Upload
gladys-fowler
View
212
Download
0
Embed Size (px)
Citation preview
By 2010, 45% of American women will be over age 50
Natl Center for Health StatisticsNatl Center for Health Statistics
Perimenopausal Transition Years100
75
50
25
0
30 35 40 45 50 55 60
Age (years)
PostmenopauseReproductive
Years
Wom
en (
%)
Changes Prior to Menopause
Anovulatory cycles
or Menstrual cycle length
FSH level (day 3)
Inhibin B
1. Klein NA, Soules MR. Clin Obstet Gynecol. 1998;41:912-920.2. Munster K et al. Br J Obstet Gynaecol. 1992;99:422-429.
Perimenopause• Time of transition characterized by unstable endocrine
physiology and highly variable, unpredictable hormone profiles1
• Although cycle length begins to shorten, potential for ovulation and pregnancy is preserved for a number of years1,2
The Perimenopausal Transition: Endocrine Changes
Mean Circulating Hormone LevelsMean Circulating Hormone Levels
Adapted from Speroff, Glass, and Kase. Clinical Gynecology and Endocrinology. 6th ed.Williams & Wilkins;1999:653.
8070
6050403020100
FSH &LHIU/L
EstradiolEstronepg/mL
2001601208040
044 46 48 50 52 54 56 58
Age (years)
Menopause
FSH
LH
Estradiol
Changes Associated WithDeclining Estrogen Concentrations
• Hot flushes
• Urogenital atrophy
• Mood changes
• Changes in cognitive function
• Bone loss
• Changes in skin appearance
• Increase in risk of cardiovascular disease
• Physiologic changes of the eye
Symptoms
• Early phase
– Breast tenderness
– Irregular menstruation
– Irritability
– Loss of sense of wellness
– Hot flashes/night sweats
– Sleep disturbance
• Late phase
– Cognitive dysfunction
– Irregular and abnormal flow
– Sexual dysfunction
– Somatic symptoms increase
When Does Perimenopause Occur?
Average 1 Range*
Age of Onset (y) 46 39-51
Duration (y) 3.8 2 2-8
*95% of women.1 Adapted from Speroff, Glass, and Kase. In: Clinical Gynecology and Endocrinology. 6th ed.Williams & Wilkins;1999:653.2 McKinley Maturitas 1992; 14: 103-115
Age of Menopause
Median age of natural menopause (y)1,2
Overall 51.1-51.4
Smokers 1 to 2 years younger
Likelihood of being menopausal by1,2
Age 50 y ~30%
Age 55 y* 80%
*May be more appropriate than age 50 for OC discontinuation.1. Stanford JL et al. J Chron Dis. 1987;40:995-1002.2. McKinlay SM et al. Ann Intern Med. 1985;103:350-356.
Menstrual Cycle Changes:
Hallmark of Perimenopause
Changes in Cycle Length During Perimenopause
Menstrual Cycle Length ShortensMenstrual Cycle Length Shortens
35
30
25
15 20 25 30 35 40 45
Age (years)
Mean
5th, 25th, 50th, 75th,and 95th centile values
Cyc
le L
eng
th(d
ays)
Adapted from Munster K et al. Br J Obstet Gynaecol. 1992;99:422-429.
Menstrual Cycle Changes:Hallmark of Perimenopause
• Usually shorter cycle length (eg, by 2 to 7 days)– longer or irregular less common
• Changes in quality – Heavier initially, then lighter– Spotting prior to menses
Adapted from Nachtigall LE. Clin Obstet Gynecol. 1998;41:921-927.
Vasomotor InstabilityDuring Perimenopause
“Hot flashes are one of the chief menopausal complaints for which women in Western
societies seek medical treatment.” 1
1. Kronenberg F. Ann N Y Acad Sci. 1990:592:52-86.
Vasomotor InstabilityDuring Perimenopause
• ~ 85% of perimenopausal women experience vasomotor instability
– hot flushes, night sweats, sleep disturbances
• Intensity, duration, and frequency highly variable
– 1-2 to 40 flushes/day
Nachtigall LE. Clin Obstet Gynecol. 1998;41:921-927.
Menstrual StatusMenstrual Status % Reporting Hot Flashes% Reporting Hot Flashes
PremenopausalPremenopausal** ~10 ~10
PerimenopausalPerimenopausal†† ~30 – 85% ~30 – 85%
Recently postmenopausalRecently postmenopausal ~20 – 90%~20 – 90%
4 years postmenopause4 years postmenopause ~20 – 60%~20 – 60%
Vasomotor InstabilityDuring Perimenopause
* Menstruation within the 3 prior months with no change in regularity of cycle.†3 to 11 months of amenorrhea or increased menstrual irregularity.1. McKinlay SM et al. Maturitas. 1992;14:103-115.2. Kronenberg F. Ann N Y Acad Sci. 1990:592:52-86.3. Nachtigall LE. Clin Obstet Gynecol. 1998;41:921-927
Serum Concentrations of Ovarian Hormones
Premenopause (mean) Postmenopause (mean)
Estradiol (pg/mL) 50-400 8-35 (<25)
Estrone (pg/mL) 30-300 20-60
Testosterone (ng/dL) 20-50 (35) 30
Androstenedione (ng/dL) ~130 ~50
Ovaries produce more androgen than estrogen.
Consequences of MenopausalHormone Deficiency
Last period
Age (year)
Bone loss/osteopenia
40 90+45 5550 60 65 70 75 80 85
Menopause symptoms
Sexual complaints
Urogenital atrophy and symptoms
Vascular and heart disease
Osteoporosis
• Hot flushes/night sweats
• Palpitations
• Sleep disturbance
• Chest pressure
• Shortness of breath
• Headaches
• Numbness
• Fatigue
• Weakness
• Joint pain
• Decreased sexual desire
• Vaginal dryness and painful intercourse
• Loss of urinary control
• Memory loss
• Anxiety
• Depression
The Menopausal Syndrome
Prevalence of Vasomotor Complaints
Oldenhave A, et al. Am J Obstet Gynecol. 1993;168:772-780.
Severity
0 Absence
1
2
3-4
5-6 Moderate/Severe
100
75
50
25
0
Regular menstrual bleeding
Pre/perimenopause(months since last
menstrual bleeding)
Postmenopause (years since last menstrual
bleeding)
<1 1-3 3-6 6-12 1 2 43 5 6-7 8-10 >10
Rep
orti
ng
Com
pla
ints
(%
)
Genitourinary Symptoms Associated With Menopause
Genital
• Irritation, burning, pruritus
• Leukorrhea
• Dyspareunia
• Decreased vaginal secretions
• Shortening/lessening of vaginal distensibility
Urinary
• Frequency, urgency
• Dysuria
• Nocturia
• Incontinence*
*Controversial.
Vaginal Cytology
Premenopause Postmenopause
Effect of Estrogen on Vaginal Symptoms
E2 = 17 ß-estradiol; CEE = conjugated equine estrogens.
Rioux JE, et al. Menopause. 2000;7:156-161.
Vaginal symptoms score: 0 = none, 1 = mild, 2 = moderate, 3 = severe
0.0
0.5
1.0
1.5
2.0
0 2 12 24
Mea
n C
omp
osit
e Sc
ores
Weeks of Treatment
Vaginal tablets E2 25 g (n = 80)
Vaginal cream CEE 1.25 mg (n = 79)