Best Dx/Best Rx: Menopause

From: Subject: Best Dx/Best Rx: Menopause Date: Wed, 3 Jun 2009 21:23:50 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_01A4_01C9E491.96AD2410" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_01A4_01C9E491.96AD2410 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1611.htm Best Dx/Best Rx: Menopause

Menopause

Susan D. Reed, M.D., M.P.H.
Eliza L. Sutton, M.D., F.A.C.P.
University of = Washington=20 School of Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key Clinical=20 Features

Permanent cessation of menses (≥ 12 mo = of=20 amenorrhea)=20
Menopausal transition: period of physiologic = change=20 around cessation of ovarian function
- Average duration 4 yr before menopause = (range 0=9610=20 yr)=20
- Early: variable menstrual cycle length (> = 7 days=20 different from normal)=20
- Late: ≥ 2 skipped cycles and an = interval of amenorrhea=20 (≥ 60 days)
Natural menopause: menopause at or after age = 40, with no=20 underlying pathologic cause=20
- Mean age 51 yr in developed countries =
- 95% of women experience menopause by age = 55=20
Induced menopause: menopause caused by = chemotherapy,=20 pelvic radiation, or bilateral oophorectomy=20
Premature ovarian failure (POF): menopause = before age=20 40, without iatrogenic cause=20
- Fragile X premutation in 3%=965%=20
- Immune-mediated in 30%=9650%=20
- Associated autoimmune conditions = common=20
Menstrual changes=20
- Irregular cycle length, progressing to = missed=20 menses=20
- Heavier or lighter flow, or both=20
- Eventual progression to amenorrhea =
Vasomotor instability (hot flushes and/or = night=20 sweats)=20
- Common, though unpredictable; prevalence 80% = in=20 developed countries=20
- Episodes are self-limited, typically of = several=20 minutes' duration=20
- Maximum frequency and intensity 2 yr before = and after=20 final menstrual period; gradually resolves
Changes in libido, sleep, mood, and = cognition=20
Genitourinary atrophy=20
- Typically mild and asymptomatic during = menopausal=20 transition=20
- Progressive during postmenopausal years; may = become=20 severe=20
- Atrophic vulvovaginitis=20
  - Vaginal dryness=20
  - Vulvovaginal pruritus=20
  - Vaginal dyspareunia=20
  - Postcoital spotting
- Atrophic urethritis; recurrent = cystitis=20
  - Dysuria=20
  - Urinary frequency=20
  - Incontinence =

bac= k to=20 top

Differential = Diagnosis

Menstrual changes=20
- Oligomenorrhea or amenorrhea=20
- Pregnancy=20
- Prolactinoma=20
- Thyroid dysfunction=20
- Medication or supplement use =
Menorrhagia or intermenstrual bleeding = (interval < 21=20 days)=20
- Thyroid dysfunction=20
- Pregnancy=20
- Blood dyscrasias=20
- Leiomyoma=20
- Adenomyosis=20
- Endometrial/endocervical polyps=20
- Endometriosis=20
- Endometrial or cervical neoplasia=20
- Hormone-secreting neoplasms (e.g., granulosa = cell=20 ovarian cancer)=20
- Medication or supplement use =
Genitourinary atrophy=20
- Vulvovaginal symptoms=20
  - Trichomonas vaginitis=20
  - Yeast vulvovaginitis=20
  - Desquamative inflammatory vaginitis =
  - Vestibulitis=20
  - Allergic vulvovaginitis=20
  - Vulvar dysplasia or cancer =
- Urinary symptoms=20
  - Dietary bladder irritants=20
  - Detrusor instability=20
  - Urinary tract infection=20
  - Interstitial cystitis
- Hot flushes and night sweats=20
  - Hyperthyroidism=20
  - Pheochromocytoma=20
  - Carcinoid=20
  - Occult infection (e.g., tuberculosis, = HIV)=20
  - Occult neoplasm, including lymphoma with B = symptoms
- Changes in libido, sleep, mood, and = cognition=20
  - Mood or anxiety disorders=20
  - Thyroid dysfunction=20
  - Stress=20
  - Medications or other substances=20
  - Unrecognized sleep disorder (e.g., = obstructive sleep=20 apnea, restless legs syndrome)=20
  - Early dementia =

bac= k to=20 top

Best=20 Tests

History and physical examination=20
- Age 45 or older, with progressive menstrual = changes=20 and vasomotor symptoms consistent with natural menopause=20
  - Likely to be menopause; further evaluation = may not=20 be necessary
- Recent chemotherapy or pelvic radiation, = with=20 oligomenorrhea or amenorrhea and vasomotor symptoms=20
  - Likely to be induced menopause =
- Recent bilateral oophorectomy, with = vasomotor=20 symptoms=20
  - Induced menopause
- History of significant weight loss or = opioid/substance=20 use=20
  - Consider hypothalamic amenorrhea =
- History or exam finding of galactorrhea = and/or=20 bitemporal hemianopsia=20
  - Evaluate for prolactinoma [see Laboratory = tests,=20 below]
- Speculum examination for vaginal or cervical = lesions,=20 including polyps, and to obtain Pap smear=20
  - Perform to evaluate intermenstrual = bleeding=20
- Bimanual pelvic examination for adnexal = masses or=20 uterine fibroids=20
  - Perform to evaluate heavy or frequent = menstrual=20 bleeding
Laboratory tests=20
- Follicle-stimulating hormone (FSH)=20
  - Most useful in diagnosis of POF=20
  - Widely variable during menopausal = transition=20
  - Typically 15=9625 IU/L in incipient = ovarian failure;=20 can fluctuate=20
  - FSH > 25 IU/L on repeated measurements: = complete=20 ovarian failure=20
  - Suppressed by oral contraceptives; check = during=20 off-week of pill pack
- Urine or serum =DF-human chorionic = gonadotropin=20 (=DF-hCG)=20
  - If potential for pregnancy with missed = period,=20 oligomenorrhea, or irregular vaginal bleeding with or without pain =
- Thyroid-stimulating hormone (TSH)=20
  - If menorrhagia, menstrual irregularities,=20 amenorrhea, excessive diaphoresis, or neurocognitive changes=20
- Prolactin=20
  - If suspected prolactinoma, including = oligomenorrhea=20 or amenorrhea pattern atypical of natural menopause, and in any = patient=20 with galactorrhea and/or bitemporal hemianopsia =
Coagulation studies=20
- In patients with menorrhagia that could be = secondary=20 to hemorrhagic diathesis
  - Platelet count=20
  - Prothrombin time=20
  - Partial thromboplastin time=20
  - von Willebrand factor if indicated=20
Evaluation of POF=20
- Test for premutation allele of fragile X if = results=20 useful to the patient (or to other family members) and patient = agrees=20
- Test for manifestations of other autoimmune=20 diseases=20
  - Complete blood count=20
  - Erythrocyte sedimentation rate=20
  - Rheumatoid factor=20
  - Antinuclear antibody=20
  - Serum glucose=20
  - Serum calcium=20
  - Serum phosphorus=20
  - TSH
Vaginal fluid pH and microscopic examination = (saline and=20 10% KOH preparations)=20
- In patients with vaginal dyspareunia or = vulvovaginal=20 pruritus, to evaluate for Candida, trichomoniasis, or = bacterial=20 vaginosis
Pelvic ultrasound=20
- During menopausal transition, to evaluate = endometrial=20 cavity and myometrium in women with menorrhagia or menometrorrhagia =
  - Leiomyoma=20
  - Endometrial polyps=20
  - Adenomyosis=20
  - Test cannot rule out endometrial = neoplasia=20
- After menopause, to evaluate the endometrium = and=20 myometrium of women with spotting or bleeding occurring = spontaneously or=20 with hormone therapy=20
  - Homogeneous endometrial thickness ≤ = 4 mm rules out=20 endometrial hyperplasia or cancer in 96% of cases =
Endometrial biopsy=20
- During menopausal transition, to evaluate = women at=20 risk for endometrial hyperplasia or carcinoma who have either of the = following:=20
  - Intermenstrual bleeding=20
  - Menometrorrhagia and risk factors for = endometrial=20 hyperplasia (e.g., obesity, diabetes)
- After menopause, to evaluate women at risk = for=20 endometrial hyperplasia or carcinoma who have either of the=20 following:=20
  - Vaginal bleeding after 12 mo of = amenorrhea=20
  - Endometrium ≥ 4 mm on = ultrasound=20

bac= k to=20 top

Best=20 Therapy

General Considerations=20
- Routine use of hormone therapy (HT) in = menopausal=20 transition and menopause is no longer standard care=20
  - HT increases risk for the = following:=20
    - Venous thromboembolic events in all ages = (on=20 estrogen/progestin therapy [EPT] or estrogen therapy alone = [ET])=20
    - Cardiovascular disease in all ages (on = EPT)=20
    - Stroke in all ages (on EPT or ET) =
    - Dementia for women 65=9679 years of age = (on EPT or=20 ET)
    - Breast cancer in all ages (on = EPT)
  - In women 50=9679 years of age, HT reduces = risk for the=20 following:=20
    - Osteoporotic fractures (on EPT or = ET)=20
    - Colon cancer (on EPT)
  - HT and placebo do not differ in overall or = disease-specific mortality for use up to 5=966 years in women = 50=9679 years of=20 age
- Screen for conditions common in = postmenopausal women=20 and use approaches other than HT for prevention of the = following:=20
  - Breast cancer=20
  - Colon cancer=20
  - Coronary artery disease (CAD)=20
  - Diabetes mellitus=20
  - Osteoporosis=20
  - Dementia
- POF is treated with estrogen/progestin until = age 50,=20 based on expert opinion=20
  - HT or low-dose combination = estrogen/progestin=20 contraceptive to prevent bone loss and premature CAD=20
  - If pregnancy is desired, in vitro = fertilization=20 using donor eggs
Uterine bleeding in the menopause transition, = after=20 appropriate evaluation=20
- Low-dose oral contraceptive with 20 =B5g = ethinyl=20 estradiol (also treats vasomotor symptoms)=20
  - Discontinue and reassess symptoms at age = 50=20
- Progestin intrauterine device (will not = treat=20 vasomotor symptoms)
Vasomotor symptoms=20
- Treatment recommended only for symptoms = significantly=20 impacting quality of life=20
  - Individualize treatment=20
  - Use lowest effective dose=20
  - Consider transdermal therapy=20
  - Annual evaluation recommended; discontinue = HT 1 wk=20 before assessment to allow evaluation of current severity of=20 symptoms=20
  - Treat for shortest duration that will ease = menopausal transition=20
    - Recommended limit of use is 5 years =
    - May require taper over 3=966 months at=20 discontinuance
- Low-dose oral contraceptives (off-label = use)=20
  - Best method for women in the menopause = transition=20 who are at risk for pregnancy and have heavy or frequent = menses=20
- HT=20
  - Combination estrogen/progestin, preferably = cyclic=20 HT, in women in the menopausal transition who are predominantly=20 anovulatory and do not need contraception=20
  - Unopposed estrogen in women who have had=20 hysterectomy=20
  - Types of estrogen, with lowest effective = doses for=20 vasomotor symptoms:=20
    - Oral conjugated estrogen, 0.3 = mg/day=20
    - Oral estradiol, 0.5 mg/day=20
    - Transdermal estradiol patch, 0.025 = mg/day
    - Vaginal estradiol ring 0.05 = mg/day=20
- Venlafaxine (off-label use), 37.5=96150 = mg/day=20
- Selective serotonin reuptake inhibitors = (SSRIs)=20 (off-label use)=20
  - Fluoxetine, 20 mg/day=20
  - Paroxetine CR, 12.5=9625 mg/day, or = paroxetine, 10=9620=20 mg/day
- Gabapentin (off-label use), 300=96900 = mg/day=20
Changes in libido, sleep, mood=20
- Libido: estrogen combined with = methyltestosterone (MT)=20 may be useful (off-label use)=20
  - Esterified estrogen, 0.625 mg/day, and MT, = 1.25=20 mg/day
  - Transdermal testosterone patch (not = available for=20 clinical use)
- Insomnia=20
  - HT for vasomotor instability that disrupts = sleep=20
  - Hypnotic agents (e.g., zolpidem, = trazodone)=20
- Mood=20
  - Antidepressants, with or without = adjunctive=20 HT
Genitourinary atrophy=20
- Vaginal estrogen creams=20
  - Little or no systemic absorption at low = doses=20
  - Conjugated equine estrogen cream, 0.625 = mg/g (2 g=20 per applicator)=20
    - Dose: 1/4=961/8 applicator nightly for = 2=966 wk, then=20 1=963 times/wk
  - Estradiol cream, 0.01% (0.1 mg/g, 4 g per=20 applicator)=20
    - Dose: 1/8=961/16 applicator nightly for = 2=966 wk, then=20 1=963 times/wk
- Vaginal estradiol ring: 2 mg (0.0075 = mg/day), changed=20 every 90 days=20
- Vaginal estradiol tablet: 0.025 mg, one = tablet 2=20 times/wk
- Lubricants for sexual intercourse=20
- Vaginal moisturizers =

bac= k to=20 top

Best References

Rossouw JE, et al: JAMA 288:321, 2002 [PMID=20 12117397]

Anderson GL, et al: JAMA 291:1701, 2004 [PMID = 15082697]=20

September=20 2006