Let’s Talk About Menopause

Joanna Wilson, D.O.Board-Certified Internal Medicine

North American Menopause Society Certified Practitioner

Proportion of average female lifespan spent in menopause years: 1/3 to 1/2

Menopause Update 2012Key Points

• Recognize the metabolic changes of the body due to menopause

• Appreciate the emergence of cardiovascular risk factors in menopause

• Understand the impact of menopause on bone density

• Discuss the common symptoms of menopause

Stages: -5 -4 -3 -2 -1 +1 +2

Terminology:

Reproductive Menopausal Transition Postmenopause

Early Peak Late Early Late* Early* Late

  Perimenopause  

Duration of Stage:

variable variable1yr

4 yrsuntil

demise

Menstrual Cycles:variable

toregular

regular

variable cycle length

(>7 days different from

normal)

2 skipped cycles and an

interval of amenorrhea

Amen x 12 mos none

Endocrine: normal FSH FSH FSH FSH

0

* Stages most likely to be characterized by vasomotor symptoms¥ STages of Reproductive Aging Workshop

Final Menstrual Period

Defining Menopause

Adapted from Soules et al., Fertility and Sterility, VOL. 76, NO. 5, November 2001, p. 875

Determinants of Age at Menopause (Average Age =51 years)

Unaffected by:– Race – Socioeconomic status– Number of pregnancies– Oral contraceptive use– Education– Physical characteristics– Age of menarche– Age of last pregnancy

Affected by: Smoking– Family pattern– Chemotherapy– NulliparityHysterectomy*Excessive alcohol intake*

– *=possible assn

METABOLIC CHANGESMenopause

Weight Gain in Menopause“Metastatic Fat”

• Body composition changes: muscle fat• Resting Metabolic Rate drops by 250 cal/d• “Metastatic fat”– More inflammation in blood vessels– Accumulates in liver and muscle– Increases risk of breast cancer

“I don’t know how I gained all of this weight!”

• Decrease in activity level• Sleep deprivation increases salt and carb

cravings- 600 cal/day increase• Less attention to diet

Where you gain weight matters

Metabolic Syndrome

HDL under 50Fasting sugar 100-126 or HgA1c 5.8-6.4

BP over 135 or on blood pressure Rx

Waist over 35 inches

TG over 150

Metabolic Syndrome isa warning shot…

• 5x increased risk of Diabetes• 3x increased risk of stroke or heart attack

CARDIOVASCULAR RISKSMenopause

Hypertension: Gender and Age Effects

Age Men (%) Women (%)

20-34 11.1 6.8

35-44 25.1 19.0

45-54 37.1 35.2

55-64 54.0 53.3

65-74 64.0 69.3

75 and older 66.7 78.5

Heart Disease and Stroke Statistics 2012:AHA. Circulation Epub 12.15.2011

HDL Cholesterol Levels After Menopause

90

100

110

-24 -18 -12 -6 0 6Months

% o

f le

vel a

t -6

mo

nth

s b

efo

re m

eno

pau

se

Menopause

Jensen J, et al. Influence of menopause on serum lipids and lipoproteins. Maturitas 1990; 12:321-31

LDL Cholesterol Levels After Menopause

90

100

110

-24 -18 -12 -6 0 6Months

% o

f le

vel a

t -6

mo

nth

s b

efo

re m

eno

pau

se Menopause

Jensen J, et al. Influence of menopause on serum lipids and lipoproteins. Maturitas 1990; 12:321-31

CAN’T WE USE ESTROGEN AFTER MENOPAUSE TO PREVENT HEART DISEASE?

The Women’s Health Initiative Changed How We Felt

About Hormones

Women’s Health Initiative (continued)

“The Timing Hypothesis”• Arteries are healthier in the presence of a woman’s

estrogen, progesterone, testosterone• The absence of hormones ages arteries

• It is likely that early use of hormones can prevent or improve early artery aging

• Starting hormones years after menopause worsens risks of heart attack and stroke

Women’s Health Initiative vs Kronos Early Estrogen Prevention

WHI• Systolic BP >120mmHg =

64%• Ever smokers = 50%• Average age 63

KEEPS• Systolic over 120 = 46%

• Ever smokers = 20% • Average age 53

Kronos Early Estrogen Prevention Study

What can we do now?Fitness Not Fatness

• Avoid eating out• Avoid sugar (soda,

desserts)• Diet type for body type• Cardio exercise for heart

health, mood– 70 min/week vigorous

exercise– 120 min/week moderate

exercise• Resistance training for

weight loss, bone health

BONE HEALTHMenopause

Risks for low peak bone density and loss with age

• Smoking• Sedentary lifestyle• Low body weight• Chronic steroids• Rheumatoid Arthritis• ≥3 Alcoholic drinks/day• Early menopause without hormone therapy

afterwards

COMMON SYMPTOMSMenopause

Years Before Years AfterMenopause

Prevalence of Hot Flashes

3 2 1 1 2 3

Hot Flashes and Night Sweats

• > 75% of women report hot flashes within the 2-year period surrounding their menopause

• 25% remain symptomatic for > 5 years

Kronenberg F. Ann N Y Acad Sci. 1990;592:52-86.

The Holy Grail: A Good Night’s Sleep

• Racing thoughts• Night sweats• Snoring• Apnea• Stomach acid reflux• Aches and pains• Frequent urination• Restless legs

“Doc, I think I’m losing my mind.”

forgetfulness “cloudy” thoughts “Menopause Fog” inattention• Often due to variations in estrogen• Multi-tasking, depression, sleep deprivation• Try: daily physical exercise, mental exercise,

quality sleep

Psychological Symptoms of Menopause

• Anxiety is frequent• Stressors: children leaving (or returning!) ill

parents, work, financial, marriage, physical changes

• Menopause does not cause depression– Depression is more likely to recur if present prior to

menopause

Stress Management• Meditation• Yoga• Daily moderately vigorous exercise• Counseling, support groups• Antidepressants• Vitamin D, folic acid• Nutrition• Resilience

Hair Changes in Menopause

• Female pattern hair loss (FPHL): thinning on the crown– Low estrogen with

relative high testosterone state

– Treatment may include spironolactone or topical minoxidil*, biotin 3mg/d

Dental Health During Menopause

• Fluctuations of sex hormones around menopause cause changes in gums and teeth

• Rate of systemic bone loss is a predictor of tooth loss

Pelvic tissue changes• Ureteral thickening recurrent bladder

infections, increased urinary frequency• Vaginal pH rises alters vaginal bacterial

balance vaginal infections• Loss of pelvic floor tone incontinence,

muscle spasms

Last, But Not Least: Sex

• Majority of women state their sexual relationships did not change during menopause

• Most common complaints: low libido, vaginal dryness

• Sexually Transmitted Infections• Contraception

North American Menopause Society Gallop Poll 1998.

Vaginal Changes (Ugh!)

• Mild : Skin thinning, smoothing and loss of elasticity

• OTC moisturizers: vitamin E, OTC creams/ suppositories• OTC lubricants: olive oil, water, silicone

• Moderate: Labial and perineal fusion, ureteral thickening and whitening, and dryness

• Rx: Low dose estrogen tablets, cream, ring inside the vagina

Use it or lose it!

Start the next 40 years off right!

• Weight management• Cholesterol• Blood pressure• Avoid smoking• Stress control• Nutrition• Sleep• Fitness

Learn More About Menopause

• North American Menopause Society at menopause.org

Dr. Joanna WilsonFreida Toler, Nurse Practitioner

HerCare Lecture Series

Aftershocks of Fifty Shades of GrayJanuary 18 at 4:00