the skin
• Black cohosh:  depression,  well-being,
  do not take with ET/HT
• Cranberry: acidifies urine,  bacterial
  adherence
• Dong quai: relives menopause symptoms,
  side effects of photosensitivity and
  anticoagulation
• Ephedra: vasoconstrition-appetite
  suppressant; adverse effects of
  hypertension, seizures, heart attacks,
 Complimentary
• Ginkgo: treats memory loss, but 
  headaches, depression, blood thinning
• Ginseng: (Panax) estrogenic effects
• Kava: treats menstrual cramps, soothes
  anxiety
• Licorice: anti-inflammatory, estrogenic
  effect
• Sage: helps hot flashes and night sweats
• St John’s Wort:  depression
• Wild Yam: relieve hot flashes,  libido
• Valerian: sedative effect, insomnia
• Vitex: balances hormone levels
 Complimentary
Phytoestrogens - naturally occurring compounds in
certain plants, herbs, seeds similar to estrogen
      Type                       Source
 Lignans            Found in almost all cereals and
                    vegetables, with highest
                    concentration in the oilseeds,
                    especially linseed (flaxseed)
 Coumestans         Found in sunflower seeds, red
                    clover, and bean sprouts
 Isoflavones        Most commonly found in
                    legumes with large
                    concentrations in soy beans
Reasons for CAMs
• Skepticism about traditional medicine

• Fear of ET/HT

• Greater control over their health
Some Hazards of Herbal
Remedies for Women
• Self-diagnosing and self-treatment
• Neglecting medical condition and
  masking symptoms of serious illness
• Delaying treatment of serious illness
• Allergic reactions or toxicity to herbal
  remedy
• Interactions between prescription and
  herbal remedy
• Financial drain-these products can be
Beware
• Most of the products are not quality
  controlled
• Not FDA approved
• Natural - does not mean the product
  is always safer or better
• Not usually reimbursed by insurance
  companies
 Lifestyle
• Smoking:
   – single greatest preventable cause of
     illness and death
   – reach menopause 2 years earlier
• Exercise:
   – 3 types: Strength training, Aerobic,
     Flexibility
• Nutrition:
   – Balanced diet
   –  whole grains, fruits, vegetables/  fat
   – adequate H2O intake
Lifestyle - Stress
• Participate in       • Snack on healthful,
  pleasurable            crunchy foods such
  activities             as apples
• Talk with friends    • Meditate or get a
• Make time for play     massage
• Make time for        • Take slow, deep
  regular exercise       breaths
• Don’t skip meals     • Get 8 hrs sleep a
                         night
• Take time to relax
  every day            • Laugh as much as
                         possible
Lifestyle - Weight
Maintenance
 Intervention by BMI category
 BMI         Intervention
 < 24.9      N o treatment needed
 25 – 26.9   Lifestyle changes, if comorbities present
 27 – 29.9   Lifestyle changes + drug therapy if
             comorbities
 30 – 35     Lifestyle changes + drug therapy
 35 – 36.9   Lifestyle changes + drug therapy; surgery
             if comorbities
 > 40        Lifestyle changes, drug therapy, & surgery
*Lifestyle changes = diet, exercise, and behavior
therapy
Regular Exams
 are the Key
Tell Your Doctor About:
• Health problems you seem to be
  having
• Drugs you take every day, including
  herbal medicines*
• Reactions you have had to drugs
• Chest pain
• Pain during sex
Tell Your Doctor About:
• Pain or trouble urinating
• A need to urinate more often or a
  sudden unexpected loss of urine
• Swings from hot to cold in your body
• Sudden changes in moods or deep
  sadness
Tell Your Doctor About:
• Signs of weaker bones, such as bone
  fractures without a previous injury or
  a “widows hump” which makes you
  look bent over
• Women in your family who have
  weak bones
Tell Your Doctor About:
• Any form of cancer you have had
• Women in your family who have had
  breast cancer
• Women in your family who have had
  cancer of the uterus
Tell Your Doctor About:
• Live problems you have
• Problems you have with blood clots
• Bleeding from your vagina that is not
  normal
Possible Treatments
• Hot Flashes
  – Estrogen
  – Megestrol acetate
  – Clonidine
  – SSRI drugs (anti depressants)
Possible Treatments
• Heart Disease
  – Diet and exercise
  – Reduce/quit drinking and smoking
  – Low dose aspirin
  – SERMS
  – Statin drugs
  – High blood pressure drugs
Possible Treatments
• Problems with sex/vaginal dryness
  – Vaginal moisturizers
  – Estrogen cream or ring
  – Counseling
Possible Treatments
• Problems with bladder/urination
  – Kegel exercises
  – Electronic devices
  – Drugs
  – Surgery
Possible Treatments
• Bone Weakness
  – Estrogen
  – SERMs
  – Bisphosphonates
  – Calcitonin
  – Vitamin D
Possible Treatments
• Mood Problems
  – Counseling/support group
  – SSRI drugs
  – Exercise
A Time for
   New
 Beginning
     s

				
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