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Menopause and Aging. Sylvia Ziegenbein, MD M3 Student Lecture 2007. Objectives. Define menopause Describe associated changes and symptoms Treatment options for bothersome symptoms Review physiologic changes of aging, specific age related problems and screening in elderly. Case #1.

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menopause and aging

Menopause and Aging

Sylvia Ziegenbein, MD

M3 Student Lecture

2007

objectives
Objectives
  • Define menopause
  • Describe associated changes and symptoms
  • Treatment options for bothersome symptoms
  • Review physiologic changes of aging, specific age related problems and screening in elderly
case 1
Case #1
  • 35 yo G1 P0101 female presents with c/o hot flashes and amenorrhea for 12 months. She doesn’t know why this is happening, her sxs are worsening. She wants your help.
  • DDx
  • Tests
case 2
Case #2
  • 45 yo G2 P2002 female presents with c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. She doesn’t know why this is happening, she wants your help. By the way, she wants your help to stop smoking also.
  • DDx
  • Tests
case 3
Case #3
  • 65 yo WF presents to start HRT. She heard it would help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an occasional hot flash. She is 5’4”, 108 lbs. By the way, she had a wrist fx 2 yrs ago takes her Viactiv faithfully.
case 4
Case #4
  • 49 yo WF presence b/c she can’t stand her hot flashes anymore. She can’t sleep very well b/c she wakes up 3 times a night drenched with sweat. She is an executive at First National Bank. She has a history of breast cancer 2 years ago. “Please Dr. Ziegenbein, I need some hormones or something.”
case 5
Case #5
  • 55 yo BF returns to discuss stopping her HRT. She has been taking it for 5 years now with good relief of her vasomotor sxs.
case 6
Case #6
  • 53 yo WF began continuous HRT 4 wks ago. She is now having some vaginal spotting after being amenorrheic for 14 months. She is concerned.
menopause
Menopause
  • Definition
  • Average Age
  • Related Sxs
classification system
Classification System
  • STRAW System
    • Help communication
slide11

Menopause Terminology: STRAW* Staging System

Final Menstrual Period

0

Stages:

-2

-1

+1

+2

Terminology:

Menopausal Transition

Postmenopause

Early

Late†

Early†

Late

Perimenopause

Duration of Stage:

Variable

4 yrs

Untildemise

a

b

1 yr

Menstrual

Cycles:

Variable cycle length (>7 daysdifferent from normal)

2 skippedcycles and aninterval of amenorrhea(60 days)

None

Amen. × 12 mos.

*STRAW = Stages of Reproductive Aging Workshop.

†Stages most likely to be characterized by vasomotor symptoms.

Soules MR, et al. Menopause. 2001;8:402-7.

whi hrt vs placebo
WHI: HRT vs Placebo
  • Large prospective RCT, 2002, JAMA
  • 16,608 postmenopausal women (50-79 y.o.)
        • Ave age at enrollment = 63 yrs
    • Two arms:
        • Estrogen + Progestin (Prempro 0.625/2.5), n=8506
        • Placebo, n=8102
    • Outcomes measured:
        • Primary : Coronary heart disease (CHD) and invasive breast cancer
        • Secondary : stroke, pulmonary embolism, DVT, endometrial CA, colorectal CA, hip and vertebral fractures and death from other causes
hrt arm stopped early @ 5 2 yrs
HRT Arm: Stopped Early @ 5.2 yrs
  • Invasive Breast Cancer = 38 vs 30/10,000 person yrs (HR 1.26)
  • CHD = 37 vs 30/10,000 (HR 1.29)
  • Stroke = 29 vs 21/10,000 (HR 1.41)
  • Venous Thromboembolic disease = 34 vs 16/10,000 (HR 2.11)
  • Colorectal cancer = 10 vs 16/10,000 (HR 0.63)
  • Hip fracture = 10 vs 15/10,000 (HR 0.66)
  • Vertebral fracture = 9 vs 15/10,000 (HR 0.66)
  • No change in endometrial and lung cancer
whi estrogen only vs placebo
WHI: Estrogen Only vs Placebo
  • WHI 2004: JAMA
  • 10,739 postmenopausal women
    • s/p hysterectomy (50-79 y.o.)
    • Ave. age @ enrollment = 63.6 y.o.
  • Two arms:
    • Estrogen (Premarin 0.625 mg), n=5310
    • Placebo, n=5429
  • Outcomes:
    • Primary: CHD and invasive breast cancer
    • Secondary: stroke, pulmonary embolism, DVT, colorectal cancer, hip/vertebral fractures and death from other causes
outcomes
Outcomes
  • Ave. follow up 6.8 years (Hazard Ratio)
    • Invasive breast Cancer = 26 vs 33/10,000 person yrs (0.77)
    • CHD = 49 vs 54/10,000 (0.91)
    • Venous Thromboembolic disease = 28 vs 21/10,000 (1.33)
    • Stroke = 44 vs 32/10,000 (1.39)
      • Fatal = 4 vs 4/10,000 (1.13)
      • Nonfatal = 32 vs 23/10,000 (1.39)
    • Colorectal cancer = 17 vs 16/10,000 (1.08)
    • Hip fracture = 11 vs 17/10,000 (0.61)
    • Vertebral fracture = 11 vs 17/10,000 (0.62)
menopausal complaints treatments
Menopausal Complaints: Treatments
  • Hormones vs non-hormones vs herbals
    • Efficacy
hormones contraindicated
Hormones Contraindicated
  • Breast CA
  • Endometrial CA
  • Undiagnosed vaginal bleeding
  • CHD
  • Venous thrombosis
  • Stroke
  • Pregnancy
  • What is not here, that is a CI on OCP’s?
demographics
Demographics
  • 34 million elderly now
  • 69 million in 2030
  • Gerontology
  • Health in the aged
    • Absence of ds
    • Maintain function and comfort
    • Presence of satisfactory support systems
body composition and homeostasis
Body Composition and Homeostasis
  • Decrease muscle mass
  • Increase body fat
  • Changes volume of distribution
  • Impaired baroreceptor
    • Orthostatic hypotension
  • Impaired thermoregulation
cardiovascular
Cardiovascular
  • Decrease LV compliance
    • Increased reliance on atria
  • More LVH
    • Stiffer arteries
  • Decreased beta-adrenergic responsiveness
    • Decreased max. HR with exercise
pulmonary
Pulmonary
  • Decreased elastic recoil, airways collapse earlier
  • Decreased forced vital capacity, functional residual capacity, residual volume, FEV1
  • Decreased ventilatory response and chemoreceptor function
    • Increased hypoxia and hypercapnia
renal
Renal
  • Decreased mass, # of glomeruli
  • Increased glomerulosclerosis
  • GFR slowly decreases
  • CrCl maintains
  • Decreased Na+ rentention, decreased responsiveness to AVP; less concentration of urine
  • Decreased thirst and drink response
  • Increased dehydration
endocrine
Endocrine
  • Decreased glucose tolerance
    • Independent of obesity and inactivity
    • FG decreases 1 mg/dL/decade
  • Increased insulin resistance
  • Decreased GH, IGF-1
    • Give elderly men GH, increases lean body mass
immunologic
Immunologic
  • Decreased T-cell activity
  • Decreased Ab response to foreign antigen
  • Increased autoantibodies
specific geriatric issues

Specific Geriatric Issues

Other assessments to be made.

cognitive function
Cognitive Function
  • Normal decline
  • Dementia
    • Alzheimer’s
    • Vascular
    • Others
      • Depression
      • Medications
      • EtOH
  • MMSE
sensory
Sensory
  • Visual
  • Auditory
  • Balance
incontinence
Incontinence
  • Types
  • Risk factors
  • Assess
  • Tests
  • Treatment
types of incontinence
Types of Incontinence
  • Urge
  • Stress
  • Functional
  • Overflow
  • Mixed
fall risks
Fall Risks
  • Intrinsic
    • Person oriented issues…
    • Mobility
    • “Get up and go” test
  • Extrinsic
    • Environment
polypharmacy
Polypharmacy
  • Medication List
    • Drug-drug interactions
    • Altered pharmacokinetics, pharmacodynamics
    • Herbals
    • OTC
osteoporosis
Osteoporosis
  • Screening
  • Risk Factors
  • Treatments
others
Others
  • Abuse
  • Sexuality
  • Vaccinations
  • Financial
  • Support System
  • Driving
screening
Screening
  • Thyroid
  • Cancer
    • Sxs
    • Pap
    • Mammogram
    • Colonoscopy
  • Lipids
questions

Questions???

Thank you very much for your participation!!

Good luck on your shelf!