Menopause

The physiologic cessation of menses as a result of decreasing ovarian function. It is usually a retrospective diagnosis, made when menses have not occurred for a year. Menopause may be

¨1natural,

¨2artificial, or

¨3premature.

Etiology

Natural menopause occurs at an average age of 50 to 51 yr. As ovaries age, response to pituitary-produced gonadotropins (follicle-stimulating and luteinizing hormones) decreases, initially with

¨4shorter follicular phases (hence, shorter cycles),

¨5fewer ovulation’s,

¨6decreased progesterone production, and

¨7more cycle irregularity.

Eventually, the follicle fails to respond and, without feedback of estrogen, the circulating gonadotropins rise substantially.

¨8Circulating levels of estrogen’s and progesterone are markedly reduced;

¨9androgen (androstenedione) is reduced by half,

¨10but testosterone decreases only slightly.

This transitional phase beginning before menopause and continuing after it, during which a woman passes from her reproductive stage, is properly referred to as the climacteric, although most people refer to it also as menopause.

Premature menopause refers to ovarian failure of unknown cause that occurs before age 40.

·1 Smoking is associated with early menopause.

·2 Radiation exposure,

·3 chemotherapeutic drugs, and

·4 surgery that impairs ovarian blood supply can also hasten menopause.

Artificial menopause follows ovariectomy or radiation of the pelvis, including the ovaries.

Symptoms and Signs

Menopausal women may be asymptomatic, or they may have severe symptoms.

·5 Hot flushes and sweating secondary to vasomotor instability affect 75% of women. Most have hot flushes for > 1 yr. and 25 to 50% for > 5 yr.

·6 Psychologic and emotional symptoms of

·7 fatigue,

·8 irritability,

·9 insomnia, and

·10nervousness may be related to both estrogen deprivation and the stress of aging and changing roles.

·11Lack of sleep due to disturbance by recurrent hot flushes contributes to fatigue and irritability.

·12Intermittent dizziness,

·13paresthesias, and

·14cardiac symptoms of palpitations and

·15tachycardia may occur;

·16the incidence of heart disease increases.

·17Dyspareunia,

·18increasing pelvic relaxation,

·19urinary incontinence,

·20cystitis, and vaginitis tend to occur.

·21nausea,

·22flatulence,

·23constipation,

·24diarrhea,

·25arthralgia, and

·26myalgia are common complaints.

Osteoporosis is the major health hazard. Those at highest risk are slender, white women who smoke, take corticosteroids, or have little physical activity.

Bone mass losses average 1 to 2% yr after menopause and result in numerous fractures.

Primary sites are the vertebrae, which show anterior collapse, leading to stooping and backache; hip (200,000/yr in the USA); and wrist.

These fractures may occur with little trauma, and in the elderly, with no trauma.

Diagnosis

Menopause is usually obvious. In younger patients, the diagnosis is substantiated by elevated levels of follicle-stimulating hormone (FSH).

Endocrine disorders such as

·27thyroid disease or

·28diabetes mellitus should be ruled out.

Patients with symptomatic osteoporosis should be evaluated for causes other than menopause (e.g., hyperparathyroidism).

Treatment And Nursing Care

¨1Counseling about the physiologic causes and

¨2the concerns,

¨3fears, and

¨4stresses related to this phase of life is important.

When psychic factors dominate,

¨5psychotherapy is indicated and,

if necessary,

¨6antidepressants, minor tranquilizers, and

¨7mild sedatives can be used as adjunctive therapy for

¨8depression,

¨9anxiety and

¨10irritability, and

¨11insomnia, respectively.

Estrogen replacement is the only consistent and satisfactory therapy to sustain systems dependent on ovarian hormone secretion and to relieve hot flushes.

Patient selection, determination of risk/benefit ratio, and observation during therapy are necessary.

When hot flushes and subsequent insomnia and fatigue from night-awakening decrease, the feeling of well-being usually returns.

When estrogen’s are contraindicated, treatments for reducing discomfort due to hot flushes include sedative-hypnotics (e.g., barbiturates), progestin (medroxyprogesterone acetate 10 mg/day orally).

Symptomatic

¨vaginal atrophy and

¨vaginitis and

¨atrophic changes of the lower urinary tract (especially of the urethra and

¨trigone of the bladder),

¨with urinary frequency,

¨dysuria, and

¨sometimes incontinence, are reversible with estrogen therapy.

Preventing osteoporosis requires extended estrogen replacement.

Adequate nutrition, including

¨elemental calcium (1000 mg/day for premenopausal and

¨estrogen-treated women, 1500 mg/day for untreated postmenopausal women), and

¨weight-bearing exercise are also necessary.

¨For those who have inadequate daily exposure to sunlight, vitamin D supplementation (600 u. bid) is indicated.

Nursing Care should council the patient to

¨prevent falls,

¨side effects of other drugs and

¨home hazards should be minimized.

The therapeutic effects of estrogen replacement on cardiovascular disease in postmenopausal women are becoming more clearly delineated.

Documented improvement in morbidity and mortality suggests that cardiovascular mortality is 1/3 lower in estrogen users than in nonusers, largely as a result of estrogen-induced increases in high density lipoprotein.

Although BP increases have been reported in some women receiving estrogen replacement therapy, this has not been associated with an increased risk for cerebrovascular accident.

Nursing Roles

The nurse who has an understanding of the climacteric and post-climacteric can be effective in helping women.

The nurse has three major roles in working with women who are between the age of 40 and 60. The nurse is

· an information giver,

· a supportive listener, and

· an encourage of realistic coping methods.

Information-giver.

Enough basic information about the premenopause is available that no woman has to suffer from lack of information or misinformation.

Old Wives’ tales can cause anxiety in women who are approaching premenopause, and experiencing climacteric complaints arouses fear about the normalcy of the changes occurring in their bodies.

Nurses can help women in any health care setting or in the community by giving them the correct setting or in the community by giving them the correct information.

Nurses can help find the appropriate contraceptive, demonstrate why hot flushes occur, and provide details on many other aspects of menopause that will help women decide what action is needed.

Supportive listener.

Women often need validation that their complaints are not unusual and that they are not alone in what they are experiencing.

Nurses can encourage women to discuss their fears and anxiety and to find other women with whom they can share their concerns.

Developing a supportive network can erase the stress of change.

Encourage Of Realistic Coping

Methods.

Nurses can do many things that help women cope with the climacteric.

¨They not only can start women’s groups that focus on menopause,

¨they can also identify women who need to talk to a physician when medical intervention seems indicated and

¨can help family members become more supportive of the woman who is having climacteric complaints.

Nurses need to be familiar with local resources and direct women to classes that supply the appropriate information and support.

Nurses provision of more classes and groups for women who want to discuss menopause would also be helpful.

(HRT=Hormonal Replacement Therapy)

Estrogen administration usually is cyclic.

¨If the patient has a uterus, a progestin is added to the cycle.

¨Estrogen (conjugated estrogen 0.3 to 1.25 mg/day or ethinyl estradiol 0.02 to 0.05 mg/day) is taken orally once a day from the first through the 25th day each month.

¨Progestins (e.g., medroxy-progesterone acetate 5 or 10 mg) are given from the 15th through the 25th day of the cycle.

¨Bleeding, if it occurs, should happen only during the hormone withdrawal period;

¨if bleeding occurs at other times, an endometrial biopsy should be performed.

¨Estrogen can be increased or decreased, according to the symptoms.

¨If hot flushes occur during the end of the cycle, the days without estrogen can be decreased by 1 day each month until symptoms are relieved

Topical estrogen (e.g., conjugated, natural or synthetic estrogen cream) may be used for atrophic vaginal changes and dyspareunia;

¨1 applicator/night for 5 nights, then

¨½ applicator/night for 1 mo, followed by

¨¼ applicator 2 to 3 times/wk will correct atrophic changes and maintain a healthy, cornified vaginal epithelium.

¨The estrogen is readily absorbed systemically from the vaginal mucosa.

¨Injectable estrogen (estradiol valerate 10 to 20 mg IM q 4 wk) is rarely indicated, except immediately after oophorectomy.

Contraindications to estrogen therapy include

· a history of estrogen-dependent neoplasia of the endometrium or breast,

· a history of thrombophlebitis or thromboembolism, and

· the presence or a history of severe liver disease.

Mammography should be routine in postmenopausal women and is particularly pertinent as a screen and to provide a baseline in those receiving estrogen treatment. Most evidence indicates that estrogen therapy does not increase risk for breast cancer.