Menopause is defined as one year without any periods and the average age is 51.
Perimenopause is the time before this which can be quick (1 day) or can last 10-15 years
Symptoms usually start in the late 40s. Average duration of vasomotor symptoms (hot flashes) is 7 years and can last up to 15 years. (80% of women have symptoms)
Average life expectancy is 82 years (⅓ of our lives is spent in Menopause)
Many changes may be occurring – some women experience terrible symptoms and others seem to go right into menopause without any symptoms and do just fine. During this time the ovaries are becoming less responsive to the brain’s stimulating hormones and there is eventually a decline in Estradiol from the ovaries and a rise in FSH from the brain. These two changes seem to be the primary driving factors for all of the symptoms that some women will experience.
Symptoms of Perimenopause transitioning to Menopause
Vasomotor symptoms – hot flashes, night sweats, interrupted sleep, moodiness
Genitourinary symptoms – genital system: vaginal dryness and atrophy, pain of the vestibule, vaginal infections, prolapse, irregular bleeding
Sexual dysfunction: pain with intercourse, loss of libido, slow arousal phase, anorgasmia,
urinary system: recurrent urinary tract infections, incontinence, difficulty with urination, blood in the urine.
Cardiovascular changes -increased risk for cardiovascular disease, increase in blood pressure, changes in lipids, heart palpitations,
Bone health- osteopenia, osteoporosis, bone fractures
Neurologic and cognitive symptoms – memory, word find and foggy brain, anxiety, depression, loss of focus, social impairment, work issues,
Gastrointestinal symptoms- bloating, constipation, increased gas and distention, changes in food adversities, low apetite
Dermatologic symptoms – dryness of the skin, rashes, hair loss, hair thinning, acne
Rheumatologic changes – joint aches, swelling, arthritis, autoimmune disorders
Weight gain – average 2-3#/year, mid abdominal fat deposition, loss of estrogen increases cortisol and increase in fat deposits
Life events – aging parents, adolescent children, job changes, stress, relationships.
Theme of Management – to be used as a guide for each system management
Nutrition – limit simple sugars, more complex carbohydrates, protein with each meal, more vegetables, drink more water, less caffeine, less alcohol
Exercise and physical activity – improves blood circulation to all organs,
3 general types of exercise – relaxing (walking, stretching, some yoga), muscle building (weight lifting, pilates, Yoga, resistance), aerobic/fat burning (running, swimming, biking) –
individualized for each patient to avoid physical strain or trauma and to address the issue.
Stress management and Sleep enhancement – major benefits for reducing inflammation and immune building. These go hand in hand – as stress goes up, sleep goes down (cortisol)
Vitamins/ Supplements -(if indicated) -Always best to get this through food sources but we may not eat as much, we may not absorb as much, or convert to vitamin D as well…. Depending on the situation, I may suggest additional vitamin C, vitamin D, Vitamin B 12, B complex, B6, Zinc, Iron, Biotin, Magnesium, dietary calcium.
Pharmacologic management if appropriate – outlined below per organ system.
Wellness counseling – life goals, self awareness, personal coping, deep breathing, meditation, gratitude journal, hobbies, music, distraction techniques – anything to avoid the 24/7 stress effect.
Vasomotor symptoms – hot flashes, night sweats
Valerie – 47 years old and she is developing terrible hot flashes and night sweats, drenching and needs to change her clothes in the middle of the night— she is a “super flasher”, her heart is racing, she feels it is irregularly beating with skipped beats and creating a sense of anxiety- can last for seconds to minutes. Menses skipping.
Few facts:
Risk factors for hot flashes – increased BMI, smoking, depression, alcohol use, Race
Triggers – spicy food, hot temperature foods, physical exertion, stress, caffeine, chocolate, alcohol, sugar,
**Women with hot flashes may have an Increased lifetime risk for cardiovascular disease, cognitive decline of aging and breast cancer, – more research is needed and is ongoing at this time. Possibly related to inflammation.
Management of Vasomotor Symptoms (areas highlighted are proven by randomized controlled trials to be effective in reducing hot flashes)
Nutrition – avoid triggers -reduce sugars. Research is mixed on soy isoflavones – weak binding of E receptors
Exercise – improves blood flow -stretching, relaxing exercises, avoid high intensity and traumatic types of exercise
Stress/Sleep management -improves neurotransmitter production, Cognitive Behavioral Therapy -Managing Hot Flushes and Night sweats: a Cognitive Behavioral Self Help Guide by Myra Hunter and Melanie Smith, progressive relaxation, Meditation – Clinical Hypnosis
Sleep – improves neurotransmitter production- Sleep Solutions by Dr. Chris Winters, MD
Most vitamins and supplements have not been shown to be helpful with VMS, however some mild relief may be seen with Black Cohosh (Remifemin), Relizen, and over the counter GABA – I often cycle these in/out as the effect depletes over a few weeks.
Non hormonal medical management – prescription GABA, Antidepressants, (SSRI, SNRI,), Clonidine.
GABA by prescription – Neurontin (seizure medication,)- some mild side effects but overall well tolerated. GABA is also over the counter but need to look at the dosage – usually I am starting around 300mg – up to 1500mg/day
Paroxetine (Brisdelle)- 7.5mg = Paxil is a low dose SSRI and the only nonhormonal pharmaceutical approved by the FDA for moderate to severe hot flashes). – no change in weight or on libido.
Other SSRI’s – Escitalopram (Lexapro), Citalopram (Celexa), Venlafaxine (Effexor) , Desvenlafaxine (Pristique). Avoid SSRIs if on Tamoxifen
Bupropion (Wellbutrin) may have the least effect on sexual dysfunction.
Wellness – dress in layers, sleep with a fan, lifestyle, CBT, clinical hypnosis, meditation, relaxation, acupuncture, reflexology, acupressure-progressive relaxation, no evidence that it reduces VMS but may be helpful), wearables
Genitourinary Syndrome of the Menopause (GSM)
Jenny is 62 – she presents with burning pain and dryness in the vulvovaginal area especially when having sex making it very difficult and at times impossible. She is too uncomfortable and has noticed a discharge and an odor with itching. In addition she is having more leaking of urine when coughing, sneezing or jumping.
enital symptoms – burning, itching, discharge, pain
Sexual dysfunction “sandpaper” dryness, pain, slow arousal and low libido.
Urinary symptoms – urinary infections, incomplete emptying, incontinence
Management of Genitourinary Syndrome of the Menopause – GSM
Non hormonal moisturizers – Hyaluronic acid – (Revaree, Hyalo-gyn), Replens – twice/week insertions.
Hormonal measures – vaginal estrogens (tablets, rings, creams), Intravaginal Prosterone (DHEAs- Intrarosa), topical estrogens to vulvar vestibule. – very low systemic absorption and considered safe by most oncologists.
Vaginal lasers – yearly treatment – work best in combination of the above treatment options.
Lubricants with intercourse/contact – water based (Astroglide, Good Clean Love, Ky, Slippery Stuff) silicone based ( Uberlube) and oil based options (Olive Oil, Coconut Oil, Elegance).
Libido and arousal and orgasmic loops- – Often, treating the dryness and pain resolves libido – take our “foot off the brake”
Sexual dysfunction review any relationship concerns. The hormone Testosterone can be considered as a low dose topical cream. – no significant blood levels detected. Can mix with topical estradiol cream and apply to vulvar area – labia and clitoris.
Lichen sclerosus – skin condition of the vulva – acts up during menopause is treated with topical steroids, estrogens and testosterone or the laser.
Urinary symptoms: evaluate for UTI, incomplete emptying, cystocele, prolapse, – treat accordingly, if due to atrophy will apply vaginal estrogen, if recurrent UTIs consider the laser. Consider Urology consult.
Cardiovascular concerns for the menopausal patient
Candy is a 56 year old who presents to the office with an increase in her Blood pressure, some feeling of skipped heart beats, dizziness, headaches, chest pain, and anxiety.
Risk factors for CVD in women – hormonal changes (loss of estrogen, rise of FSH), Vasomotor symptoms (hot flashes, night sweats), loss of sleep, psychosocial stressors all can affect the thickness of the vessel walls. All of these seem to increase the risk for CVD in women.
Cardiovascular disease in women – interesting facts
Women may have more adverse cardiovascular outcomes than men and the risk for CVD rises after the final menstrual period. Women are under treated for CVD.
The Diagnosis of cardiovascular disease in women may be missed due to a different presentation–
Women have more microvascular disease than men (large arteries appear clear but small vessels may be affected and therefore the typical workup for angina/MI by angiogram can miss the diagnosis of heart disease in small vessels. Both will present as ischemic heart disease but men have more large vessel disease and women may have more small vessel disease. Therefore more men will receive treatment and have a lower mortality and women may have an increase in death rate.
Prevention of cardiovascular disease in the menopausal patient
Nutrition – need a heart healthy diet – fruits, vegetables, grains, low or non fat dairy, limit saturated fats and trans fats – individualize your diet – some like the Mediterranean diet- popular
Activity/Exercise- daily – walking, biking, swimming, classes, etc….. (as outlined previously)
stress/sleep – meditation, stress management to reduce inflammation
Vitamins – as reviewed previously
Meds: referral to – internist/cardiologist/lipidologists – preferably one that can recognize the pattern of cardiovascular disease in women of coronary microvasculature. Preventative cardiology –
Wellness -as reviewed previously
Bone loss in the Menopausal Patient
Betty is a 65 year old woman who presents with no symptoms but is found on a recent Bone Density Screening test to have significant osteopenia/early osteoporosis. She recently fractured her foot last year when she tripped on a step and her mother has had a lot of bone fractures as well.
Significant bone loss occurs with the loss of estrogen in the transition of perimenopause to menopause
Risk Factors: age, thin, genetics, smoking, drugs (steroids), prior fracture, alcohol, chronic diseases (DM).
Diagnosis: a history of vertebral or hip fracture, or the BMD shows a T score of less than -2.5. Even if the bone density improves after diagnosis of osteoporosis- they retain the diagnosis and treatment persists. If the patient is diagnosed with osteopenia and suffers a fracture of the humerus, pelvis or forearm or has multiple fractures or has a FRAX score that is elevated she would also qualify for the diagnosis of osteoporosis.
Managing Bone loss in the menopausal patient.
Maximizing bone health: “Lifelong process and Long Term Management”
Basic Bone health Program – maximizing Nutrition, exercise, dietary calcium, vitamin D.
If Osteoporotic or severe osteopenia- add in pharmaceutical agents.
Nutrition – focus on protein, vegetables, no smoking, limit ETOH,
Exercise – relaxing forms of exercise – stretching, walking, yoga – watch balance.
Muscle building – resistance – weight bearing – weights, Pilates, yoga, strengthen core.
Aerobic exercise – swimming, running, biking, some pilates, Yoga
Stress/Sleep – as above.
Vitamins/ supplements – dietary calcium , vitamin D
Pharmaceutical agents – Evista, Bisphosphonates, Forteo, Prolia, Reclast –The bisphosphonates are usually prescribed for 3-5 years – can interrupt treatment if BMD improves and can re-introduce again later
Refer to bone Specialist –
Wellness – check eye slight, balance, prevent falls, strengthen core.
Cognition and the Menopause
Cindy is a 52 year old woman who presents with feeling like she is losing her memory, can’t remember where she left things, and can’t find the right words at times. Her mother had Alzheimer’s disease and she is worried that she will develop this as well. She may also be more anxious and depressed with a loss of focus.
Dementia- ⅔ of cases of dementia are women – early treatment in perimenopause—- ongoing research.
Depression and anxiety increase with the loss of estrogen—-(Estrogen’s effect on the brain – increases synapses and connections in the hippocampus and prefrontal cortex., Reduces beta-amyloid deposition and improves clearance, Increases cerebral blood flow and metabolism)
Research ongoing with the Interaction of estrogen with APOE Genotype = genetic RF for Alzheimer’s
Management of Neurological Symptoms and Prevention of Cognitive Decline
Nutrition – as above, healthy food choices, reduce inflammation, healthy fats, oils.
Exercise the body – – increases blood flow to the brain (as does Saunas)
Exercise the brain – – learn new tasks, music, new skills
Stress management/ Sleep enhancement – I am a huge fan of this here, again reducing inflammation overall
Vitamins – as above.
Pharmacological options – referral to psychiatrist/neurologist/internist
Wellness – as above and also support groups, memory clinics.
Gastrointestinal Changes in perimenopause to menopause transition
Gabby is 48 and presents with bloating, constipation, increased gas distention, unable to tolerate some foods
A change in microbiome of the gut may alter food sensitivities
Loss of Estrogen can slow down the peristalsis of the intestines and reduce GI transit time and increase Gas distention and bloating .
Management of Gastrointestinal symptoms
Nutrition – reduce gas producing foods, balance fiber and magnesium
Exercise – daily – aerobic, stimulates the intestines.
Stress management (mind/gut connection), Sleep, linked to serotonin
Vitamins – add Magnesium, reduce calcium and iron (binding), inflammation may reduce absorption of nutrients
Pharmacological management per GI MD
Wellness – consider acupuncture, massage
Dermatological changes in the Menopause
Debbie is a 59 year old woman who presents with thinning of her hair, a new rash on her elbows, acne and overall dryness of her skin.
She is really bothered by her hair falling out which she describes in clumps.
Patients should have routine and regular skin checks
Alopecia is due to loss of estradiol, increased relative testosterone production with aging, can be autoimmune and accelerated due to perimenopause transition.
Management of Dermatological issues in the Menopausal patient
Nutrition – as outlined previously – healthy nutritious foods
Exercise to improve blood flow
stress/sleep to improve immune function.
Vitamins – Iron, Vitamin B12 with Biotin,
Pharmacological management: Spironolactone, Minoxidil for alopecia
Referral to dermatologist. Renova
Wellness – skin care routine. Routine and regular skin checks
Rheumatology/ autoimmune changes in the Menopausal patient
Remy complains of Increased joint aches, arthritis, autoimmune disorders, hives.
Nutrition –
Exercise-
stress/sleep –
Vitamins –
Meds – management per Rheumatologist.
Consider rheumatologist – psoriatic arthritis , lupus, lichen sclerosus