Let?s now review menopause in general.
95% of women experience menopause between the ages of 44 and 45
with the average age being 51. Menopause before the age of 40
which occurs in 1% of the population is pathologic and this is referred to as POI
or Primary Ovarian Insufficiency. There is another lecture set that you can look at
to learn more about POI.
Symptoms of menopause could be characterized as an estrogen withdrawal
so their entire reproductive life the female is exposed to estrogen
and when the ovaries stops cycling that estrogen is decreased
and that causes a withdrawal at the level of the brain even.
So what are the symptoms? Well, they?re typically called vasomotor symptoms
but they are described in the medical literature as hot flushes.
However, your patients? may state, "I?m having hot flashes". Okay, which is different.
However, they mean the same thing. So the patient can actually present
and say, "I usually soak through my pajamas every night",
because they?re having night sweats.
Sometimes they can have vaginal dryness and itching.
It can be so irritated that sex is painful and also they might think
they have urinary tract infection because of the itching and burning
when they urinate. They may suffer from poor memory
because their sleep gets interrupted by the continuous night sweats
and the hot flushes even waking them up when they?re not aware of it.
They can have weight gain and trouble losing weight.
Their hair may thin and they may have irregular periods.
Now, let?s talk about emotional symptoms. In the menopausal transition,
a woman can have mood swings and irritability, stress and anxiety,
and fatigue mostly because of the night sweats in the vasomotor symptoms
could be waking her up from a deep REM sleep.
In the menopause we can see that hair becomes thinner and loses its luster.
Breasts often droop and flatten. Nipples become smaller and may as well flatten
and the skin and mucous membranes become drier
and skin develops a rougher structure. The abdomen loses some muscle tone
and the woman can suffer from stress and urge incontinence.
Again, there?s vaginal dryness, itching and shrinking
so again which would be normal sexual life
may now become painful source of difficulty for the woman.
The woman also may experience headaches and hot flushes
which are sometimes called hot flashes.
Her teeth can loosen and her gums can recede.
She may have cardiovascular disease.
She can suffer from backaches and her body
and pubic hair becomes thicker and darker.
And she may have some bone loss that leads to increased bone fragility and fractures.
Let?s now review some vasomotor symptoms/hot flushes.
These are very common and occurring in about 50% to 90% of all women.
Remember, it?s a feeling or a rush of warmth in the face
that sometimes last up to 45 minutes and this is very disturbing.
What if this happened to a woman while she?s trying to conduct a meeting
or present in court? This can happen at night and these are termed night sweats.
They correlate with declining estrogen levels
and they are thought to be a disruption in thermoregulatory process.
Let?s now talk about menopause management.
First, you wanna do a thorough history in physical
especially a history of present illness, a gynecological history, and a sexual history.
If the patient tells you that she was sexually active but is now stopped,
you wanna ask why? Is she having pain? Does she have vaginal dryness?
Does she have a loss of libido? And on pelvic exam,
that?s key to investigate vaginal atrophy especially in the context of sexual complaints.
There is a system that we use although not something you would typically see
in a medical record. There is a system that?s accepted in assessing reproductive aging
and includes criteria for perimenopause, the final menstrual period,
and postmenopause based upon bleeding patterns, endocrine findings, and symptoms.
Again, we don?t typically check an endocrine profile on these patients
but if one were to be done you could potentially stage these patients
based on a STRAW system.
Let?s now talk about the preventative care in a menopausal woman.
So women who are in their perimenopause or menopause
who come to your clinic provide you with an opportunity
to give them anticipatory guidance about aging.
We should review screening modalities with them and this includes cervical cytology.
Typically, up to age 65 we do cytology every 3 years.
However, there is a lecture about cervical cytology and the new recommendations.
We also test for diabetes at age 45 every 3 years.
We also get a TSH starting age 50 every 5 years.
We also encourage patient to undergo colonoscopy at age 50
and if they?re African-American at age 45 and if the findings are normal
at the time of colonoscopy then every 10 years.
Mammography should be done annually
although there are some recommendations that it should be done biannually.
And of course, the DEXA should be done at age 65 and every 2 years
if there are additional risk factors that are present.