Menopause Definition

Cessation of menses for at least one full year in a previously menstruating female.

Causes

• Normal aging
• Premature ovarian failure (as in menopause before age 40)
• Surgery
• Chemical or medication
• Radiation

History

• Mean age at onset 51 years
• Usually occurs when a woman is between 45 and 55 years of age
• Irregular menstrual cycles
• Initially, cycles may be short, with occasional menorrhagia
• Later, cycles become longer and more spaced out, with scant menstrual flow
• Eventually, menstruation ceases altogether
• Hot flushes and night sweats may occur
• Vaginal dryness, irritation, itching may be present
• Painful intercourse may be present
• Urinary urgency, frequency and dysuria may be present (because of urethral atrophy)
• Mild-to-severe mood swings may be present
• Anxiety, nervousness
• Sleep disturbances
• Depression may occur

Physical Findings

• Mood and affect: evidence of depression
• Breast atrophy
• Vaginal introitus smaller
• Vaginal walls smooth, thin, pale, dry
• Cervix small
• Uterus feels small
• Ovaries not palpable

Differential Diagnosis

• Abnormal vaginal bleeding
• Infectious cystitis
• Infectious vaginitis

Complications

• Difficulties in adjusting to this new stage of life
• Anxiety
• Depression
• Osteoporosis

Diagnostic Tests

• Determine levels of follicle-stimulating hormone (FSH) and thyroid-stimulating hormone (TSH) (if diagnosis is unclear or if the client is less than 40 years of age)
• Bone density testing (initiated by physician)
• Screening mammography every 2 years

Management

Goals of Treatment

• Offer support and reassurance
• Prevent complications

Appropriate Consultation

Arrange elective consultation with a physician if symptoms are severe, complications are present, client is less than 40 years of age or client desires hormone replacement therapy (HRT).

Nonpharmacologic Interventions

Client Education

• Explain process as a normal part of aging
• Assess client's feelings about aging
• Provide a supportive environment rather than dismissing symptoms, as these symptoms are real to the client
• Discuss the risks and benefits of HRT
• Encourage balanced nutrition and regular physical activity for physical and mental well-being
• Advise client to return to clinic if vaginal bleeding occurs at any time after menopause
• Suggest use of lubricants before coitus if intercourse is painful

Pharmacologic Interventions

Herbs and Vitamins that May Be Useful in Menopause

Evening Primrose (Primrose Oil)

Active ingredients: gamma-linolenic acid (GLA) and linoleic acid

The seed oil is a good source of GLA, which is an essential fatty acid (a nutrient that the body cannot make but that is essential to good health). Evening primrose oil has been used for premenstrual syndrome (PMS) and mastalgia (sore breasts). There are no known contraindications or drug interactions.

Flaxseed Oil (Linseed Oil)

Active ingredients: fatty acids (palmitic, steric, oleic, linoleic and linolenic acids)

Flaxseed oil is a good source of essential fatty acids (a nutrient that the body cannot make but that is essential to good health). Flaxseed oil is rich in GLA and is used by many for PMS and breast tenderness. There are no reports of toxic effects when used at recommended doses.

Vitamin E (400-1200 IU/day)

Food sources: polyunsaturated vegetable oil, seeds and nuts

Vitamin E is an antioxidant. Studies done in the late 1940s showed that vitamin E relieved hot flashes and postmenopausal vaginal dryness, but more recent studies are lacking. There are other benefits. It is known from the Nurses Health Study that women who took vitamin E over a 2-year period reduced their risk of fatal heart attacks by 40%.

Vitamin E potentiates (causes a greater effect of) anticoagulant drugs such as coumadin and acetylsalicylic acid (ASA).

Vitamin B₆ (50 mg PO, once daily)

Food sources: whole grains, bananas, potatoes, nuts and seeds, cauliflower

Pyridoxine is involved in the production of brain hormones (neurotransmitters). More than 50 other chemical processes in the body depend on pyridoxine. Vitamin B₆ levels can be low in people with depression and in women taking estrogen in the form of birth control pills or hormone replacement therapy. It is safe to use when taken in recommended doses.

Calcium (500 mg PO, 1-3 times/day) and vitamin D (400-800 IU PO od) are recommended if diet is inadequate in calcium-rich foods.

Calcium may be contraindicated in patients with a history of renal stones.

Source: Canadian Consensus Conference on Menopause and Osteoporosis (Society of Obstetricians and Gynaecologists of Canada, 1998)

Hormone Replacement Therapy

HRT is always initiated by a physician. There are several regimens and several delivery methods (e.g., pills, patches, creams for conjugated estrogens). One example, for a postmenopausal woman with intact uterus:

conjugated estrogens (Premarin) (B class drug), 0.635 mg PO once daily

and

medroxyprogesterone (Provera) (B class drug), 10 mg PO once daily

Another example, for a postmenopausal woman without uterus:

conjugated estrogens (Premarin) (B class drug), 0.635 mg PO once daily

Hormone replacement therapy should be continued for 7-10 years for the most benefit in preventing loss of bone density and for its potential cardioprotective benefits.

Monitoring and Follow-Up

• Follow-up 1-2 months after beginning any therapy for menopause, then follow every 6 months
• Monitor for signs of osteoporosis, abnormal uterine bleeding