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SOURCE

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.

CONDITION/DISORDER SYNONYMS

  • Climacteric.

  • Change of life.

DEFINITION

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

ETIOLOGY

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

PATHOPHYSIOLOGY

  • 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.

EPIDEMIOLOGY

  • 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.

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

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

  • Sleep disturbances.

  • Mood changes.

  • Impaired concentration and memory.

  • Vaginal dryness.

  • Dyspareunia.

  • Arthralgia.

DIAGNOSIS

  • Complete medical history and physical examination.

  • Menopause determined retrospectively after 12 consecutive months of amenorrhea.

LABORATORY TESTS

  • Serum FSH levels.

    • Perimenopause: 10–12 IU/L

    • Menopause: exceed 40 IU/L

  • Thyroid function tests.

  • Iron stores.

  • Lipid profile.

DIFFERENTIAL DIAGNOSIS

  • 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)

DESIRED OUTCOMES

  • Relieve symptoms.

  • Improve quality of life.

  • Minimize adverse effects.

TREATMENT: GENERAL APPROACH

  • 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.

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.

TREATMENT: NONPHARMACOLOGIC THERAPY

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

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