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SOURCE

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Source: Kalantaridou SN, Borgelt LM, Dang DK, Calis KA. Hormone therapy in women. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146067309. Accessed May 17, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Climacteric.

  • Change of life.

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DEFINITION

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  • Menopause is permanent cessation of menses after loss of ovarian follicular activity.

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ETIOLOGY

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  • May be due to normal aging process, surgery (total abdominal hysterectomy, bilateral oophorectomy), medications (eg, chemotherapy), or pelvic irradiation.

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PATHOPHYSIOLOGY

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  • Loss of ovarian follicular activity; postmenopausal ovaries no longer primary site of estradiol or progesterone synthesis.

  • As women age, follicle-stimulating hormone (FSH) rises and ovarian inhibin declines. When ovarian function ceases, serum FSH concentrations are >40 IU/L. Menopause characterized by:

    • 10- to 15-fold increase in circulating FSH concentrations compared with concentrations of FSH in follicular phase.

    • 4- to 5-fold increase in luteinizing hormone (LH)

    • >90% decrease in circulating estradiol concentrations.

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EPIDEMIOLOGY

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  • Median age at onset in the United States: 51 years (but can vary from 40 to 58 years).

  • Women who have undergone hysterectomy must rely on symptoms to estimate the actual time of menopause and are more likely to have earlier menopause.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Vasomotor symptoms (eg, hot flushes and night sweats)

  • Sleep disturbances.

  • Mood changes.

  • Impaired concentration and memory.

  • Vaginal dryness.

  • Dyspareunia.

  • Arthralgia.

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DIAGNOSIS

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  • Complete medical history and physical examination.

  • Menopause determined retrospectively after 12 consecutive months of amenorrhea.

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LABORATORY TESTS
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  • Serum FSH levels.

    • Perimenopause: 10–12 IU/L

    • Menopause: exceed 40 IU/L

  • Thyroid function tests.

  • Iron stores.

  • Lipid profile.

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DIFFERENTIAL DIAGNOSIS
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  • Pregnancy.

  • Premature ovarian failure.

  • Hypothyroidism or hyperthyroidism

  • Hyperprolactinemia.

  • Polycystic ovary syndrome.

  • Hypothalamic amenorrhea (eg, stress, weight change, exercise)

  • Other endocrine causes (eg, Cushing’s syndrome, Addison’s disease)

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DESIRED OUTCOMES

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  • Relieve symptoms.

  • Improve quality of life.

  • Minimize adverse effects.

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TREATMENT: GENERAL APPROACH

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  • Figure 1: Algorithm for pharmacotherapy of menopausal symptoms.

  • Vaginal dryness because of vaginal atrophy often requires local or systemic estrogen therapy.

    • Topical estrogen cream, tablets, or vaginal ring.

    • Vaginal estrogen may be more effective and avoids high circulating estrogen levels.

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FIGURE 1.

Algorithm for pharmacologic management of menopause symptoms. Reprinted with permission from Wells BG, DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 10th ed. New York, NY: McGraw-Hill; 2017.

Graphic Jump Location
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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Lifestyle modification including wearing layered clothing that can be removed or added as ...

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