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 2012
Key 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
Defining Menopause
Final Menstrual Period
-5
-4
-3
-2
-1
0
Stages:
+1
+2
Terminology:
Reproductive
Early
Peak
Menopausal Transition
Late
Postmenopause
Late*
Early
Early*
Late
Perimenopause
Duration of
Stage:
Menstrual Cycles:
Endocrine:
variable
variable
to
regular
normal FSH
variable
variable cycle
length
regular
(>7 days
different from
normal)
FSH
* Stages most
2 skipped
cycles and an
interval of
amenorrhea
1
yr
Amen x
12 mos
FSH
likely to be characterized by vasomotor symptoms
¥ STages of Reproductive Aging Workshop
Adapted from Soules et al., Fertility and Sterility, VOL. 76, NO. 5,
November 2001, p. 875
until
demise
4 yrs
none
FSH
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
– Nulliparity
 Hysterectomy*
 Excessive alcohol intake*
– *=possible assn
Menopause
METABOLIC CHANGES
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
Fasting sugar
100-126
or
HgA1c 5.86.4
HDL under 50
BP over 135
or
on blood
pressure Rx
TG over 150
Waist over 35
inches
Metabolic Syndrome is
a warning shot…
• 5x increased risk of Diabetes
• 3x increased risk of stroke or heart attack
Menopause
CARDIOVASCULAR RISKS
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
% of level at -6 months before menopause
110
100
Menopause
90
-24
-18
-6
-12
0
Months
Jensen J, et al. Influence of menopause on serum lipids and lipoproteins. Maturitas 1990; 12:321-31
6
% of level at -6 months before menopause
LDL Cholesterol Levels After Menopause
Menopause
110
100
90
-24
-18
-6
-12
0
Months
Jensen J, et al. Influence of menopause on serum lipids and lipoproteins. Maturitas 1990; 12:321-31
6
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
Menopause
BONE HEALTH
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
Menopause
COMMON SYMPTOMS
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
Prevalence of Hot Flashes
Menopause
Years Before
Years After
3
2
1
1
Kronenberg F. Ann N Y Acad Sci. 1990;592:52-86.
2
3
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 Wilson
Freida Toler, Nurse Practitioner
HerCare Lecture Series
Aftershocks of Fifty Shades of Gray
January 18 at 4:00