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Overview |
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Definition |
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Menopause is the cessation of regular menstrual cycles, a normal
physiological and biological event (unless from oophorectomy) that occurs in
women at an average age of 51. Today, 50 million women in the United States have
reached menopause. The experience of menopause varies enormously between
individuals and among cultural groups. While up to 80% of American women
experience hot flashes within a collection of symptoms, a study of Mayan Indians
found that no women experienced hot flashes. Although women's life expectancy
has greatly increased over time, the average age of menopause onset remains
constant. Most women will spend one-third of their life
postmenopausal. |
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Etiology |
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- Ovarian failure
- Depletion of oocytes
- Depletion of functional gonadotropin-sensitive ovarian
follicles—reduces and eventually eliminates estradiol
production, resulting in cessation of menses
- Estrone—predominant postmenopausal estrogen
is one-third as potent as estradiol
- Hysterectomy and certain medical treatments for endometriosis and
cancer
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Risk Factors |
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- Premature ovarian failure—menopause before
age 40; karyotypic abnormalities and autoimmune disorders need to be ruled
out
- Age
- Smoking—hastens follicular
depletion
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Signs and Symptoms |
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- Amenorrhea—the cessation of uterine bleeding
for more than one year is clinically determined to be menopause; average
duration is four years from early menstrual changes to complete cessation of
menses
- Vasomotor symptoms—including hot flashes
(flushing of face, neck, and upper trunk; may be accompanied by palpitations,
dizziness, headaches); night sweats (with subsequent depression and irritability
from insomnia); cold hands and feet
- Vaginal atrophy—dryness may result in
postcoital bleeding; vulvar pruritus
- Urinary tract atrophy—increased frequency,
burning, nocturia, incontinence
- Mood symptoms—depression, irritability,
tension; usually correlate with sleep disturbances
- Facial hirsutism (from androgens) and wrinkles (from lack of
estrogen)
- Osteoporosis—bone fractures possible; risk
increases with premature menopause
- Coronary heart disease (CHD)—twice as many
women die from CHD than cancer. Marked increase in susceptibility after
menopause.
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Differential
Diagnosis |
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- Pregnancy—perimenopausal women may neglect
to use contraception
- Endometrial cancer
- Excessive exercise—causing cessation of
menses
- Uterine leiomyoma
- Hypothalamic dysfunction
- Mood and anxiety disorders
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Diagnosis |
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Physical Examination |
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Unless there is premature menopause or concurrent illness, the patient
appears normal. The uterus may be smaller on bimanual
examination. |
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Laboratory Tests |
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- Follicle-stimulating hormone (FSH)—values
rise in response to estrogen decline; 40 mIU/mL is diagnostic of menopause; may
fluctuate daily until postmenopause; diagnoses premature ovarian failure; helps
rule out differential diagnosis
- Estradiol-17 beta decreases from 120 pg/mL to below 20 pg/mL; estrone
becomes the main circulating estrogen; eventually, estradiol results only from
estrone conversion
- Estrone—production decreases from 80 to 300
mg/day to 40 mg/day
- Androstenedione (primary androgen)—decreases
from 1,500 to 800 mg/mL; testosterone levels decline far less than estrogen
- Luteinizing hormone (LH)—maximum increase
two to three years postmenopause; abnormal pulse frequency and amplitude
patterns; levels drop below FSH levels
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Pathology/Pathophysiology |
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- Follicular atresia
- Thinning of vaginal epithelium
- Lack of estrogen decreases bone density and intestinal calcium
absorption
- Arteriosclerosis
- Osteoporosis
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Imaging |
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May be done for osteoporosis detection |
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Other Diagnostic
Procedures |
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Menopause is defined as a 12-month cessation of menses, usually with history
of vasomotor complications. FSH measurement is rarely used solely for diagnosis.
Commonly used procedures are endometrial sampling, Pap smears, and regular
pelvic exams. Endometrial biopsy for differential
diagnosis. |
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Treatment Options |
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Treatment Strategy |
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Estrogen replacement therapy can help prevent osteoporosis and coronary
artery disease. Serious side effects of hormone replacement therapy warrant
careful individual evaluation and consideration of alternatives. Supplementation
with calcium and other micronutrients and regular exercise help prevent these
conditions. |
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Drug Therapies |
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- Estrogen—relieves hot flashes and vaginal
atrophy and retards osteoporotic bone loss and fractures. Studies point toward
possible CHD and Alzheimer's disease prevention. Use the lowest effective dose.
Continuous administration avoids uterine bleeding. Estrogen use increases risk
of breast cancer, uterine (endometrial) cancer, thromboembolism, pulmonary
embolus, and gallbladder disease. Side effects include bloating, nausea,
adult-onset asthma, and breast tenderness.
- Conjugated equine estrogens (e.g., Premarin 0.625 mg/day, or 1.25
mg/day with severe vasomotor symptoms)—most commonly
used form; can cause metabolic changes in the liver; contraindicated with
obesity, smoking, hypertension or cholesterol, varicose veins
- Estradiol—most easily metabolized delivering
estrogen directly into the bloodstream; available in transdermal patch (e.g.,
Estraderm, 1.0 mg/day of estradiol, 0.05 mg/day of transcutaneous
estrogen)
- Vaginal creams—for urogenital atrophy, four
to six weeks for initial effect, then twice weekly
- Progesterone—may potentiate estrogen,
allowing for lower estrogen dosage (e.g., medroxyprogesterone, 2.5 to 10
mg/day); eliminates uterine cancer caused by estrogen therapy; may slow
osteoporosis but does not prevent CHD or urogenital atrophy; side
effects—bloating, depression, breast
tenderness
- Methyltestosterone—increases libido; may
decrease osteoporosis of the spine; 1.25 to 5.0 mg/day; side
effect—facial hirsutism
- Alendronate—equally effective treatment for
osteoporosis prevention
- Lipid-lowering drugs and aspirin—alternative
treatment for CHD
- Estriol—weaker form of estrogen; best used
in combination with 10% each estrone and estradiol (e.g., Tri-estrogen 2.5 to 5
mg/day, therapeutically equivalent to 0.625 to 1.25 mg/day conjugated estrogen);
add progesterone for women with intact uterus; early studies show fewer adverse
effects than other estrogens
- Estrogel—rubbed on abdomen and absorbed into
the body; commonly used in France
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Complementary and Alternative
Therapies |
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Alternative therapies may be effective alone or in conjunction with standard
treatment. Alternative medicine has much to offer for improving cardiovascular
health and preventing osteoporosis. Relaxation techniques, stress management,
yoga, and meditation can help with perimenopausal symptoms. Weight-bearing and
aerobic exercise are crucial for cardiovascular health and osteoporosis
prevention. Exercise increases endorphin release, aiding pain relief and mood
elevation. Walking, swimming, and biking are less stressful on the
joints. |
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Nutrition |
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- Soy (25 to 50 mg soy/day) contains soy isoflavones (phytoestrogens);
studies suggest relief of hot flashes and vaginal atrophy, and increased
protection from osteoporosis and breast cancer.
- Vitamin E (400 to 1,600 IU/day) can balance vasomotor instability,
decrease hot flashes, and is cardioprotective. High doses may be contraindicated
in hypertension.
- Calcium/magnesium (1,000/500 mg/day for women taking estrogen and
1,500/750 mg/day for those who are not) is best absorbed with meals and
sufficient gastric juices. Citrate or citramate forms may be the most absorbable
forms.
- Avoiding smoking, alcohol, caffeine, and spicy foods may help
decrease hot flashes.
- A combination of vitamin C (1,200 mg), hesperidin (900 mg), and
hesperidin methylchalcone (900 mg) relieves hot flashes in a majority of
women.
- Gamma-oryzanol (from rice bran oil) 300 mg/day gives partial or total
relief of hot flashes in over 80 percent of
users.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
- Black cohosh (Cimicifuga racemosa) relieves vasomotor symptoms
and depression; Remifemin is the most tested extract of black cohosh. Toxicology
studies show long-term use to be safe; side effect may be mild stomach upset;
historic use in climacteric depression; 2 mg/day
- Chaste tree (Vitex agnus cactus) for irregular menstrual
cycles; normalizes pituitary function; may take up to six months for full
therapeutic effect
- Angelica (Angelica archangelica) relieves vasomotor
symptoms
- Licorice (Glycyrrhiza glabra) is an estrogen-balancing herb,
especially with chronic stress (regulates cortisol); not for use with
hypertension; 250 mg tid, 30 to 60 drops tincture tid, or 1 cup of tea
tid
- Ginkgo (Ginkgo biloba) improves memory and peripheral
circulation, to treat depression and prevent Alzheimer's disease; may take up to
12 weeks for full effect; 120 mg bid to
tid
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing, use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Mulimen—German combination remedy
(chasteberry, black cohosh, St. John's wort, cuttlefish ink) shown effective for
hot flashes in 1992 study
- Ferrum phosphoricum, graphites,
lycopodium—for symptoms occurring during sexual
intercourse
- Amyl nitrosum, Lachesis, Sulphur—for
hot flashes
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Physical Medicine |
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Kegel exercises increase pelvic muscle tone, which helps to prevent
incontinence and bladder or uterine prolapse. |
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Acupuncture |
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Acupuncture enhances endorphin release and stimulates kidney function. May
also help to balance hormones and relieve vasomotor
symptoms. |
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Massage |
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Massage increases circulation and promotes general relaxation. Use
water-soluble nonestrogen lubricants, vegetable oil, or vitamin E oil for
vaginal atrophy. |
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Patient Monitoring |
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Women should have an annual Pap smear and
mammography. |
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Other
Considerations |
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Prevention |
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Menopause is not a disease but a natural process of aging. Certain symptoms
may be prevented and more serious complications avoided with appropriate
treatment. |
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Complications/Sequelae |
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Possible complications from estrogen use include the
following.
- Breast cancer—no correlation with <5
years' use
- Endometrial cancer—eliminated by concurrent
progesterone use
- Thromboembolism—30 in 100,000
risk
- Pulmonary embolus
- Pancreatitis—use of transdermal patch
obviates most of the risk
- Gallbladder disease—twice as
prevalent
- Adult-onset asthma—twice as
prevalent
Complications possibly prevented from estrogen use include the
following.
- Decrease in vasomotor symptoms
- Osteoporosis—slows progression, reducing
fractures 30% to 50%
- CHD—observational studies indicate decreased
CHD; not confirmed by randomized clinical trials
- Alzheimer's disease—effects on central
nervous system may decrease risk; unproven
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Prognosis |
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All symptoms of menopause will progress more slowly and risks for several
diseases can be reduced if managed appropriately.
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References |
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Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:291-292.
Blumenthal M, ed. The Complete German Commission E Monographs:
Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:108, 466.
Devine A, Dick IM, Heal SJ, et al. A 4-year follow-up study of the effects of
calcium supplementation on bone density in elderly postmenopausal women.
Osteoporosis Int. 1997;7:23-28.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:647-648, 871-872.
Kistner RW, ed. Kistner's Gynecology: Principles and Practice. 6th ed.
St. Louis, Mo: Mosby-Year Book; 1995.
Murray MT. The Healing Power of Herbs: The Enlightened Person's Guide to
the Wonders of Medicinal Plants. Rocklin, Calif: Prima Publishing;
1995:163-164.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998.
Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the
premenstrual syndrome: effects on premenstrual and menstrual symptoms.
Premenstrual Syndrome Study Group. Am J Obstet Gynecol.
1998;179:444-452.
Villa ML, Packer E, Cheema M, et al. Effects of aluminum hydroxide on the
parathyroid-vitamin D axis of postmenopausal women. J Clin Endocrinol
Metab. 1991;73:1256-1261.
Vorberg G. Treatment of menopause
symptoms—successful hormone-free therapy with
Remifemin®. ZFA. 1984;60:626-629.
Weiss RF. Herbal Medicines. Beaconsfield, England: Beaconsfield
Publishers; 1998:317-319. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |