Menopause: Symptoms, Concerns, and Management Strategies

Presentation about menopause, including information about common symptoms such as hot flashes, sleeplessness, and weight gain as well as other physiologic changes such as bone loss and cardiovascular risks. Dr. Gibbons and Dr. Cummings will offer recommendations on treatment and management options that can help you navigate this important life transition.

1. Stephanie Cummings, MD Menopause

2. Menopause Defined as the permanent cessation of menstruation Menopause is complete after one year without a menstrual period Postmenopausal The average age of menopause in North America is 51 Affected by genetics and smoking Serum follicle stimulating hormone (FSH) levels: 70-100

3. Late Reproductive Years Typically women in their 40’s Menstrual cycles are still ovulatory , but the follicular phase begins to shorten Shorter interval between menstrual periods FSH begins to rise, but estradiol levels are still preserved

4. Perimenopause Menopausal Transition The years before menopause characterized by the physiologic changes associated with menopause Fluctuations are seen in blood hormone levels Follicle stimulating hormone (FSH) rises Estradiol and progesterone decrease Begins on average 4 years before the final menstrual period

5. Perimenopause The intermenstrual interval begins to lengthen Normal: 25-35 days Perimenopause : 40-50 days The early follicular FSH levels continue to rise Changes in the menstrual cycle become more pronounced Skipped cycles Episodes of amenorrhea Increased frequency of anovulatory cycles

6. Perimenopause During this time, some women experience heavy or prolonged bleeding Anovulatory cycles Prolonged exposure to unopposed estrogen These symptoms are more common in women with fibroids and obese women

7. Menopausal Symptoms Vasomotor symptoms Hot flashes/night sweats Vaginal symptoms Vaginal dryness Vaginal atrophy Sleep Disturbances Mood disorders

8. Vasomotor Symptoms Hot flashes are the hallmark symptom The sudden sensation of extreme heat in the upper body that last 1-5 minutes Typically the neck, face, and chest They occur several times per day, but can be as frequent as several times per hour More commonly occur at night Night sweats Associated with perspiration, flushing, clamminess, chills, anxiety, and at times palpitations

9. Vasomotor Symptoms 80% of women experience hot flashes Only 20-30% seek treatment More than 80% of women who experience hot flashes will have them for more than one year Most will spontaneously resolve within 4-5 years

10. Physiology of Hot Flashes Multifactorial Due to changes in reproductive hormones Estrogen allow the body to tolerate a wider range of temperature changes without becoming symptomatic (the thermoregulatory zone) During the menopausal transition, the body becomes more sensitive to subtle changes in core temperature

11. Sleep Disturbances Many times due to vasomotor symptoms occurring at night During the menopausal transition, new onset mood disorders can also contribute to insomnia Depression/anxiety Also consider primary sleep disorders Sleep apnea Restless leg syndrome Correcting vasomotor symptoms may not completely resolve sleep disturbances

12. Vaginal Symptoms Vaginal dryness, atrophy, and itching The cells lining the vagina and urethra are estrogen-dependent Estrogen deficiency leads to the thinning of the vaginal epithelium Loss of elasticity in the vagina leads to a shortening and narrowing of the vagina The tissues also become more fragile and may tear Loss of subcutaneous fat in the labia may result in narrowing of the introitus

13. Vaginal Symptoms Vaginal pH becomes more alkaline Increased risk of urinary tract infections Vaginal secretions may decrease May cause pain with intercourse In the early menopause transition, a slight decrease in lubrication may be the first sign of decreasing levels of estrogen May progress to vaginal dryness during daily activities

14. Long Term Effects of Estrogen Deficiency Bone loss and osteoporosis Cardiovascular disease and changes to the lipid profile Skin changes Limited data regarding dementia, arthritis, and balance

15. Bone Loss Begins during the menopausal transition Rates of bone loss appear to be the highest during the one year before through two years after the final menstrual period Bone density screening should begin at age 65 unless a woman has significant risk factors History of a fragility fracture Weight less than 127 pounds Medical causes of bone loss (medications, diseases) Current smoker Alcoholism Parental medical history of a hip fracture Rheumatoid arthritis

16. Bone Loss FRAX score Can be used in women under 65 to assess risk for fracture If risk of osteoporotic fracture is 9.3% (similar to a 65 year old woman), a bone density scan is reasonable to order Routine screening of newly menopausal women is not recommended If treatment is started, a repeat scan should be done in 2 years For women with normal testing at 65, a screening interval of 15 years is suggested

17. Cardiovascular Disease Lipid profiles begin to change during the menopausal transition LDL levels increase HDL levels remain similar, but the protective effect may decrease Triglycerides increase Risk of cardiovascular disease increases after menopause Similar risk to males

18. Skin Changes Collagen content of skin and bones is decreased due to lack of estrogen Decreased collagen may lead to increased aging as well as wrinkling of the skin

19. References The American College of Obstetricians and Gynecologists. Management of menopausal symptoms. Practice Bulletin 141. January 2014. The American College of Obstetricians and Gynecologists. Osteoporosis. Practice Bulletin 129. September 2012. Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med 2006;355:2338–47. Freedman RR. Physiology of hot flashes. Am J Hum Biol 2001;13:453–64. Casper R. Clinical manifestations and diagnosis of menopause. UpToDate . February 4, 2014 Casper F. Santen R. Menopausal hot flashes. UpToDate . January 2014.