Menopause and Postmenopausal Therapy

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.

TREATMENT: NONPHARMACOLOGIC THERAPY