The Third Stage in a Woman's Life Faculty Objectives Menopause/Clini
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7/29/2010 Faculty Gabriele Darch, CRNP Menopause: The Third Stage Nurse Practitioner Senior in a Woman’s Life Ramona Hawkins, CRNP Nurse Practitioner Senior Satellite Conference and Live Webcast Beth Nichols, CRNP Nurse Practitioner Director Wednesday, July 28, 2010 2:00-4:00 pm Central Time Grace Thomas, MD Women’s Health Medical Director Produced by the Alabama Department of Public Health Video Communications and Distance Learning Division Alabama Department of Public Health Objectives Menopause/Clinical Definition • Describe the signs and symptoms • Absence of menstrual cycle for of menopause 12 consecutive months • Discuss treatment regimens related • Average age is 51-52 to symptom relief • FSH testing is no longer • Identify women’s health issues recommended to diagnose related to aging menopause Menopause/Clinical Definition Menopause/Clinical Definition • Menopause can be • When menopause occurs before – Surgically induced by TAH-BSO age 40 – Caused by disruption of ovarian – Premature menopause ftifunction throug h: – Premature ovarian failure (or • Medication insufficiency) • Chemotherapy • Radiation 1 7/29/2010 Perimenopause Perimenopause • Refers to the years preceding the • What’s happening? end of menses marked by: – The number of ovarian follicles – Irregular menstrual cycles decreases – Vasomotor syypmptoms – FSH (follicle -stimulating hormone) – Vaginal dryness levels increase, causing ovarian – Sleep deprivation follicles to be lost at an accelerated – Mood changes rate until they are depleted • Lasts approximately 2-8 years – LH (luteinizing hormone) increases Perimenopause Perimenopause • Most of the endogenous estradiol • Estrogen levels are markedly after menopause results from reduced due to decrease in ovarian peripheral conversion of estrone function from androstenedione secreted by • The ovary secretes low levels of the adrenals androgen • Because of these hormone fluctuations, FSH testing does not provide a true picture of a woman’s menopausal status Perimenopause Contraception After 50 • LH or estradiol levels are also not indicated “. And then she • Pregnancy can still occur, although a asked, “What’s the best form of birth woman’s fertility is lessened control after 50?” • 77% of pregnancies in the age range “I said, “Nudity.” of 40-44 are unintended (second only to adolescents) • Important for women to be on SOME form of birth control during this time 2 7/29/2010 Perimenopause/Contraception Perimenopause/Contraception • COCs can be used by healthy (no • Paragard IUD and sterilization medical conditions) perimenopausal provide contraception without women who are non-smokers and of hormones normal weight • Barrier methods can also be • Progestin only methods (Mirena IUD, considered although not optimal POPs, and DMPA) can be used for • Emergency contraception should be women who have health conditions provided routinely in this age group that preclude the use of estrogen Most Commonly Most Commonly Reported Symptoms Reported Symptoms • Vasomotor • You sell your home heating system – Hot flushes, night sweats at a yard sale • Sleeppp disruption • YouhavetowritepostYou have to write post-it notes with • Urogenital atrophy your kids’ names on them – Vaginal dryness • You change your underwear after a – Dyspareunia sneeze – Urinary difficulties Vasomotor Symptom Relief Vasomotor Symptom Relief • Vasomotor symptoms, including • North American Menopause Society both hot flushes and night sweats, (NAMS) recommends lifestyle are the primary reason women seek changes alone or in combination care at the time of menopause with nonprescription remedies for women with mild vasomotor symptoms 3 7/29/2010 Symptom Relief A Little History of Hormone Therapy • However • Estrogen has been utilized since the – Vasomotor symptoms are most 1960s with the advent of Conjugated effectively treated with systemic Eqqguine Estrogen made from hormone therapy (HT) pregnant mare’s urine • Estrogen alone was found to contribute to endometrial cancer A Little History A Little History of Hormone Therapy of Hormone Therapy • Progestin added to estrogen therapy I • From the 1980s to 1990s hormone • Estrogen/progestin combination therapy was widely prescribed proved protective against • IfIn fac t, es trogen /proges tithtin therapy endometrial cancer was considered to be the fountain of youth Why Older Women Shouldn’t Women’s Health Initiative WHI Sunbathe in the Nude • WHI enrolled 16,000 women nationwide between the ages of 50 and 70 • One major question of the study: Does HT prevent heart disease? 4 7/29/2010 Women’s Health Initiative WHI Women’s Health Initiative WHI • WHI trial of combined estrogen and • In 2004, the “estrogen alone” arm of the study was discontinued progestin therapy demonstrated that • Estrogen alone did not appear to EPT did not prevent heart disease in affect coronary heart disease ↔ (as healthy women comparedtd to p lace bo) • CHD was actually slightly increased • Estrogen alone appears to • Use of HT decreased markedly after – ↑ risk of stroke the results of the WHI were made – ↓ risk of hip fracture public – ↔ breast cancer Women’s Health Initiative WHI Symptom Relief • Recent reanalysis of data • Vasomotor symptoms are most – Increased risk of CHD in older effectively treated with systemic women and those a number of hormone therapy years beyond menopause • Use the lowest dose for the shortest – No increased risk of CHD in duration women between the ages of 50 and 59 or within 10 years of menopause Vasomotor Symptom Relief Vasomotor Symptom Relief Hormone Therapy • Progestin therapy alone can • What are the most commonly used effectively treat hot flushes and may combinations of HT either ET or remain an option E/PT? • Medroxy-progesterone acetate, either • Can’t make a general statement oral or as a 3 month IM injection • Treatment is based on individual patient symptoms/risk factors 5 7/29/2010 Alternatives to Hormone Alternatives to Hormone Therapy for Treatment of Therapy for Treatment of Vasomotor Symptoms Vasomotor Symptoms • Lifestyle changes – Manage stress with meditation, – Eat a healthy diet exercise, and yoga – Limit caffeine and alcohol – Get support by talking about your menopausal symptoms with like- – Quit smoking minded friends, family, and health – Exercise regularly care professionals – Maintain a healthy weight Meno-paws Alternatives to Hormone Therapy • Nonprescription medications – Isoflavone supplements – Soy products – Black cohosh – Vitamin E I Meditate, I do Yoga, I chant …and I still want to smack someone!! Vasomotor Symptom Vasomotor Symptom Relief Non-hormonal Relief Non-hormonal Prescription Medications Prescription Medications • Antidepressants /SSRIs • Anticonvulsants – Paroxetine (Paxil) – Gabapentin (Neurontin) – Venlaxafine (Effexor) • Antihypertensives – Fluoxetine (Prozac) – Clonidine and Methyldopa • Bellergal 6 7/29/2010 Sleep Disturbance: Symptom Relief Symptom Relief Non-hormonal Medications Non-hormonal Prescription Medications • Sleep Aids • Sleep Aids • Nonprescription – Eszopiclone (Lunesta) • Diphenhydramine hydrochloride (Benadryl) – Zolpidem tartrate (Ambien) • Dimenhydrinate (Dramamine) – Benzodiazepines (Xanax, Valium, Ativan, Klonopin) Urogenital Atrophy Urogenital Atrophy • Affects 75% of postmenopausal • On exam, vaginal changes may women include – Vaginal dryness • Petechiae – Pruutusritus • Erythema – Bleeding • Pallor – Dyspareunia • Loss of elasticity and rugal folds – Dysuria • Diminished secretions • Urinary urgency/incontinence • Vaginal shortening and narrowing Symptom Relief Symptom Relief Urogenital Atrophy Urogenital Atrophy • Vaginal estrogen preparations found • Non-hormonal alternatives equally effective – Creams (0.5 g) used one to three – Vaginal moisturizers times weekly • Over the counter - KY jelly, – Tablets (25 mcg) inserted vaginally Replens and Astroglide twice weekly – Regular sexual activity – Rings (7.5 mcg/d) slow release- placed vaginally every 3 months) 7 7/29/2010 “Bio-identical” What Does it Mean? What’s the Buzz on Bio-identical Hormones? • Medications containing estrogen, progesterone, and other hormones that are chemicallyyp exact duplicates of hormones produced by women, primarily in the ovaries • Bio-identical is a marketing term, not a medical term Bio-identical Hormone Bio-identical Hormone Therapy Therapy FDA Approved • Confusing to consumers and some Bio-identical Hormones health professionals • Oral • Some “bio-identical hormones” are – Estrace (1975) FDA-approved brand-name – Estradiol generic (1997) prescription drugs – Prometrium (1998) • Made from plants (or plant-derived) compounds Bio-identical Hormone Bio-identical Hormone Therapy FDA Approved Therapy FDA Approved Bio-identical Hormones Bio-identical Hormones • Transdermal (gels, lotion, spray) • Transdermal (Patches) – EstroGel gg(el (2004), Estrasorb – Estraderm (1985) lotion (2006) – Vivelle (1995) – Divigel gel (2007), Elestrin gel – Climara (1995) (2008) – Vivelle Dot (1998) – Evamist spray (2008) 8 7/29/2010 Bio-identical Hormone Bio-identical Therapy FDA Approved Hormone Therapy Bio-identical Hormones • Some bio-identical hormones are • Vaginal “custom-compounded” recipes – Estrace cream (1984) prepared by a pharmacist – Estring ring (1996) – Not FDA approved – Prochieve 4% gel (1997) • Contain not only the active – Vagifem tablets (1998) hormone(s) but other ingredients – Femring ring (2003) that bind everything together Bio-identical Bio-identical Hormone Therapy Hormone Therapy • Benefits • Potential risks - not government approved – Individualized