Menopause
VETERANS HEALTH ADMINISTRATION
Objectives
Define menopause and perimenopause
Answer patient questions and provide education for
common symptoms and treatment options
Appropriately triage women presenting with
menopause-like symptoms
VETERANS HEALTH ADMINISTRATION
Nursing Goals
Clarify
• Rule out
emergency
conditions
- Cardiac
- Infection
- Hypoglycemia
- Med reaction
- Respiratory
• Rule out conditions
needing F/U
VETERANS HEALTH ADMINISTRATION
Identify
Potential
Causes
• Determine
impact on the
Veteran
- Physical
- Emotional
- Psychosocial
Prioritize
Urgency
• Resources
• Education
• Support
Case Study 1
A 47-year-old woman Veteran
presents at your clinic
complaining of severe and
frequent hot flashes. She’s
also noticed several months of
irregular menstrual cycles. She
wants more information.
VETERANS HEALTH ADMINISTRATION
Perimenopause
Menopause
Premature
Menopause
• Transition from regular ovulatory cycles
toward permanent infertility
• Begins at different ages, even in the 30’s. May
last for years. Includes 1 year after last cycle.
• Irregular cycles and menopause-like symptoms
• Permanent cessation of ovarian function
• No menses for >12 months
• Loss of menstrual cycles before age 40
Perimenopause Symptoms & Treatment
Symptoms may start at anytime
Typically irregular menses & hot flashes
Treatment options similar to menopause options.
Help patient determine what is important to her…
• How are your symptoms affecting your usual routines?
• What are some things you might do to manage the
symptoms?
• How important is it to you to manage your symptoms?
VETERANS HEALTH ADMINISTRATION
Poll Question
How many years have you worked in women’s
health (both non-VA and VA experience)?
a) Less than 1 year
b) 1-3 years
c) 4-10 years
d) More than 10 years
VETERANS HEALTH ADMINISTRATION
Menopause Symptoms
Vasomotor Symptoms
Menstrual changes
Urogenital atrophy
Average age of menopause is 51. Every woman will experience
some type of change during her transition to menopause.
VETERANS HEALTH ADMINISTRATION
Menstrual Changes
“Normal” menstrual flow
• 21-35 days apart
• Lasts 3-7 days
− 2.4 tbsp of menstrual
fluid average
− Normal range 1–6 tbsp
• Contains blood, cervical
mucus, vaginal secretions,
endometrial tissue
• Reddish-brown, slightly
darker than venous blood
VETERANS HEALTH ADMINISTRATION
Menstrual changes
• Experienced by 90% of women
• Begin 4-8 yrs before menopause
• Flow ranges from very scant to
very heavy, bright red bleeding
• Duration: 1 day to 10-12 days
• Cycle length/frequency: may
stretch to every 60-90 days or
shorten to every 20 days
Pregnancy is still possible …
ask about birth control!
Vasomotor Symptoms
• Feelings of intense heat for 30 seconds to 10 minutes
• 75% of women report vasomotor flashes
– 15% report severe flashes for >15 years
• Women with certain risk factors are more likely to
experience hot flashes:
–
–
–
–
Smoking
Obesity
Physical inactivity
Ethnicity (most common in African-American woman and
least common in women of Japanese/Chinese descent)
VETERANS HEALTH ADMINISTRATION
Urogenital Atrophy
Physical Exam Changes
• Loss of labial/vulvar fullness
• Pale epithelium with less folds
• Decreased vaginal secretions
Vaginal dryness/irritation +/- discharge
Dyspareunia (painful intercourse)
Urinary symptoms (frequency, incontinence)
Mood
Swings
Changes
in Libido
Insomnia
Other
Menopause
Symptoms
Memory
Lapses
Hair
Changes
Headache
VETERANS HEALTH ADMINISTRATION
Case Study 2
A 51-year-old woman Veteran
presents to your primary care
clinic for a well woman exam.
While you are talking to her,
you notice that her face
becomes flushed and she is
sweating profusely.
What questions would you
ask?
VETERANS HEALTH ADMINISTRATION
What Questions Would You Ask?
1.
2.
3.
4.
5.
When did the hot flashes start?
How often do they occur, when do they occur, how long do they last?
What makes your hot flashes worse?
What relieves the symptoms?
Are you experiencing any other symptoms?
• Vaginal bleeding
• Night sweats and/or insomnia
• Memory problems
• Urinary incontinence
• Problems with sexual activity
• Weight gain
• Depression or anxiety
6. Do you smoke?
7. How often do you exercise?
8. What treatments have you tried and how did they work?
Case 2, continued
You find out that she
experiences severe and
frequent hot flashes that are
affecting her job. Her last
menstrual period was 18
months ago, although last
month she had some spotting
that lasted one week. She also
mentioned that she smokes 1
pack per day.
VETERANS HEALTH ADMINISTRATION
Nursing Goals
1. Clarify
• Rule out emergency condition: symptoms do not sound like acute problem
• Rule out conditions needing additional follow-up: episode of postmenopausal bleeding needs further evaluation
2. Identify potential causes
• Determine the impact on her life: hot flashes affecting her job
3. Prioritize urgency
• Resources: Pap (recommended every 3 years for low-risk women), smoking
cessation classes, GYN consult
• Education: postmenopausal bleeding and relief measures for menopausal
symptoms
• Support: menopause websites, PACT teamlet numbers, other options in the
facility
• Tests you might anticipate: pelvic US to evaluate bleeding; maybe TSH but
labs not generally necessary
VETERANS HEALTH ADMINISTRATION
Smoking and Menopause
• Women who smoke >10 cigarettes/day are 40% more likely to go
into menopause earlier than nonsmokers
– Early menopause can to lead to heart disease, stroke, and
osteoporosis
• Smokers have more severe hot flashes and sleeping difficulties
• Women who smoke are 35% more likely to break a hip after
menopause than nonsmokers
– Former smokers have a 15% greater risk of hip fracture
Employ motivational interviewing:
 Is it ok if I give you information about how smoking affects you during
menopause?
 What are some reasons why you might think about quitting?
 What are some things that you can do to cut down on your smoking?
“Your body
knows more
about
menopause
than your
provider does!”
Poll Question
What statement best describes your own personal
views about hormone replacement therapy (HRT)?
a) The risks outweigh any benefits for HRT use
b) I am not sure what to think about HRT risks and
benefits
c) The patient is the only one who should decide
whether to use or avoid HRT use
VETERANS HEALTH ADMINISTRATION
• HRT was initially prescribed for
vasomotor symptoms in the 1960s
• In his book, Feminine Forever, Dr.
Robert Wilson stated : “Instead of
being condemned to witness the
death of their own womanhood,
they will remain fully feminine—
physically and emotionally—for as
long as they live…Menopause is
curable.”
• He also wrote: “All postmenopausal women are castrates”.
But, with HRT, a woman’s “breasts
and genital organs will not shrivel.
She will be much more pleasant to
live with and will not become dull
and unattractive”.
1960. Premarin is
Fountain of Youth!
1970s. Poison! (linked
to endometrial Ca)
1980s: Good!
(prevents osteoporosis)
1990. Use expands!
(protects heart)
2002. Poison!
(WHI study)
2013 ?
What we thought we knew…
• Estrogen therapy seemed logical based on the
hypothesis that menopause:
– Decreased estrogen
– Accelerated cardiovascular disease
– Thus, giving estrogen will protect the heart
• HRT was prescribed based on this hypothesis and
observational trials for many years
• Then, Women’s Health Initiative (WHI) results came
out…
VETERANS HEALTH ADMINISTRATION
What WHI told us…
• CHD, stroke, DVT/PE, and breast cancer risk increased
with estrogen + progesterone
• Stroke and DVT/PE risk increased with estrogen
• No beneficial effect of hormone replacement therapy
on cognitive function in older post-menopausal
women when given for up to 5 years
– HRT in late menopause may have deleterious effects
VETERANS HEALTH ADMINISTRATION
Nurses’ Health Study
In the latest report, compiled with data from 70,533
postmenopausal women followed for 20 years, the
overall risk of CHD in current users of HRT was reduced,
with a relative risk of 0.61 after adjusting for age and
cardiovascular risk factors. Short-term HRT use was
associated with greater coronary benefit than longterm use.
VETERANS HEALTH ADMINISTRATION
Poll Question
What statement best describes your own personal views about
hormone replacement therapy (HRT)?
a) The risks outweigh any benefits for HRT use
b) I am not sure what to think about HRT risks and benefits
c) The patient is the only one who should decide whether to
use or avoid HRT use
Poll Question #3
There is no correct response. It’s important to understand that
health care workers and women Veterans may have any one of the
feelings described here. What matters is that we work with women
to identify their feelings and educate them about how to empower
themselves to control their symptoms.
VETERANS HEALTH ADMINISTRATION
Managing
Menopausal
Symptoms
Case Study 3
A 58-year-old menopausal female calls
to ask if it’s ok to take Black Cohosh for
hot flashes. She says it helped a friend.
• Prior visit 3 months ago
• BP was 130/80, labs WNL
• Mother and MGM had breast CA
“My co-workers are constantly making remarks about
how soaked I get. It’s embarrassing!”
VETERANS HEALTH ADMINISTRATION
Nursing Goals
1. Clarify
• Rule out emergency conditions: her symptoms do not sound like
an acute problem
• Rule out conditions that need additional follow-up: none
2. Identify potential causes
• Determine the impact on her life: embarrassed by her hot
flashes, possibly affecting her job
• Strong family hx of breast cancer (mother and grandmother) is
a consideration for how to manage her hot flashes
3. Prioritize urgency: this Veteran needs information about how to
control her symptoms
VETERANS HEALTH ADMINISTRATION
Hot Flashes: Lifestyle Changes
• Identify triggers and avoid them if possible
– Spicy foods, alcohol, caffeine, stress, hot places
• Dress in layers and remove layers, sip a cold drink when flashes
occur
• Use fans at home or in workplace
• Consider losing weight to decrease frequency
• Relax
─ Some women find relief through yoga, meditation, relaxation,
or other stress-reducing techniques. Even if these don't quell
hot flashes, they may provide other benefits such as easing
sleep disturbances that tend to occur with menopause.
• Don’t smoke
VETERANS HEALTH ADMINISTRATION
Herbal/Vitamin Remedies for Hot Flashes
Vitamin E
Black cohosh (can harm the liver)
Evening primrose oil
Ginseng (may help with mood, insomnia)
Wild yam (“natural progesterone”)
Phytoestrogens: isoflavones (soy, red clover)
Phytoestrogens: lignans (crushed flaxseed)
Chasteberry
Dong quai (bleeding problems w blood thinners)
Licorice root
Kava (may ease anxiety, can damage the liver)
No effect
Mixed results
No effect
No effect
No effect
Mixed results
Mixed results
No effect
No effect
No effect
No effect
Note: Many herbs are estrogenic and the risks are unclear
Mind-Body Therapies for Hot Flashes
Treatment
Efficacy
Comment
Paced respiration
May be effective Small randomized
trial
Acupuncture
Mixed results
Yoga
May be effective Small pilots and 1
randomized trial
Exercise
Mixed results
Homeopathy/
magnet therapy
No effect
Medications that Control Hot Flashes
MPA (Provera) or Megace: Progestin
Venlafaxine (Effexor): Anti-depressant
Desvenlafaxine (Pristiq): Anti-depressant
Fluoxetine (Prozac): Anti-depressant
Paroxetine (Paxil): Anti-depressant
Gabapentin (Neurontin): Anti-seizure
Clonidine (Catapres): Anti-hypertensive
Most notable relief of hot flashes
VETERANS HEALTH ADMINISTRATION
Current HRT Indications
Vasomotor symptoms
Vaginal or vulvar atrophy
Lowest dose and shortest time
• Avoid if >10 years since menopause
• Use for 5 years or less
• All routes of systemic therapy equally effective
• Transdermal estrogen - lower risk of blood clots than oral
• Progesterone must be added for women with a uterus
Individualized decision between Veteran & provider
Hot Flashes
Bio-Identical Hormones
Bio-identical hormones
− Typically custom-compounded formulations
− Not tested or approved by FDA
− Safety/efficacy are unknown
− Similar risks/side effects as traditional HRT
VETERANS HEALTH ADMINISTRATION
Vaginal and Urinary Symptoms
Vaginal
Dryness
Pruritus
Dyspareunia
Painful
urination
Urinary
urgency or
incontinence
Frequent
urinary tract
infections
Thin watery
discharge
VETERANS HEALTH ADMINISTRATION
Vaginal Atrophy Management
Pros
Lubricant
• Astroglide
• K-Y Jelly
Cons
OTC • Eases pain during Doesn’t change
intercourse
vaginal tissue
Vaginal moisturizer OTC • Eases symptoms
• Replens
• Improves
epithelium
Most expensive
option
Rx
• Eases symptoms
only • Improves
epithelium
• No systemic
effects
Not for women
with breast CA
Vaginal estrogen
• Premarin Cream
Estring
• Vagifem
Resources
North American Menopause Society. Information on menopause
and educational materials.
http://www.menopause.org/edumaterials.aspx
PubMed Health. Fact sheet: menopause.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004974/
U.S. DHHS. Menopause and menopause treatments fact sheet.
http://www.womenshealth.gov/publications/our-publications/factsheet/menopause-treatment.cfm
U.S. DHHS. Menopause symptom relief and treatments.
http://www.womenshealth.gov/menopause/symptom-relieftreatment/
VETERANS HEALTH ADMINISTRATION
Resources
NHLBI. Facts about menopausal hormone therapy.
http://www.nhlbi.nih.gov/health/women/pht_facts.pdf
NIA. Hormones and menopause: tips from National Institute on
Aging.
http://www.nia.nih.gov/sites/default/files/TipSheet_HormonesAnd
Menopause_0.pdf
NCI. Fact sheet: Menopausal hormone therapy and cancer.
http://www.cancer.gov/cancertopics/factsheet/Risk/menopausalhormones
National Center for Complimentary and Alternative Medicine. Herbs
at a glance. http://nccam.nih.gov/health/herbsataglance.htm
VETERANS HEALTH ADMINISTRATION
VETERANS HEALTH ADMINISTRATION