Menopause and Beyond

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE 5 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Well-WomanNOT FOR SALE OR DISTRIBUTION Care: NOT FOR SALE OR DISTRIBUTION

Menopause© Jones & Bartlett Learning, LLC and Beyond© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Beth M. Kelsey

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR(1) SALE Anti-müllerian OR hormoneDISTRIBUTION (AMH)—produced exclusively by Menopause granulosa cells of preantral /small ovarian follicles; inhibits FSH-dependent follicular growth; may play a role in follicle • Demographics recruitment and selection; marker of ovarian reserve; AMH 1. An estimated 6,000 U.S. women reach menopause every day; more begins to decrease as early as a woman’s late twenties and than 2 million per year © Jones & Bartlett Learning, LLC thirties; undetectable about© Jonesfive years after& Bartlett menopause Learning, LLC (2) Inhibin B—major ovarian peptide; rises and falls in first 2. By 2020, the number of U.S.NOT women FOR older thanSALE 51 is expectedOR DISTRIBUTION to be NOT FOR SALE OR DISTRIBUTION half of follicular phase, peaks midcycle, falls to lowest level more than 50 million in luteal phase; forms negative feedback loop to fine-tune 3. With life expectancy of U.S. women estimated at 80.8 years, pituitary FSH regulation; as number of ovarian follicles de- women can expect to live about one-third of their lives beyond clines, inhibin B levels fall and FSH levels rise menopause© Jones & Bartlett Learning, LLC (3) Antral© Jonesfollicle count—determined & Bartlett Learning,by ultrasound evaluation LLC • Definitions NOT FOR SALE OR DISTRIBUTION of ovaryNOT used FOR primarily SALE as factor OR in fertilityDISTRIBUTION counseling 1. Menopause—permanent cessation of ovulation and menses; aver- e. Stages include reproductive (early, peak, late), menopausal age age in United States is 52 years; genetically predetermined; transition (early, late), and postmenopause (early, late) confirmed after 12 consecutive months without a period f. Menopausal transition (early)—duration variable; menstrual 2. Menopause transition—span of time when menstrual cycle and cycle length variable (persistent difference of seven or more © Jones &endocrine Bartlett changes Learning, begin to occur LLC and ending with the final men- © Jonesdays & Bartlettin length of consecutiveLearning, cycles); LLC FSH in early follicular strual period (FMP) phase elevated but variable; AMH low; inhibin B low; antral fol- NOT FOR SALE OR DISTRIBUTION NOT FORlicle SALE count low OR DISTRIBUTION 3. Perimenopause—extends from beginning of menopause transition until 12 months after FMP g. Menopausal transition (late)—duration one to three years; intervals of amenorrhea > 60 days; may have extreme fluctua- 4. Postmenopause—refers to the years following menopause tions in hormone levels; FSH fluctuates between postmeno- 5. Premature menopause—cessation© Jones of ovulation & Bartlett and menses Learning, before LLCpausal levels and those consistent© Jones with reproductive & Bartlett stages; Learning, LLC age 40; spontaneous or induced AMH low; inhibin B low; antral follicle count low; vasomotor 6. STRAW reproductive-agingNOT continuum FOR (North SALE American OR Meno- DISTRIBUTIONsymptoms likely NOT FOR SALE OR DISTRIBUTION pause Society, 2014) h. Postmenopause (early)—divided into two phases a. Standardized definition of reproductive aging based on spe- (1) First 12 months after FMP—FSH elevated but variable; cific clinical criteria, endocrine parameters, and characteristic AMH low; inhibin B low; antral follicle count very low; va- markers© Jones & Bartlett Learning, LLC somotor© Jones symptoms & most Bartlett likely Learning, LLC b. MenstrualNOT FORcycle changes SALE are consideredOR DISTRIBUTION the principal clinical (2) SecondNOT postmenopausal FOR SALE year untilOR point DISTRIBUTION in time when high criteria FSH and low estradiol levels begin to stabilize—duration c. Characteristic markers include vasomotor symptoms and three to six years; FSH stabilizes; AMH very low; inhibin B symptoms of urogenital atrophy very low; antral follicle count very low d. Endocrine parameters, including follicle-stimulating hormone i. Postmenopause (late)—duration remaining lifespan; increasing © Jones & Bartlett(FSH), are considered Learning, as supportive LLC criteria not typically © Jonessymptoms & Bartlett of urogenital Learning, atrophy LLC NOT FOR SALEmeasured OR for purposesDISTRIBUTION of staging reproductive aging or NOT FORj. Criteria SALE may varyOR in DISTRIBUTION relation to factors such as body size, life- menopause style characteristics, and health status

74 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

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• Physiology 4. Bone integrity—increased bone loss associated with decrease © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1. Reproductive aging results in changes in the hypothalamic- in estrogen; greatest loss in first few years after menopause then NOT FOR SALEpituitary-ovarian OR DISTRIBUTION (HPO) axis NOT FORslows SALE but continues OR DISTRIBUTION 2. Ovarian aging with follicular atresia is predominant event leading 5. External and internal genitalia to menopause a. Labia—decrease in subcutaneous fat and tissue elasticity 3. With decrease in number of responsive follicles, there is a decrease b. Vagina in production of estradiol© Jones & Bartlett Learning, LLC (1) Decrease in estrogen© and Jones concomitant & Bartlett change in vaginalLearning, LLC 4. Decrease in estradiol NOTas well asFOR decrease SALE in inhibin OR B, anDISTRIBUTION ovarian microbes increases NOTvaginal FORpH from SALE acidic to alkalineOR DISTRIBUTION envi- peptide, result in rise in FSH through negative feedback system ronment; pH > 5.0 (2) Decrease in estrogen results in vaginal epithelium with 5. During menopause transition, there is variability of hormone higher proportion of parabasal cells than mature superficial secretion and inconsistent ovulation—one reason that measuring cells estradiol and/or FSH levels is not reliable to determine menopause © Jones & Bartlett Learning, LLC ©(a) Jones Epithelium & becomesBartlett thinner, Learning, less vascular, LLC and less 6. Elevated estradiol levels may occur in some cycles during NOT FOR SALE OR DISTRIBUTION NOTelastic FOR SALE OR DISTRIBUTION menopause transition because of a luteal out-of-phase (LOOP) (b) Vaginal walls appear thin, smooth, and pale event—elevated FSH level adequate to recruit a second follicle in (c) Vaginal walls may have small petechiae and be friable luteal phase of a cycle, resulting in a follicular-like rise in estradiol to touch secretion c. Cervix—decrease in size; os may become flush with vaginal © Jones &7. Bartlett Elevated estradiol Learning, levels may LLC also occur with conversion of andro-© Jones & Bartlettwalls; may become Learning, stenotic LLC gen to estrogen through aromatization, which also increases with NOT FOR SALE OR DISTRIBUTION NOT FORd. SALE Uterus and OR ovaries—decrease DISTRIBUTION in size; ovaries usually not age and body weight palpable 8. Menstrual cycle length typically begins to vary in the early meno- 6. Urinary tract pause transition and then, as one moves into late menopause tran- a. Urethra and trigone of the bladder have high concentration sition, there are episodes of amenorrhea of 60 consecutive days or of estrogen receptors; as with the vulva and vagina, decreased more; individual women© Jonesmay have different& Bartlett patterns Learning, LLC estrogen may result in atrophic© Jones changes & Bartlett Learning, LLC 9. The hallmark for the endNOT of the FOR menopause SALE transition OR DISTRIBUTIONand initia- b. Urethral meatus may becomeNOT more FOR prominent SALE as labiaOR minoraDISTRIBUTION tion of the postmenopause is the FMP thin and introitus retracts 10. Elevated FSH and luteinizing hormone (LH) levels and low estradiol • Mood changes and cognitive function levels stabilize after the first one to two years postmenopause 1. Majority of women do not have psychological problems attribut- 11. After menopause, estrone becomes the predominant circulating able to menopause estrogen© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 2. Women with history of previous clinical depression, premenstrual 12. EstroneNOT isFOR derived SALE primarily OR through DISTRIBUTION peripheral conversion in adi- syndrome,NOT or FORpostpartum SALE depression OR mayDISTRIBUTION be more vulnerable to pose tissue (i.e., aromatization) of androstenedione, an androgen recurrent depression during perimenopause produced by adrenal cortex and ovarian stroma 3. Perimenopausal depression may be an interplay between hor- 13. Generally rely on cessation of menses, hypoestrogenic symptoms, monal fluctuations, stressful events, lifestyle factors, psychosocial and age for diagnosis of menopause © Jones & Bartlett Learning, LLC © Jones &support Bartlett Learning, LLC • Laboratory findings NOT FOR SALE OR DISTRIBUTION NOT FOR4. About SALE one-fourth OR DISTRIBUTIONof women do report some mood changes during 1. FSH—greater than 40 mIU/mL menopause transition 2. LH—threefold elevation after menopause (20–100 mIU/mL) 5. Individual characteristics and self-perception appear to be 3. Estradiol—less than 20 pg/mL important determinants of each woman’s experience of the perimenopause • Physical changes © Jones & Bartlett Learning, LLC6. No evidence that memory ©or cognitiveJones skills & Bartlettdecline directly Learning, as a LLC 1. Some related to hormonal changes; some related to normal result of normal menopause transition changes with aging; someNOT related FOR to combination SALE OR of both DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 7. Ability to concentrate may be reduced by sleep disturbances and 2. Body weight and fat distribution fatigue related to hot flashes a. No data to support that menopause hormonal changes are 8. Women’s Health Initiative Memory Study (WHIMS)—risk of responsible for weight gain; more likely the result of aging and dementia increased in healthy women aged 65 to 79 years using lifestyle © Jones & Bartlett Learning, LLC estrogen© Joneswith progesterone & Bartlett therapy Learning, LLC b.NOT Some FOR evidence SALE that changes OR in DISTRIBUTION body composition and fat distri- NOT FOR SALE OR DISTRIBUTION bution may be related to menopause; change in fat distribution 9. Unclear how estrogen or estrogen with progesterone therapy af- from subcutaneous stores to visceral abdominal fat fects cognitive function in younger menopausal women 3. Skin • Cardiovascular system effects a. Skin has a significant number of estrogen receptors 1. Increase in LDL-C, VLDL-C, triglycerides; possible decrease in © Jones & Bartlettb. Declines Learning, in skin collagen LLC and skin thickness correlate with © Jones &HDL-C Bartlett Learning, LLC NOT FOR SALEyears OR since DISTRIBUTION menopause NOT FOR2. Increase SALE in certainOR DISTRIBUTION fibrinolytic and procoagulation factors that c. Scalp, pubic, and axillary hair becomes thinner and drier regulate clotting processes

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3. Increase in endothelin and decrease in angiotensin-converting screening strategies are more effective than the others (Grade A © Jones &enzyme Bartlett (vasoconstrictors); Learning, increase LLC in nitric oxide and decrease in © JonesStrong & Bartlett Recommendation) Learning, LLC NOT FORprostacyclin SALE OR (vasodilators) DISTRIBUTION NOT3. FOR Breast SALEcancer screening—mammography OR DISTRIBUTION 4. Extent of impact of decreased estrogen levels on cardiovascular a. ACS—yearly beginning at age 45 years for women at average disease not definitively established risk; women age 55 and older can transition to biennial screening or continue annual screening if they prefer © Jones & Bartlett Learning, LLCb. ACOG—yearly starting at age© 40 Jones years & Bartlett Learning, LLC Well-Woman Visit NOTAges FOR 40 to SALE 64 OR DISTRIBUTIONc. USPSTF—biennial screeningNOT from age FOR 50 to 74SALE years (Grade OR BDISTRIBUTION Recommendation) • Comprehensive health history 4. Human immunodeficiency virus ( HIV) screening if sexually 1. Identify disease risk factors, health-promoting behaviors, active—yearly if high risk symptoms of disease, current status of diagnosed conditions, 5. Hepatitis C—screen once if born between 1945 and 1965 and no medications used © Jones & Bartlett Learning, LLC other risk factors© Jones & Bartlett Learning, LLC 2. Identify psychological and social concerns—emotional, physical, NOT FOR SALE OR DISTRIBUTION 6. Diabetes screening—everyNOT FOR SALEthree years OR starting DISTRIBUTION age 45 (American sexual abuse by family or partner, current or past; drug/alcohol Diabetes Association, 2016) use; depression 7. Lipid screening (United States Preventive Services Taskforce, 2008) 3. Discuss sexuality/sexual history—sexual orientation, gender identity, sexual practices, sexual satisfaction, dyspareunia, use of a. Screen women aged 45 years and older for lipid disorders if © Jones &contraception Bartlett if Learning,needed; use of condoms LLC © Jonesthey & Bartlettare at increased Learning, risk for coronary LLC heart disease (CHD) (Grade A Strong Recommendation) 4. Ask about menopausal symptoms, symptoms of pelvic prolapse, NOT FOR SALE OR DISTRIBUTION NOT FORb. Screen SALE women OR aged DISTRIBUTION 20 to 45 years for lipid disorders if they urinary and fecal incontinence are at increased risk for coronary heart disease (Grade B 5. Learn what is most important to the individual woman as it relates Recommendation) to her health and quality of life as she moves through perimeno- c. CHD risk factors for women include being 55 years of age or pause and beyond © Jones & Bartlett Learning, LLColder, family history of premature© Jones CHD (male & Bartlettrelative < 55 Learning, LLC • Physical examination years, female relative < 65), cigarette smoking, hypertension, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Height—yearly; height loss greater than 1.5 inches (3.8 cm) may HDL at less than 40 mg/dL, diabetes mellitus be associated with vertebral compression fractures and thus d. No recommendation on interval of screening; USPSTF states osteoporosis every five years is reasonable 2. Weight/body mass index (BMI)—yearly 8. Other as indicated by health history and risk factors 3. Blood© pressure—yearly Jones & Bartlett Learning, LLC • Immunizations© Jones & Bartlett Learning, LLC 4. ClinicalNOT breast FOR examination SALE (CBE) OR DISTRIBUTION 1. Influenza annuallyNOT FOR SALE OR DISTRIBUTION a. American College of Obstetricians and Gynecologists 2. Herpes zoster (shingles)—one-time dose for all individuals 60 (ACOG)—yearly CBE years of age or older, regardless of previous history of shingles b. American Cancer Society (ACS), United States Preventive Ser- 3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vice Task Force (USPSTF)—CBE not recommended for women a. Recommended three-dose vaccination series including Tdap © Jones & Bartlettat average risk Learning, for breast cancer LLC © Jones & Bartlett Learning, LLC dose for adults with unknown or incomplete history of primary NOT FOR5. Pelvic SALE examination—if OR DISTRIBUTION need pap test or otherwise indicated; NOT FORTd vaccinationSALE OR DISTRIBUTION performing routine pelvic exam (external genitalia, speculum, b. Recommended one dose of Tdap for adults who have not previ- bimanual) should be a shared, informed decision between patient ously received Tdap and healthcare provider c. Booster Td vaccination every 10 years for adults 6. Other as indicated by history and/or risk factors © Jones & Bartlett Learning, LLC4. Other as indicated by health history/risk© Jones factors & Bartlett Learning, LLC • Screening tests NOT FOR SALE OR DISTRIBUTION• Counseling/education NOT FOR SALE OR DISTRIBUTION 1. Cervical cancer screening (ACS, ACOG, USPSTF)—cytology 1. Lifestyle modifications to reduce disease risk factors/promote with HPV test every five years or cytology alone every health—nutrition, physical activity, safer sex practices, smoking cessa- three years tion, avoiding alcohol and other substance abuse; stress management 2. Colorectal cancer screening 2. Contraception if needed—see Chapter 4 of this text for informa- a. ACS—beginning© Jones & at ageBartlett 50 colonoscopy Learning, every 10 years,LLC flexible tion about ©contraception Jones &for Bartlettwomen older Learning, than 40 years; hormonalLLC sigmoidoscopyNOT FOR every SALE five years, OR double-contrast DISTRIBUTION barium enema contraceptionNOT may FOR alleviate SALE some menopause OR DISTRIBUTION transition symptoms every five years, or computed tomography (CT) colonography 3. Breast self-awareness (virtual colonoscopy) every five years b. ACOG—colonoscopy every 10 years for average-risk women 4. Recommended screening tests schedule beginning at age 50 years and at age 45 years for African Amer- 5. Expected hormonal and menstrual changes during perimenopause © Jones & Bartlettican women Learning, LLC © Jones6. Management & Bartlett of perimenopause Learning, symptoms LLC NOT FORc. SALE USPSTF—begin OR DISTRIBUTION colorectal cancer screening at age 50; no NOT7. FOR Other asSALE indicated OR by health DISTRIBUTION history/physical examination head-to-head studies demonstrating any of the various findings/risk factors

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b. Estrogen-progesterone therapy (EPT)—combination of es- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Vasomotor Symptoms (VMS) trogen and progestogen (either progesterone or progestin, a NOT FOR SALE OR DISTRIBUTION NOT FOR SALEsynthetic OR form DISTRIBUTION of progesterone), progestogen main purpose is • Definition—recurrent, transient episodes of flushing accompanied by to reduce risk of endometrial cancer in women with a uterus sensation of warmth to intense heat on upper body and face associated with unopposed estrogen 1. May include profuse sweating and palpitations c. Estrogen types 2. May awaken during night,© Jones leading to& insomnia, Bartlett sleep Learning, disturbance, LLC (1) 17β-estradiol—only© human Jones estrogen & Bartlett available in Learning, LLC FDA-approved, single-estrogen product cognitive (memory) andNOT affective FOR (anxiety) SALE disruptions OR DISTRIBUTION with loss NOT FOR SALE OR DISTRIBUTION of REM sleep (2) Conjugated estrogen (CE)—mixture of estrogens obtained from natural sources (i.e., urine of pregnant mares) • Demographics/prevalence (3) Synthetic estrogen—esterified estrogen, synthetic conju- 1. About 75% of U.S. women experience hot flashes during gated estrogen, ethinyl estradiol, estropipate perimenopause © Jones & Bartlett Learning, LLC d. Progestogen © Jones types & Bartlett Learning, LLC 2. Usually begins in late menopause transition, with greatest fre- NOT FOR SALE OR DISTRIBUTION (1)NOT Progesterone—compound FOR SALE OR identical DISTRIBUTION to endogenous steroid quency and severity within first two years after FMP hormone produced by ovaries, or micronized progesterone 3. Most women experience hot flashes for six months to two years, (2) Progestin—synthetic product that has progesterone-like but some may experience for 10 or more years activity but is not identical to endogenous progesterone 4. Induced menopause (surgical, chemotherapy) may result in more (medroxyprogesterone acetate [MPA], norethindrone, nor- © Jones & Bartlettfrequent and Learning, severe hot flashes LLC © Jones & Bartlettethindrone Learning, acetate, drospirenone, LLC levonorgestrel) NOT FOR SALE5. Greater OR proportion DISTRIBUTION of women who are overweight or obese reportNOT FORe. SALE Selective OR estrogen-receptor DISTRIBUTION modulators (SERMs), also hot flashes compared with women of normal weight known as estrogen receptor agonists/antagonists (ERAAs)— estrogen-like compounds that act as estrogen agonists or an- • Etiology—specific mechanism unknown; gonadotropin-related ef- tagonists depending on the SERM and target tissue fect on the central thermoregulatory function of the hypothalamus (1) Bazedoxifene (BZA) is a SERM with estrogen antagonist ef- (measurable increase in core body temperature, increase in body fects on endometrial and breast tissue and estrogen agonist surface temperature, peripheral© Jones vasodilation, & Bartlett then decrease Learning, in core LLC © Jones & Bartlett Learning, LLC effects on bone temperature) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (2) BZA combined with CE (BZA/CE) provides an alternative • Management—nonpharmacologic to adding a progestogen to prevent endometrial hyperplasia 1. Lifestyle changes may be helpful, especially for mild VMS (3) Study data indicate less unscheduled uterine bleeding and 2. Maintain a healthy body weight—in women who are obese, weight less breast tenderness than seen with CE combined with loss© Joneshas been associated & Bartlett in reduction Learning, in hot flash LLC frequency ©MPA Jones (CE/MPA) & Bartlettand similar preventionLearning, of bone LLC loss, vasomotor symptoms, and vulvovaginal atrophy compared with 3. RefrainNOT fromFOR smoking—current SALE OR andDISTRIBUTION past cigarette smoking NOT FOR SALE OR DISTRIBUTION increases relative risk of hot flashes; may be related to effect on CE/MPA estrogen metabolism f. Bioidentical hormones 4. Exercise regularly—some data to support regular, moderate exer- (1) Hormones chemically identical to hormones produced by cise is associated with decreased incidence of hot flashes women during their reproductive years (17β-estradiol, estrone, estradiol, progesterone, testosterone) © Jones &5. Bartlett Keep core bodyLearning, temperature LLC as cool as possible—sleep in cool © Jones & Bartlett Learning, LLC (2) Bioidentical hormone therapy (BHT) provides one or more room, keep insulated bottle of ice water available, wear layers and NOT FOR SALE OR DISTRIBUTION NOT FOR SALEof these OR hormones DISTRIBUTION as active ingredients natural fibers (3) 17β-estradiol is available in several FDA-approved ET prod- 6. Practice relaxation techniques—anxiety associated with increased ucts in oral, transdermal, and vaginal preparations severity and frequency of hot flashes (4) Progesterone is available in an FDA-approved oral capsule 7. Soy foods/isoflavone supplements—data from meta-analysis of 17 and vaginal gels small randomized controlled© Jones trials (Taku, & Bartlett Melby, Kronenberg, Learning, Kurzer, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION (5) Custom-compoundedNOT BHT FORuses commercially SALE OR available DISTRIBUTION & Messina, 2012) support efficacy to reduce hot flash frequency and hormones with the type and amount prescribed by the severity; soy products vary in composition and concentration clinician 8. Black cohosh—conflicting data regarding beneficial effect on hot (6) Custom-compounded BHT products are not FDA approved; flash frequency and severity; multiple products and formulations there is no evidence that they are safer than conventional available; rare side effects of intestinal upset, headache, dizzi- HT; the same contraindications apply to their use ness© Jones with larger & doses; Bartlett safety for Learning, use beyond six LLCmonths not yet © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION (7)NOT No evidence FOR that SALE saliva testing OR DISTRIBUTIONis effective for customizing established hormone dosing regimens 9. No data to support caffeine, alcohol, spicy foods, big meals as trig- 2. Indications for HT gers of hot flashes a. Relief of moderate to severe VMS and/or vulvovaginal atrophy • Management—Pharmacologic (Hormonal Therapy [HT]) (VVA) not relieved by lifestyle changes © Jones &1. Bartlett Terminology Learning, LLC © Jones &b. Bartlett Prevention of Learning, osteoporosis LLC NOT FOR SALEa. Estrogen OR therapyDISTRIBUTION (ET)—unopposed estrogen prescribed forNOT FORc. SALE HT should OR not DISTRIBUTIONbe used to prevent coronary heart disease, women who have had a hysterectomy stroke, or dementia

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3. Contraindications e. Consider low-dose vaginal ET for symptoms of vulvovaginal © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a. Active or history of deep vein thrombosis or pulmonary atrophy not relieved by nonhormonal therapies NOT FOR SALEembolism OR DISTRIBUTION NOT FORf. Consider SALE nonhormonal OR DISTRIBUTION therapies for osteoporosis if long-term b. Active or history of arterial thromboembolic disease (e.g., therapy needed stroke, myocardial infarction) 7. Routes of administration c. Known, suspected, or history of breast cancer a. Oral d. Known or suspected estrogen-dependent© Jones & Bartlettcancer Learning, LLC(1) ET, EPT, CE/BZA © Jones & Bartlett Learning, LLC e. Liver dysfunction or diseaseNOT FOR SALE OR DISTRIBUTION(2) First-pass metabolism determinesNOT FOR bioavailability SALE OR DISTRIBUTION f. Undiagnosed abnormal uterine bleeding (3) Increased HDL-C and decreased LDL-C g. Known or suspected pregnancy (4) Increased triglycerides, C-reactive protein h. Low-dose vaginal ET with only local (no systemic) effects may b. Transdermal /topical be considered with above contraindications (1) Systemic absorption 4. Potential© Jones risks & Bartlett Learning, LLC (2) Patch—estrogen © Jones and & progestogenBartlett combined Learning, or estrogen LLC only a. EndometrialNOT FOR hyperplasia/cancer—estrogen SALE OR DISTRIBUTION alone (3) TopicalNOT sprays, FOR gels, SALEand emulsions—17β-estradiol OR DISTRIBUTION b. Breast cancer (4) May use lower doses as not dependent on GI absorption (1) Relationship with HT inclusive and no first-pass hepatic metabolism (2) Possible small but significant increase of breast cancer with (5) No significant impact on HDL-C, LDL-C, triglycerides, © Jones & Bartlettlong-term Learning, use LLC © Jones & C-reactiveBartlett protein Learning, LLC c. Thromboembolic disorders—coronary heart disease, (6) May have less adverse effects on gallbladder and coagula- NOT FOR SALEstroke, VTE OR DISTRIBUTION NOT FOR SALEtion factors OR than DISTRIBUTION oral estrogen (1) Relationship with HT inconclusive (7) Need added progestogen with intact uterus (2) Women who start HT at or close to menopause do not (8) Topical progesterone preparations may not provide suffi- incur the same risks as those who start several years after cient endometrial protection menopause © Jones & Bartlett Learning, LLCc. Estrogen vaginal ring (Femring)© Jones & Bartlett Learning, LLC (3) Oral ET affects cardiovascularNOT FOR markers—positive SALE OR effects DISTRIBUTION are (1) Systemic absorption NOT FOR SALE OR DISTRIBUTION increase in HDL-C and decrease in LDL-C levels; negative ef- (2) Approved for treatment of VMS and vulvovaginal atrophy fects are increase in triglycerides and C-reactive protein levels (3) Ninety-day duration (4) Transdermal ET has no effect on cardiovascular markers (4) Need added progestogen if have intact uterus (5) VTE risk is lower with transdermal ET than with oral ET d. Estrogen vaginal ring (Estring) (6)© No Jones HT regimen & shouldBartlett be used Learning, for primary or LLC secondary (1) Low© dose Jones with little & or Bartlett no systemic Learning, absorption LLC prevention of cardiovascular disease or stroke NOT FOR SALE OR DISTRIBUTION (2) UsedNOT for treatment FOR ofSALE vulvovaginal OR atrophy DISTRIBUTION (7) HT should be avoided in women with elevated risk for (3) Will not provide relief from VMS stroke (4) Ninety-day duration 5. Assessment and education prior to initiation of HT (5) Progestogen does not need to be added with low-dose vagi- a. Health history with attention to specific contraindications and nal ring precautions © Jones & Bartlett Learning, LLC © Jonese. Vaginal & Bartlett estrogen creamsLearning, and tablets LLC b. General physical examination, cervical cancer screening per NOT FOR SALE OR DISTRIBUTION NOT FOR(1) SALE Used for treatmentOR DISTRIBUTION of vulvovaginal atrophy recommended schedule (2) Little or no systemic absorption c. Clinical breast examination and screening mammogram per recommended schedule (3) Will not provide relief from VMS d. Informed and shared decision making concerning HT use (4) Progestogen does not need to be added with low-dose vagi- based on woman’s symptoms,© Jones treatment & goals,Bartlett risk-benefit Learning, LLC nal estrogens © Jones & Bartlett Learning, LLC analysis NOT FOR SALE OR DISTRIBUTIONf. Progestogens NOT FOR SALE OR DISTRIBUTION e. Provide anticipatory guidance on possible need to adjust type (1) Oral—medroxyprogesterone acetate (MPA), norethin- and amount of HT for symptom relief or to alleviate possible drone, norethindrone acetate, drospirenone, micronized side effects (e.g., breast tenderness, headaches, bloating, mood progesterone changes); expected bleeding patterns and what to report (2) Transdermal in EPT patches—norethindrone acetate, 6. Routine© follow-upJones after & Bartlett HT initiation Learning, LLC levonorgestrel© Jones & Bartlett Learning, LLC a. EvaluateNOT continuing FOR SALE need for ORHT at DISTRIBUTION annual well-woman visits (3) Intrauterine—levonorgestrelNOT FOR SALE intrauterineOR DISTRIBUTION system and discontinue as appropriate (LNG-IUS) b. No data available regarding choice of abrupt cessation versus (4) Vaginal—progesterone gel, micronized progesterone insert tapering to avoid resumption of menopausal symptoms 8. Regimen options c. Approximately 50% experience recurrence of symptoms with a. Recommendations for progestogen use for endometrial protec- © Jones & Bartlettdiscontinuation Learning, regardless of LLCage or length of time HT was used © Jonestion & withBartlett standard Learning, estrogen dosing LLC NOT FORd. SALE Decision OR to continue DISTRIBUTION HT should be individualized based on NOT FOR(1) SALE Twelve to ORfourteen DISTRIBUTION days each month of 5 mg of medroxy- severity of symptoms and risk-benefit ratio progesterone acetate (MPA) or equivalent

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(2) Daily doses of 2.5 mg MPA or equivalent • Management—pharmacologic (nonhormonal) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (3) LNG-IUS 1. Selective serotonin reuptake inhibitor (SSRI)—paroxetine 7.5 mg NOT FOR SALE(4) OR Vaginal DISTRIBUTION progesterone gel 45 mg daily or 12–14 days eachNOT FORtaken SALE once dailyOR atDISTRIBUTION bedtime is only nonhormonal prescription month medication approved by FDA for treatment of VMS b. Continuous-cyclic EPT 2. Other SSRIs and serotonin norepinephrine reuptake inhibitors (1) Estrogen every day (SNRIs) have demonstrated positive results in treatment of hot (2) Progestogen added© Jones 12 to 14 days& Bartlett each month Learning, LLC flashes © Jones & Bartlett Learning, LLC (3) No estrogen-freeNOT period FOR during SALE which vasomotor OR DISTRIBUTION symp- 3. Gabapentin, an anticonvulsantNOT medication, FOR SALE has been ORshown DISTRIBUTION to be toms can occur effective in reduction of severity and frequency of hot flashes (4) Withdrawal bleeding when progestogen withdrawn each month; may start one to two days earlier depending on dose and type of progestogen used Genitourinary Syndrome of c.© Continuous-combinedJones & Bartlett EPT Learning, LLC © Jones & Bartlett Learning, LLC NOT(1) Estrogen FOR andSALE progestogen OR DISTRIBUTIONevery day MenopauseNOT FOR (GSM) SALE OR DISTRIBUTION (2) Lower cumulative dose of progestogen than with cyclic 1. Definition—collection of symptoms and physical findings associated regimens with decreased estrogen and other sex steroids involving changes to (3) May initially have unpredictable bleeding the labia majora/minora, vestibule/introitus, clitoris, vagina, urethra (4) After several months endometrium atrophies and amenor- and bladder (North American Menopause Society, 2014); symptoms © Jones & Bartlettrhea Learning, usually results LLC © Jones &include Bartlett but are notLearning, limited to: LLC NOT FOR SALE(5) OR No estrogen-free DISTRIBUTION period during which vasomotor symp-NOT FORa. SALE Genital dryness,OR DISTRIBUTION burning, irritation toms can occur b. Sexual symptoms of lack of lubrication, discomfort or pain, d. Combination CE/BZA —FDA approved for treatment of impaired function moderate to severe vasomotor symptoms and prevention of c. Urinary symptoms of frequency, nocturia, urgency, dysuria, and osteoporosis recurrent urinary tract infections e. Continuous unopposed© Jones estrogen—for & Bartlett women without Learning, uterus LLC2. Demographics—affects up© to Jones50% of midlife & Bartlett and older women Learning, LLC 3. Etiology f. Progestogen only mayNOT be usedFOR if estrogen SALE is contraindicatedOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a. Signs and symptoms associated with GSM are related to reduced (1) Effective in relieving vasomotor symptoms; may have a circulating estrogen and aging positive impact on calcium balance b. High concentration of estrogen receptors in vagina, vestibule, (2) Not effective in relief of vulvovaginal symptoms; may have urethra, and bladder trigone modulate cell proliferation and © Jonesadverse &effect Bartlett on lipid metabolism Learning, LLC maturation© Jones & Bartlett Learning, LLC • SideNOT effects ofFOR HT SALE OR DISTRIBUTION c. LowNOT circulating FOR levels SALE of estrogen OR resultDISTRIBUTION in anatomic and physi- 1. Breast tenderness—estrogen or progestogen (usually subsides after ologic changes in urogenital tissues first few weeks) (1) Reduced collagen, decreased elastin, epithelium thinning, and fewer blood vessels 2. Nausea—estrogen (relieved if taken at mealtime or bedtime) (2) Decreased vaginal blood flow, diminished lubrication, de- 3. Skin irritation with transdermal patches creased elasticity and flexibility of vaginal vault, decreased © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 4. Fluid retention and bloating—estrogen or progestogen vaginal tissue strength NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 5. Alterations in mood—progestogen (3) Thinning and regression of labia minora, retraction of introitus, more prominent urethral meatus • Management of side effects may include: (4) Decreased vaginal lactobacilli and increased vaginal pH 1. Lowering dose 4. Management/treatment 2. Altering route of administration a. Symptoms of GSM can have a negative effect on quality of life that © Jones & Bartlett Learning, LLC may extend to activities© of dailyJones living, & exercise, Bartlett sexual Learning,function, LLC 3. Changing to different formulation NOT FOR SALE OR DISTRIBUTION interpersonal relationshipsNOT FOR SALE OR DISTRIBUTION • Management of bleeding during HT b. Rule out other causes of symptoms 1. Continuous-cyclic regimen—usually experience some uterine c. Nonhormonal therapies bleeding; starts last few days of progestogen administration or (1) Vaginal lubricants—effects immediate; intended to reduce during progestogen-free days; earlier bleeding, heavy or persistent friction on atrophic vulvovaginal structures during sex; may bleeding© Jones may indicate& Bartlett endometrial Learning, hyperplasia andLLC warrants en- ©be Jones water-, silicone-, & Bartlett or oil-based Learning, LLC dometrialNOT FOR evaluation SALE OR DISTRIBUTION (2)NOT Vaginal FOR moisturizers—applied SALE OR DISTRIBUTION several times weekly for 2. Continuous-combined regimen—erratic spotting and light bleed- longer-term relief of vaginal dryness; help to maintain vaginal ing of one to five days duration in first year; need endometrial moisture and lower vaginal pH evaluation if bleeding heavier or longer than usual or if resumes (3) Regular sexual activity—promotes blood flow to genital area after several months of amenorrhea (4) Noncoital methods of sexual expression if penetration is © Jones & Bartlett Learning, LLC © Jones & Bartlettpainful—massage, Learning, oral stimulation, LLC mutual masturbation 3. Use of LNG-IUS for progestogen may result in less bleeding d. Hormonal therapies NOT FOR SALE4. CE/BZA—data OR DISTRIBUTION indicate less unscheduled uterine bleeding thanNOT FOR SALE(1) Low-dose OR vaginalDISTRIBUTION estrogen—consider if nonhormonal therapies CE/MPA do not relieve symptoms or if have severe GSM symptoms

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(2) Ospemifine—SERM approved in 2013 for treatment of mod- 2. Skin © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC erate to severe dyspareunia related to vulvovaginal atrophy; a. Thinner, decreased elasticity, cell regeneration slower; seba- NOT FOR SALEdaily ORoral dose DISTRIBUTION NOT FORceous SALE and sweat OR gland DISTRIBUTION activity decreases: dry skin, pruritus, (a) Estrogen agonist effect on vaginal tissue to thicken and increased risk of skin infection, decreased wound healing make less fragile; decrease in vaginal pH; may take sev- b. Cutaneous sun exposure damage contributes to increase in skin eral weeks for full relief of symptoms changes—wrinkles; irregular pigmentation; solar lentigines (b) No FDA indication for bone health protection listed © Jones & Bartlett Learning, LLC(brown/age spots); telangiectasia;© Jones cherry angiomas; & Bartlett sebor- Learning, LLC (c) Weak estrogen agonist effect on uterus and breasts— rheic keratosis; and actinic keratosis, which are premalignant FDA requires listingNOT of FORsame contraindications SALE OR asDISTRIBUTION those sun-induced growths NOT FOR SALE OR DISTRIBUTION for use of estrogen 3. Eyes—decreased tear production, pupils smaller, lens stiffens: dry (d) Should not be used with estrogen or another SERM eyes, decreased near vision, decreased adaptation to darkness (e) Use of progestogen with ospemifine has not been evaluated in clinical trials 4. Ears—atrophy of auditory neurons; increased cerumen; sclerosis ©(f) Jones Most common & Bartlett side effects Learning, are hot flashes, LLCvaginal dis- of tympanic© membrane: Jones sensorineural& Bartlett hearing Learning, loss (high fre-LLC NOTcharge, FOR muscle SALE spasm, OR increased DISTRIBUTION sweating quency first),NOT conductive FOR hearing SALE loss OR DISTRIBUTION (3) Systemic ET/EPT—only if also using for relief of moderate 5. Mouth, nose, and teeth—decreased number of taste buds, atrophy to severe VMS of salivary glands, gingival tissue less elastic, softening of teeth, decrease in olfactory neurons: decreased appetite, dry mouth, loss of teeth, difficulty chewing © Jones Older & Bartlett Adults Learning, LLC © Jones6. Thorax & andBartlett lungs—rib Learning, cage less mobile, LLC decreased strength of NOT FOR SALE OR DISTRIBUTION NOT FORexpiratory SALE muscles, OR alveoli DISTRIBUTION less elastic: decreased ability to clear • Definitions lungs with less efficient cough; decreased ventilation at lung bases; 1. Aging—process of becoming older; genetically determined and decreased reserve for response to exercise, stress, or disease environmentally modulated 7. Heart—left ventricular wall thickens, myocardium becomes less 2. Elderly—generally accepted in developed countries as referring to elastic, fibrosis and sclerosis of heart valves and within conduction individuals 65 years of age ©and Jones older & Bartlett Learning, LLCsystem (SA node), stroke volume© decreases, Jones heart & Bartlett rate slows but Learning, LLC 3. Theories on aging—biologic,NOT sociologic, FOR developmental SALE OR DISTRIBUTIONresting heart rate not significantlyNOT influenced: FOR cardiac SALE output OR dur- DISTRIBUTION ing exercise declines with less efficient response to increased oxy- • Demographics (Administration on Aging, 2014 data) gen demand and longer recovery time to baseline, irregular heart 1. Elderly individuals represent 14.1% of the U.S. population, about rhythms, mild ECG changes one in every seven Americans 8. Peripheral vascular system—aorta and large arteries stiffen: rise in 2. By year© 2030, Jones 25% of & Americans Bartlett will Learning,be older than 65 LLC years systolic blood© Jonespressure, tendency & Bartlett toward orthostaticLearning, hypotension LLC 3. U.S. womenNOT at FOR age 65 haveSALE a 20.5 OR year’s DISTRIBUTION life expectancy (85.5 years) 9. GastrointestinalNOT (GI) FOR system—decreased SALE OR motility DISTRIBUTION of intestines, 4. Most elderly individuals live in the community; about 4% reside in decreased secretion of digestive enzymes and protective mucous in institutional facilities intestinal tract, decrease in liver size and hepatic blood flow: constipation, indigestion, decrease in ability to metabolize some drugs 5. About 28% of noninstitutionalized elderly individuals live alone; and alcohol, increased risk of stomach ulcers and GI bleeding with women are four times more likely to be widowed than men and long-acting nonsteroidal anti-inflammatory drugs © Jones &over Bartlett twice as likely Learning, to be living alone LLC © Jones & Bartlett Learning, LLC 10. Musculoskeletal system—bone demineralization, decreased NOT FOR6. About SALE 9.5% ORof elderly DISTRIBUTION individuals are below poverty level; poverty NOT FOR SALE OR DISTRIBUTION muscle mass and strength, decreased range of motion, joint and is more prevalent in elderly women than in elderly men cartilage erosion: decreased bone density, decreased agility and 7. Leading causes of death for U.S. women overall at age 65 and older endurance, gait disturbances, increased risk for falls in rank order are: 11. Neurologic system—general decrease in brain volume and cere- a. Heart disease © Jones & Bartlett Learning, LLCbral blood flow, decrease in velocity© Jones of nerve impulse & Bartlett conduction, Learning, LLC b. Cancer NOT FOR SALE OR DISTRIBUTIONdiminished sensory perceptionsNOT of touch FOR and pain SALE stimuli, ORmotor DISTRIBUTION c. Chronic obstructive pulmonary disease responses slow: slower reaction time, possible decreased response d. Stroke to pain, decrease in coordination and balance e. Alzheimer’s disease 12. Genitourinary—vulvovaginal atrophy, ovarian atrophy, decreased f. Diabetes bladder capacity and tone: dyspareunia; ovaries usually not pal- g. Influenza/pneumonia© Jones & Bartlett Learning, LLC pable; urinary© Jones frequency, & urgency, Bartlett incontinence; Learning, pelvic prolapse LLC h. UnintentionalNOT FOR injuries SALE OR DISTRIBUTION • Cognitive changesNOT FOR SALE OR DISTRIBUTION i. Kidney disease 1. Definitions/characteristics (Institute of Medicine, 2015) j. Hypertension a. Cognition is multidimensional, including mental functions in- • Anatomical and physiologic changes with aging/potential clinical im- volved in attention, thinking, understanding, learning, remem- © Jonesplications & Bartlett (not all-inclusive) Learning, LLC © Jonesbering, & Bartlett solving problems, Learning, and making LLC decisions NOT FOR1. Extent SALE and rateOR of DISTRIBUTIONchanges and clinical implications vary with NOT FORb. Cognitive SALE aging OR is inherent DISTRIBUTION in all humans as they age; highly dy- individual namic process with variability within and between individuals

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c. Some cognitive domains may not change, some decline, and bimanual) should be a shared, informed decision between patient © Jones & Bartlettsome may Learning, actually improve LLC © Jones &and Bartlett healthcare providerLearning, LLC NOT FOR SALEd. Factors OR that DISTRIBUTION may influence cognitive aging include genetics,NOT FOR6. Other SALE as indicated OR DISTRIBUTION by history and/or risk factors education, environment, culture, chronic medical conditions, • Functional assessment physical activity, and other health behaviors 1. Evaluation of individual’s ability to carry out basic tasks for self-care e. Cognitive aging is not a neurologic or psychiatric disease (activities of daily living [ADL]) and tasks needed to support inde- 2. Abnormal (pathologic)© causes Jones for cognitive & Bartlett changes Learning,include: LLC pendent living (instrumental© activitiesJones of daily& Bartlett living [IADL]) Learning, LLC a. Dementia (most commonNOT form FOR is Alzheimer’s SALE disease)—OR DISTRIBUTION insidious a. ADL—ability to eat, bathe,NOT dress, FOR groom, SALE ambulate, OR toilet DISTRIBUTION onset; slowly progressive; persistent; recent memory and new b. IADL—ability to use phone, get to appointments, shop, prepare learning especially impaired; changes in speech, mood, thought meals, take medications, manage money processes, judgment; behavior may become inappropriate; may have delusions and/or hallucinations; may have fragmented sleep 2. Provides information for healthcare provider to: a. Identify specific areas in which help is needed/not needed b.© DeliriumJones (may & beBartlett caused by infection,Learning, toxins, medications,LLC © Jones & Bartlett Learning, LLC b. Identify changes in abilities from one period of time to another NOTwithdrawal FOR from SALE alcohol ORor other DISTRIBUTION substances, trauma, neurologic NOT FOR SALE OR DISTRIBUTION or neoplastic disorders)—sudden onset; fluctuating with lucid c. Determine need for any special services intervals, worse at night; lasts hours to weeks; immediate and d. Assess safety of a particular living situation recent memory impaired; changes in alertness, attention, speech, 3. Includes assessment of physical, cognitive, emotional, and social mood, thought processes, judgment; may be agitated or somno- functions lent; may have delusions and/or hallucinations; disrupted sleep © Jones & Bartlett Learning, LLC © Jones4. & Affected Bartlett by medical Learning, conditions, sensoryLLC deficits, resources, sup- c. Depression—may have some cognitive symptoms along with port system NOT FOR SALEdepressed OR DISTRIBUTION mood, such as inability to think or concentrate, in-NOT FOR SALE OR DISTRIBUTION decisiveness, psychomotor agitation or retardation; individuals • Screening tests with diagnosis of dementia may also have clinical depression 1. Cervical cancer screening (ACS, ACOG, USPSTF)—age > 65 years d. Mini Mental Status Examination (MMSE)—screens for demen- a. No screening following adequate negative prior screening; do tia, although not definitive;© Jones may &be usedBartlett to detect Learning, progression LLC not resume screening even© Jonesif woman reports& Bartlett new sexual Learning, partner LLC of dementia b. Women with history of CIN2 or a more serious diagnosis NOT FOR SALE OR DISTRIBUTION should continue routineNOT screening FOR for at SALE least 20 years OR after DISTRIBUTION spontaneous regression or treatment Well-Woman Visit Age 65 and Beyond c. No screening after hysterectomy with cervix removed unless history of CIN2 or more severe diagnosis in past 20 years or • Comprehensive© Jones health & Bartlett history Learning, LLC cervical© Jones cancer ever & Bartlett Learning, LLC 1. IdentifyNOT diseaseFOR risk SALE factors/health-promoting OR DISTRIBUTION behaviors, symptoms 2. ColorectalNOT cancer FOR screening SALE OR DISTRIBUTION of disease, current status of diagnosed conditions, medications used a. ACS—beginning at age 50, colonoscopy every 10 years, flexible 2. Identify psychological and social concerns—social support sys- sigmoidoscopy every five years, double-contrast barium enema tems; isolation; emotional, physical, sexual, financial abuse or every five years, or computed tomography (CT) colonography neglect by family or partner; drug/alcohol use; depression (virtual colonoscopy) every five years © Jones &3. Bartlett Discuss sexuality/sexual Learning, history—sexual LLC orientation, gender identity,© Jones &b. Bartlett ACOG—colonoscopy Learning, every 10 LLC years for average-risk women sexual practices, sexual satisfaction, dyspareunia, use of condoms beginning at age 50 years and at age 45 years for African Amer- NOT FOR SALE OR DISTRIBUTION NOT FOR SALEican women OR DISTRIBUTION 4. Ask about menopausal symptoms, symptoms of pelvic prolapse, c. USPSTF—begin colorectal cancer screening at age 50; no urinary and fecal incontinence head-to-head studies demonstrating any of the various screen- 5. Learn what is most important to the individual woman as it relates ing strategies are more effective than the others (Grade A to her health and quality of life © Jones & Bartlett Learning, LLC Strong Recommendation)© Jones & Bartlett Learning, LLC • Physical examination NOT FOR SALE OR DISTRIBUTION3. Breast cancer screening—mammographyNOT FOR SALE OR DISTRIBUTION 1. Height—yearly; height loss greater than 1.5 inches (3.8 cm) may a. ACS—yearly, beginning at age 45 years for women at average be associated with vertebral compression fractures (VCFs) and risk; women age 55 and older can transition to biennial screen- thus osteoporosis ing or continue annual screening if they prefer 2. Weight/body mass index (BMI)—yearly b. ACOG—yearly, starting at age 40 years 3. Blood© Jones pressure—at & Bartlett each visit Learning, LLC c. USPSTF—biennial© Jones & screeningBartlett from Learning, age 50 to 74 years LLC (Grade B recommendation) 4. ClinicalNOT breastFOR examination SALE OR (CBE) DISTRIBUTION NOT FOR SALE OR DISTRIBUTION d. ACS and ACOG—no definitive age to discontinue mammo- a. American College of Obstetricians and Gynecologists gram screening; base on woman’s health and whether or not she (ACOG)—yearly CBE would be candidate for treatment of breast cancer b. American Cancer Society (ACS), United States Preventive Ser- 4. HIV screening if sexually active—yearly if high risk vice Task Force (USPSTF)—CBE not recommended for women © Jones & Bartlettat average Learning, risk for breast LLC cancer © Jones5. & Hepatitis Bartlett C—screen Learning, once if born LLC between 1945 and 1965 and no other risk factors NOT FOR SALE5. Pelvic examination—ifOR DISTRIBUTION need pap test or otherwise indicated; NOT FOR SALE OR DISTRIBUTION performing routine pelvic exam (external genitalia, speculum, 6. Diabetes screening—every three years starting age 45 (American Diabetes Association, 2016) © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

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7. Lipid screening (United States Preventive Services Taskforce, 2008) © Jonese. For & mostBartlett immunocompetent Learning, adults LLC age 65 years and older, the © Jones &a. ScreenBartlett women Learning, age 45 years and LLC older for lipid disorders if they two vaccines should be given at least one year apart NOT FOR SALEare at increased OR DISTRIBUTION risk for coronary heart disease (CHD) (Grade A NOT5. FOR Other asSALE indicated OR by health DISTRIBUTION history/risk factors Strong Recommendation) • Counseling/education b. Screen women age 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease (Grade B 1. Lifestyle modifications to reduce disease risk factors and promote Recommendation) health—nutrition, physical activity, safer sex practices, smoking © Jones & Bartlett Learning, LLCcessation, avoiding alcohol or other© Jones substance &abuse. Bartlett stress man- Learning, LLC c. CHD risk factors for women include being 55 years of age or agement, fall prevention older, family history of prematureNOT FOR CHD SALE(male relative OR < DISTRIBUTION55 NOT FOR SALE OR DISTRIBUTION years, female relative < 65), cigarette smoking, hypertension, 2. Breast self-awareness HDL at less than 40 mg/dL, diabetes mellitus 3. Recommended screening tests schedule d. No recommendation on interval of screening; USPSTF states 4. Discussion about establishing advance directives, living wills, du- every five years is reasonable rable power of attorney for health care, palliative care © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 8. Bone mineral density (BMD)—National Osteoporosis Foundation 5. Other as indicated by health history/physical examination (2013)NOT FOR SALE OR DISTRIBUTION findings/riskNOT factors FOR SALE OR DISTRIBUTION a. Screen all women 65 years of age or older for osteoporosis/osteopenia with BMD test b. No available specific recommendations on frequency of screen- Pharmacologic Considerations for © Jones & Bartletting or when toLearning, discontinue LLC © JonesElderly & PatientsBartlett Learning, LLC NOT FORc. SALE Data from OR the NIHDISTRIBUTION Osteoporotic Fractures Study (Gourlay NOT FOR SALE OR DISTRIBUTION et al., 2012) of women 65 years of age or older over 15 years 1. Majority of the elderly have one or more chronic conditions and indicated that: are taking multiple medications—prescription and over the coun- (1) Less than 1% who initially had normal BMD (T-score > ter (OTC) −1.00) went on to develop osteoporosis (T-score < −2.50) 2. Age-related decreases in metabolism and excretion of drugs may during the study © Jones & Bartlett Learning, LLCresult in increased plasma concentrations© Jones & Bartlett Learning, LLC (2) Only 5% with mild osteopenia (T-score −1.01 to −1.49) NOT FOR SALE OR DISTRIBUTION3. Increased risk for adverse drug NOTreactions FOR (ADRs)—drug–drug/ SALE OR DISTRIBUTION went on to develop osteoporosis during the study drug–food/drug–herb interactions, side effects, toxic effects (3) 10% with moderate osteopenia (T-score −1.50 to −1.99) at 4. Common ADRs in elderly—dizziness, gastrointestinal symptoms, baseline developed osteoporosis within five years edema, urinary retention or incontinence, confusion (4) 10% with advanced osteopenia (T-score −2.00 to 2.49) at 5. Other considerations that may lead to problems with use of ©baseline Jones developed & Bartlett within a year Learning, LLC medications—memory© Jones deficit, & Bartlett visual deficit, Learning, mobility problems, LLC (5) Findings suggest that women with baseline normal BMD or NOT FOR SALE OR DISTRIBUTION multiple providersNOT FORand pharmacies, SALE cost OR DISTRIBUTION mild osteopenia do not need frequent screening and could 6. Conduct comprehensive drug assessments—prescription medica- wait up to 15 years before rescreening tions, OTC medications, herbals, and dietary supplements (6) Findings suggest that women with baseline moderate or 7. Be alert to medications as possible cause for untoward physiologi- advanced osteopenia need more frequent screening cal or mental status changes © Jones• Immunizations & Bartlett Learning, LLC © Jones8. Start & with Bartlett low doses andLearning, increase slowly LLC NOT FOR1. Influenza SALE annually OR DISTRIBUTION NOT9. FOR Use American SALE Geriatric OR DISTRIBUTION Society Beers Criteria for potentially in- 2. Herpes zoster (shingles)—one-time dose for all individuals 60 appropriate medication use in older adults (American Geriatric years of age or older regardless of previous history of shingles Society, 2015) 3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) a. Lists medications best avoided in older adults in general or those a. Recommended three-dose vaccination series including Tdap with certain diseases or syndromes and medications that should dose for adults with unknown© Jones or incomplete & Bartlett history of Learning, primary LLCbe prescribed at reduced dosage© Jones or with careful & Bartlett monitoring Learning, to LLC Td vaccination NOT FOR SALE OR DISTRIBUTIONavoid adverse events NOT FOR SALE OR DISTRIBUTION b. Examples of drugs to avoid when possible with elderly patients b. Recommended one dose of Tdap for adults who have not previ- because of increased risk for adverse events include: ously received Tdap (1) Long-acting nonsteroidal anti-inflammatory drugs—increased c. Booster Td vaccination every 10 years for adults risk for indigestion, stomach ulcers, GI bleeding 4. Pneumococcal© Jones vaccine & Bartlett Learning, LLC (2) Benzodiazepines—increased © Jones & Bartlett risk Learning, for falls and confusion; LLC a. One dose of 13-valent pneumococcal conjugate vaccine long half-life (PCV13)NOT for FOR all adults SALE age 65 ORyears andDISTRIBUTION older who have not pre- (3) DrugsNOT with anticholinergicFOR SALE effects OR (e.g., DISTRIBUTION amitriptyline, dicyclo- viously received it mine, oxybutynin)—increased risk for confusion, constipation, b. One dose of 23-valent pneumococcal polysaccharide vaccine urinary retention, blurred vision, low blood pressure (PPSV23) for all adults age 65 years and older regardless of pre- (4) Muscle relaxants—increased risk for falls and confusion, vious history of vaccination with pneumococcal vaccines constipation, urinary retention © Jones &c. Bartlett PCV13 and PPSV23 Learning, should not LLC be administered at the same © Jones(5) & CertainBartlett diabetes Learning, medications: sulfonylureasLLC (e.g., glyburide, NOT FOR SALEoffice visit OR DISTRIBUTION NOT FOR SALEchlorpropamide)—increased OR DISTRIBUTION risk for hypoglycemia d. When both are indicated, PCV13 should be given before 10. Benefits and risks should always be considered; needed treatment for PPSV23 whenever possible symptoms and conditions should not be withheld based solely on age © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR Questions SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. The predominant estrogen after menopause is: 9. Based on data from the 2012 NIH Osteoporotic Fractures Study, the a. estradiol. most appropriate screening follow-up for a woman with a normal bone b. estriol. mineral density test at age 65 would be to repeat screening at age: c. estrone. a. 66. d. estropipate. © Jones & Bartlett Learning, LLC b. 67. © Jones & Bartlett Learning, LLC 2. A 51-year-old female asksNOT you ifFOR she should SALE take estrogenOR DISTRIBUTION to help c. 70. NOT FOR SALE OR DISTRIBUTION her memory because she is sometimes forgetful and has difficulty d. 80. concentrating. Her mother had dementia at age 65. The best initial 10. A 70-year-old woman at the clinic for a well-woman exam in No- response would be to: vember has the following immunization history: herpes zoster a. advise her that she may benefit from taking estrogen for about vaccine, 13-valent pneumococcal conjugate vaccine (PCV13), and ©five Jones years. & Bartlett Learning, LLC tetanus-diphtheria-pertussis© Jones & Bartlett (Tdap) booster Learning, at age 65. SheLLC has not b. NOTask about FOR other SALE menopausal OR symptoms DISTRIBUTION such as hot flashes and had anyNOT vaccinations FOR in SALE the past five OR years. DISTRIBUTION At this visit, recom- night sweats. mended vaccinations include: c. tell her the WHIMS study showed an increase in dementia for a. herpes zoster, influenza, 23-valent polysaccharide pneumococcal women her age who took estrogen. vaccine (PPSV23). d. tell her that her memory changes are likely caused by depression. b. influenza. © Jones &3. BartlettA 58-year-old Learning, female with vaginal LLC dryness causing irritation and© Jones c.& influenza, Bartlett PPSV23. Learning, LLC NOT FOR SALEdyspareunia OR has DISTRIBUTION no problem with hot flashes. Of the following treat-NOT FORd. SALEherpes zoster, OR influenza, DISTRIBUTION tetanus-diphtheria (Td) booster. ment choices, the best for her would be: 11. When comparing conjugated estrogen combined with bazedoxifene a. continuous-combined regimen hormone therapy (HT). (CE/BZA) to conjugated estrogen combined with medroxyproges- b. continuous-cyclic HT with added testosterone. terone acetate (CE/MPA), data have shown: c. low-dose estrogen vaginal ring. a. better prevention of bone loss with CE/BZA. d. progestin-only therapy. © Jones & Bartlett Learning, LLC b. less prevention of hot flashes© Jones with CE/BZA. & Bartlett Learning, LLC 4. Which of the followingNOT lab values FOR would SALE be expected OR with DISTRIBUTION c. less unscheduled bleedingNOT with CE/BZA.FOR SALE OR DISTRIBUTION menopause? d. more breast tenderness with CE/BZA. a. Decreased FSH, increased LH, decreased estradiol 12. An advantage of continuous-combined HT over continuous-cyclic b. Decreased LH, increased FSH, increased estradiol HT regimens is: c. Increased FSH, increased LH, decreased estradiol a. no estrogen-free period during which vasomotor symptoms can d. Increased LH, decreased FSH, increased estradiol © Jones & Bartlett Learning, LLC occur.© Jones & Bartlett Learning, LLC 5. A NOT 52-year-old FOR female SALE who had OR a hysterectomy DISTRIBUTION two years ago for dys- b. predictable NOT FORwithdrawal SALE bleeding OR each DISTRIBUTION month. functional uterine bleeding presents with complaints of severe hot c. lower cumulative dose of progestin. flashes and night sweats for the past few months. Of the following d. less negative impact on triglyceride levels. treatment choices, the most appropriate for her vasomotor symp- 13. An advantage of the transdermal patch over oral delivery of estro- toms at this time would be: gen for the woman experiencing menopausal symptoms is that the a. continuous-combined oral HT. transdermal delivery method: © Jones & Bartlettb. ospemifine Learning, (estrogen agonist/antagonist). LLC © Jones & Bartlett Learning, LLC a. does not require addition of a progestogen. NOT FOR SALEc. transdermal OR DISTRIBUTION estrogen patch. NOT FOR SALE OR DISTRIBUTION b. has less adverse effects on coagulation factors. d. vaginal estrogen cream. c. improves vulvovaginal symptoms more quickly. 6. Which of the following is n ot an FDA-approved indication for the d. increases HDL-C and decreases LDL-C levels. use of HT? 14. Which of the following women should have an endometrial biopsy/ a. Prevention of cardiovascular disease © Jones & Bartlett Learning, LLC evaluation? © Jones & Bartlett Learning, LLC b. Prevention of osteoporosis a. Woman on continuous-cyclic HT regimen with amenorrhea c. Relief of moderate toNOT severe FORsymptoms SALE of vulvovaginal OR DISTRIBUTION atrophy NOT FOR SALE OR DISTRIBUTION b. Woman on continuous-cyclic HT regimen with bleeding starting d. Relief of moderate to severe vasomotor symptom last few days of progestogen administration each month 7. Which of the following would not be an expected pelvic examina- c. Woman on continuous-combined HT regimen with irregular tion finding in a 70-year-old woman? bleeding in the first year of use a.© Narrow Jones vaginal & canalBartlett Learning, LLC d. Woman © Jones on continuous-combined & Bartlett HTLearning, regimen with LLC spotting that b. Palpable ovaries occurs after several months of amenorrhea c.NOT Small uterusFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 15. The woman who is going to take ospemifine for treatment of dyspa- d. Thin vaginal walls reunia related to vulvovaginal atrophy should be advised that she: 8. A major ovarian peptide that contributes to FSH regulation is: a. will need to take a progestogen in addition to prevent endome- a. anti-müllerian hormone trial hyperplasia. © Jones & Bartlettb. inhibin BLearning, LLC © Jones b.& may Bartlett also use vaginalLearning, estrogen toLLC further enhance effect. c. progesterone NOT FOR SALE OR DISTRIBUTION NOT FORc. SALEmay experience OR DISTRIBUTIONhot flashes as a side effect of this medication. d. prostaglandin d. should take the medication two to three hours before having sexual intercourse.

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16. The number one cause of death in U.S. women age 65 and older is: © Jonesc. Plant-based & Bartlett (estriol) Learning, oral estrogen LLC © Jonesa. & cancer. Bartlett Learning, LLC d. Transdermal estrogen patch NOT FORb. SALEdiabetes. OR DISTRIBUTION NOT22. FORWhich ofSALE the following OR statementsDISTRIBUTION regarding pain and pain manage- c. heart disease. ment in elderly patients is correct? d. pneumonia. a. Age-related increase in excretion of drugs may require more fre- 17. Normal changes with aging include decreases in all for the following quent dosing of pain medications. except: © Jones & Bartlett Learning, LLCb. Benzodiazepine medications such© Jones as alprazolam & Bartlett may be a better Learning, LLC a. cerumen production. option than a pain medication. b. number of taste buds. NOT FOR SALE OR DISTRIBUTIONc. Elderly patients may have an increasedNOT FOR response SALE to painful OR DISTRIBUTION c. sweat gland activity. stimuli compared to younger adults. d. tear production. d. Long-acting nonsteroidal anti-inflammatory drugs may be 18. A 68-year-old female had her last cervical cancer screening done more likely to cause adverse gastrointestinal reactions in elderly patients. at age 65© and Jones results were& Bartlett normal. She Learning, has no history of LLC abnormal © Jones & Bartlett Learning, LLC screenings. She has recently started having sexual intercourse with a 23. Which of the following statements regarding depression in the el- new maleNOT partner FOR and asks SALE if she shouldOR DISTRIBUTION start having cervical cancer derly is correct?NOT FOR SALE OR DISTRIBUTION screening again. An appropriate answer would be that she: a. The Mini Mental Status Exam (MMSE) is a good screening tool a. does not need pap tests but should have HPV testing every five for depression in elderly individuals. years. b. The elderly individual is more likely to have delusions or halluci- b. does not need to resume either pap tests or HPV testing. nations with depression. © Jones c.& should Bartlett have a Learning,pap test with HPV LLC co-testing in five years and, if it © Jonesc. No & changes Bartlett in cognition Learning, should be expectedLLC with the elderly in- NOT FOR SALEis negative, OR can stopDISTRIBUTION screening. NOT FORdividual SALE who has OR clinical DISTRIBUTION depression. d. should resume pap test with HPV co-testing every five years. d. The individual with a diagnosis of dementia may also have clini- 19. Expected physical findings with aging include: cal depression. a. decrease in total body fat. 24. A 53-year-old female asks you if increasing her soy product intake b. increase in benign skin lesions. or taking an isoflavone supplement has any benefit for her now that c. increase in resting heart ©rate. Jones & Bartlett Learning, LLCshe is menopausal. Information you© Joneswould want & to Bartlettprovide would Learning, LLC d. increase in liver size. NOT FOR SALE OR DISTRIBUTIONinclude there is evidence to supportNOT increasing FOR soy SALE product intakeOR DISTRIBUTION 20. According to USPSTF recommendations, an 80-year-old female may help to: should have: a. improve memory and concentration in menopausal women a. a clinical breast examination and a screening mammogram b. prevent osteoporosis in menopausal women annually. c. prevent skin changes that typically occur with aging b. a clinical© Jones breast examination & Bartlett annually Learning, but no screening LLC d. reduce hot© flash Jones frequency & Bartlettand severity Learning,for some women LLC mammogram.NOT FOR SALE OR DISTRIBUTION 25. A menopausalNOT female FOR experiencing SALE discomfort OR DISTRIBUTION with sexual inter- c. neither a clinical breast examination nor a screening course related to vaginal dryness wants to know whether she should mammogram. use a vaginal lubricant or a vaginal moisturizer. Correct information d. a screening mammogram biennially but no clinical breast to provide would include all of the following except: examination. a. lubricants are intended to reduce friction during sex © Jones21. Which & Bartlett of the following Learning, estrogen therapy LLC options does not require © Jonesb. lubricants & Bartlett may take Learning, several weeks of LLC use before becoming NOT FORopposition SALE by OR a progestogen DISTRIBUTION in a woman with an intact uterus? NOT FOReffective SALE OR DISTRIBUTION a. Bioidentical oral estrogen formulation c. moisturizers provide longer-term relief of vaginal dryness than b. Estring vaginal ring lubricants d. moisturizers are typically applied several times weekly

Answers with Rationales© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. c. estrone 3. c. low-dose estrogen vaginal ring The predominant estrogen after menopause is estrone. Estrone is The menopausal woman who has symptoms related to vulvar/vagi- converted from androstenedione produced by the adrenal gland nal atrophy and no vasomotor symptoms is best treated with local and ovarian stroma. low-dose vaginal estrogen. 2. b. ask© about Jones other menopausal & Bartlett symptoms Learning, such as hot LLC flashes and 4. c. Increased© FSH, Jones increased & LH,Bartlett decreased Learning, estradiol LLC night NOTsweats FOR SALE OR DISTRIBUTION During theNOT menopause FOR transition, SALE there OR is a DISTRIBUTIONdecreased production Although more history and physical examination may be war- of estradiol as the number of responsive ovarian follicles decreases. ranted, the best answer choice is to initially ask about other This decrease in estradiol triggers the increased release of FSH and menopausal symptoms such as hot flashes and night sweats. LH from the anterior pituitary gland. These vasomotor symptoms can contribute to memory impair- 5. c. transdermal estrogen patch © Jones &ment Bartlett and difficulty Learning, concentrating LLC as a result of sleep disturbance. © Jones The transdermal& Bartlett estrogen Learning, patch delivery LLC method has no significant If she has vasomotor symptoms, short-term hormone therapy impact on HDL-C, LDL-C, triglycerides, or C-reactive protein. The NOT FORmay SALE be an option.OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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estrogen agonist/antagonist (ospemifene) and vaginal estrogen © Jones &combination Bartlett with Learning, ospemifine. No LLC studies have looked at using a © Jones & Bartlettcream are indicatedLearning, for vulvovaginal LLC atrophy and related symp- progestogen with ospemifine. NOT FOR SALEtoms. OralOR HT DISTRIBUTION may increase HDL-C, triglycerides, and C-reactiveNOT FOR16. c. SALE heart disease OR DISTRIBUTION protein and decrease LDL-C. Heart disease is the number one cause of death in women age 65 6. a. Prevention of cardiovascular disease and older. The FDA-approved indications for the use of hormone therapy in- 17. a. cerumen production clude relief of moderate© toJones severe menopausal & Bartlett symptoms Learning, related to LLC There is an increase in cerumen© Jones production & withBartlett aging. There Learning, is LLC estrogen deficiency (vasomotor instability, vulvar/vaginal atrophy), NOT FOR SALE OR DISTRIBUTIONa decrease in number of tasteNOT buds, FOR sweat gland SALE activity, OR and DISTRIBUTION tear and prevention of osteoporosis. production. 7. b. Palpable ovaries 18. b. does not need to resume either pap tests or HPV testing Three to five years after menopause, ovaries are atrophic and are The American Cancer Society, American College of Obstetricians usually not palpable. and Gynecologists, and U.S. Preventive Services Task Force recom- 8. b.© inhibin Jones B & Bartlett Learning, LLC mend© no Jonesfurther cervical & Bartlett cancer screening Learning, in women ageLLC 65 and InhibinNOT B FOR is a major SALE ovarian OR peptide DISTRIBUTION that rises and falls in the first older followingNOT FOR adequate SALE negative OR prior DISTRIBUTION screening and no history of half of the follicular phase, peaks midcycle, and falls to its lowest CIN2 or more serious diagnosis. Screening should not be resumed level in luteal phase. It forms a negative feedback loop to fine-tune even if the woman reports a new sexual partner. pituitary FSH regulation. 19. b. increase in benign skin lesions 9. d. 80 Aging along with cutaneous sun exposure damage results in an in- © Jones & Bartlett The 2012 NIH Learning, Osteoporotic LLCFractures Study findings suggest that© Jones &crease Bartlett in several Learning, types of benign skinLLC lesions. NOT FOR SALEwomen OR with DISTRIBUTIONa baseline normal BMD or mild osteopenia do not NOT FOR20. c. SALE neither a ORclinical DISTRIBUTION breast examination nor a screening need frequent screening and can wait up to 15 years before re- mammogram screening. Less than 1% of women who initially had a normal BMD The U.S. Preventive Services Task Force recommends against rou- went on to develop osteoporosis during the 15 years of the study. tine clinical breast examination at any age and recommends bien- 10. c. influenza, PPSV23 nial mammograms from age 50 to 74. Influenza vaccine is recommended© Jones annually.& Bartlett For individuals Learning, age 65 LLC21. b. Estring vaginal ring © Jones & Bartlett Learning, LLC years and older a one-timeNOT dose FOR of PCV13 SALE is recommended, OR DISTRIBUTION with Estring vaginal ring has littleNOT or no FORsystemic SALE absorption OR and DISTRIBUTIONdoes one-time dose of PPSV23 at least one year later. not require opposition by a progestogen. 11. c. less unscheduled bleeding with CE/BZA 22. d. Long-acting nonsteroidal anti-inflammatory drugs may be more Data indicate less unscheduled bleeding and less breast tenderness likely to cause gastrointestinal adverse reactions in elderly patients. with CE/BZA than with CE/MPA. The decrease in protective mucous in the intestinal tract with aging 12. c.© lower Jones cumulative & Bartlett dose of progestogen Learning, LLC may put© elderlyJones individuals & Bartlett at more riskLearning, for indigestion, LLC stomach Estrogen NOT FOR and progestogen SALE are OR taken DISTRIBUTION every day with a ulcers,NOT and gastrointestinal FOR SALE bleeding OR with DISTRIBUTION use of long-acting nonste- continuous-combined HT regimen with lower cumulative dose of roidal anti-inflammatory drugs. progestogen than a continuous-cyclic HT regimen in which estro- 23. d. The individual with a diagnosis of dementia may also have clini- gen is taken every day and larger doses of progestogen are added 10 cal depression to 14 days each month. Dementia and clinical depression may co-exist. Clinical depression © Jones &13. Bartlett b. has less adverseLearning, effects on LLC coagulation factors © Jones &may Bartlett include mild Learning, cognitive changes LLC such as inability to concen- NOT FOR SALE Estrogen OR delivered DISTRIBUTION via a transdermal patch has no effect on car-NOT FORtrate SALE and indecisiveness OR DISTRIBUTION but not the other changes associated with diovascular markers (HDL-C, LDL-C, triglycerides, C-reactive dementia. The Mini Mental Status Exam (MMSE) is a screening protein). There is less effect on coagulation factors and a lower risk tool for dementia. of venous thromboembolism with transdermal estrogen compared 24. d. reduce hot flash frequency and severity for some women with oral estrogen in the menopausal woman. Data from a meta-analysis of 17 small randomized controlled tri- 14. d. Woman on continuous-combined© Jones & HT Bartlett regimen with Learning, spotting LLC als (Taku, Melby, Kronenberg,© JonesKurzer, & Messina,& Bartlett 2012) support Learning, LLC that occurs after severalNOT months FOR of amenorrhea SALE OR DISTRIBUTIONthe efficacy of soy productsNOT in reducing FOR hot SALEflash frequency OR andDISTRIBUTION Women using continuous-combined HT may initially have some severity for some women. Inform women that soy products vary in unpredictable spotting and bleeding. After several months of use, composition and concentration. the endometrium atrophies and amenorrhea usually results. If spot- 25. b. lubricants may take several weeks of use before becoming ting or bleeding recurs after several months of amenorrhea, endo- effective metrial© Jones evaluation & Bartlettis warranted. Learning, LLC Vaginal© lubricantsJones have & Bartlettan immediate Learning, effect and are intended LLC to re- 15. c.NOT may experience FOR SALE hot flashes OR as aDISTRIBUTION side effect of this medication duce frictionNOT onFOR atrophic SALE vulvovaginal OR DISTRIBUTIONstructures during sex. Vagi- Ospemifine is a SERM taken as a daily oral dose to treat moder- nal moisturizers are applied several times weekly for longer-term ate to severe dyspareunia related to vulvovaginal atrophy. Hot relief of vaginal dryness. Moisturizers help to maintain vaginal flashes are a common side effect. Estrogen should not be used in moisture and lower vaginal pH.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR Bibliography SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Administration on Aging. (2014). A profile of older Americans: 2014. http://www.aoa North American Menopause Society. (2014). Menopause practice: A Clinician’s guide .acl.gov/aging_statistics/profile/2014/docs/2014-Profile.pdf (5th ed.). Mayfield Heights, OH: Author. American College of Obstetricians and Gynecologists. (2011). Practice bulletin # 122: Oeffinger, K., Fontham, E., Etzioni, R., Herzig, A., Michaelson, J., Shih, Y.,. . . Breast cancer screening. Obstetrics and Gynecology, 118 (2), 372–382. Wender, R. (2015). Breast cancer screening for women at average risk: 2015 American College of Obstetricians and© Gynecologists. Jones (2013).& Bartlett Well-woman Learning,care: LLCguideline update from the American Cancer© SocietyJones . Journal & ofBartlett American Medical Learning, LLC Assessments and recommendations . Washington, DC: Author. Association, 314 (15), 1599–1614. American College of Obstetricians andNOT Gynecologists. FOR (2016). SALE Practice OR bulletin DISTRIBUTION # 157: Portman, D., & Gass, M. (2014). GenitourinaryNOT syndrome FOR of menopause: SALE New OR ter- DISTRIBUTION Summary cervical cancer screening and prevention. Obstetrics and Gynecology , minology for vulvovaginal atrophy from the International Society for the Study of 127 (1), 185–187. Women’s Sexual Health and the North American Menopause Society. Menopause, American Diabetes Association. (2016). Classification and diagnosis of diabetes 21 (10), 1063–1068. mellitus. Diabetes Care , 39 (Suppl. 1), S13–S22. Saslow, D., Solomon, D., Lawson, H., Killackey, M., Kulasingam, S. L., Cain, J.,. . . American Geriatric© Jones Society. (2015). & Bartlett American Geriatric Learning, Society 2015 updatedLLC Beers ACS-ASCCP-ASCP© CervicalJones Cancer & Guideline Bartlett Committee. Learning, (2012). American LLC criteria for potentially inappropriate medication use in older adults. Journal of Cancer Society, American Society for Colposcopy and Cervical Pathology, and American GeriatricNOT Society,FOR 63 SALE (11), 2227–2246. OR DISTRIBUTION American SocietyNOT for Clinical FOR Pathology SALE screening OR guidelines DISTRIBUTION for the prevention Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2014). Mosby’s guide to physical and early detection of cervical cancer. CA Cancer Journal for Clinicians, 62 (3), examination (8th ed.). St. Louis, MO: Mosby. 147–172. Bickley, L. (2012). Bates’ guide to physical examination and history taking (11th ed.). Schuiling, K., & Likis, F. (2017). Women’s gynecologic health (3rd ed.). Burlington, Philadelphia, PA: Lippincott Williams & Wilkins. MA: Jones & Bartlett Learning. Brucker, M., & King, T. (2017). Pharmacology for women’s health (2nd ed.). Shifren, J., & Bass, M. (2014). The North American Menopause Society recommenda- © Jones Burlington, & Bartlett MA: Jones Learning, & Bartlett Learning. LLC © Jonestions for &clinical Bartlett care of midlife Learning, women. Menopause, LLC 21 (10), 1038–1062. NOT FOR Gourlay, SALEM., Fine, J., ORPreisser, DISTRIBUTION J., May, R., Li, C., Lui, L.,... Ensrud, K. (2012). NOT Smith, FOR R., Andrews, SALE K., Brooks, OR D., DISTRIBUTION DeSantis, C., Fedewa, S., Lortet-Tieulent, J.,. . . Bone-density testing interval and transition to osteoporosis in older women. New Wender, S. (2016). Cancer screening in the United States, 2016: A review of cur- England Journal of Medicine, 366 , 225–233. rent American Cancer Society guidelines and current issues in cancer screening. Institute of Medicine. (2015). Cognitive aging: Progress in understanding and opportu- CA Cancer Journal for Clinicians, 66 (2), 96–114. nities for action . Washington, DC: National Academies Press. Taku, K., Melby, M., Kronenberg, F., Kurzer, M., & Messina, M. (2012). Extracted Kobayashi, M., Bennett, N., Gierke, R., Almendares, O., Moore, M., Whitney, C.,. . . or synthesized soybean isoflavones reduce menopausal hot flash frequency and Pilishvili, T. (2015). Intervals between© PCV13Jones and PPSV23 & Bartlett vaccines: Recommen- Learning, LLCseverity: Systematic review and meta-analysis© Jones of randomized & controlledBartlett trials. Learning, LLC dations of the Advisory CommitteeNOT on Immunization FOR PracticesSALE (ACIP). OR M DISTRIBUTION MWR, Menopause, 19 (7), 776–790. NOT FOR SALE OR DISTRIBUTION 64 (34), 944–947. Touhy, T., & Jett, K. (2016). Ebersole and Hess’ toward healthy aging : Human needs and Kramer, D. (2016). Special considerations in the gerontological patient. In S. Miller nursing response (9th ed.). St. Louis, MO: Mosby Elsevier. (Ed.). Adult- g erontology nurse practitioner c ertification review g uide (6th ed.) United States Preventive Services Task Force. (2008). Screening for lipid disorders (pp. 31–45). Burlington, MA: Jones & Bartlett Learning. in adults: U.S. Preventive Services Task Force recommendation statement. National Osteoporosis Foundation. (2013). Clinician’s guide to prevention and treat- http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm. ment of osteoporosis© Jones . Washington, & Bartlett DC: Author. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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