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Menopause and AgingMenopause and Aging
Sylvia Ziegenbein, MDM3 Student Lecture
2007
Sylvia Ziegenbein, MDM3 Student Lecture
2007
ObjectivesObjectives
Define menopause Describe associated changes and
symptoms Treatment options for bothersome
symptoms Review physiologic changes of aging,
specific age related problems and screening in elderly
Define menopause Describe associated changes and
symptoms Treatment options for bothersome
symptoms Review physiologic changes of aging,
specific age related problems and screening in elderly
Case #1Case #1
35 yo G1 P0101 female presents with c/o hot flashes and amenorrhea for 12 months. She doesn’t know why this is happening, her sxs are worsening. She wants your help.
DDx Tests
35 yo G1 P0101 female presents with c/o hot flashes and amenorrhea for 12 months. She doesn’t know why this is happening, her sxs are worsening. She wants your help.
DDx Tests
Case #2Case #2 45 yo G2 P2002 female presents with
c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. She doesn’t know why this is happening, she wants your help. By the way, she wants your help to stop smoking also.
DDx Tests
45 yo G2 P2002 female presents with c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. She doesn’t know why this is happening, she wants your help. By the way, she wants your help to stop smoking also.
DDx Tests
Case #3Case #3 65 yo WF presents to start HRT. She
heard it would help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an occasional hot flash. She is 5’4”, 108 lbs. By the way, she had a wrist fx 2 yrs ago takes her Viactiv faithfully.
65 yo WF presents to start HRT. She heard it would help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an occasional hot flash. She is 5’4”, 108 lbs. By the way, she had a wrist fx 2 yrs ago takes her Viactiv faithfully.
Case #4Case #4 49 yo WF presence b/c she can’t stand
her hot flashes anymore. She can’t sleep very well b/c she wakes up 3 times a night drenched with sweat. She is an executive at First National Bank. She has a history of breast cancer 2 years ago. “Please Dr. Ziegenbein, I need some hormones or something.”
49 yo WF presence b/c she can’t stand her hot flashes anymore. She can’t sleep very well b/c she wakes up 3 times a night drenched with sweat. She is an executive at First National Bank. She has a history of breast cancer 2 years ago. “Please Dr. Ziegenbein, I need some hormones or something.”
Case #5Case #5
55 yo BF returns to discuss stopping her HRT. She has been taking it for 5 years now with good relief of her vasomotor sxs.
55 yo BF returns to discuss stopping her HRT. She has been taking it for 5 years now with good relief of her vasomotor sxs.
Case #6Case #6
53 yo WF began continuous HRT 4 wks ago. She is now having some vaginal spotting after being amenorrheic for 14 months. She is concerned.
53 yo WF began continuous HRT 4 wks ago. She is now having some vaginal spotting after being amenorrheic for 14 months. She is concerned.
MenopauseMenopause
Definition Average Age Related Sxs
Definition Average Age Related Sxs
Classification SystemClassification System
STRAW System Help communication
STRAW System Help communication
Menopause Terminology: STRAW* Staging System
*STRAW = Stages of Reproductive Aging Workshop.†Stages most likely to be characterized by vasomotor symptoms.Soules MR, et al. Menopause. 2001;8:402-7.
Stages:Stages: -2-2 -1-1 +1+1 +2+2
Terminology:
Duration of Stage:
Menstrual Cycles:
Menopausal TransitionMenopausal Transition PostmenopausePostmenopause
EarlyEarly EarlyEarly††LateLate†† LateLate
PerimenopausePerimenopause
VariableVariable
Variable Variable cycle length cycle length
(>7 days(>7 daysdifferent different
from normal)from normal)
2 skipped2 skippedcycles and ancycles and an
interval of interval of amenorrheaamenorrhea((60 days)60 days)
4 yrs4 yrsUntilUntil
demisedemise
NoneNone
00Final Menstrual PeriodFinal Menstrual Period
1 yr1 yr
Am
en. ×
12
mos
.A
men
. × 1
2 m
os.
aa bb
Vasomotor symptoms:Why don’t we treat every women with hormones?
Vasomotor symptoms:Why don’t we treat every women with hormones?
WHI: HRT vs PlaceboWHI: HRT vs Placebo Large prospective RCT, 2002, JAMA 16,608 postmenopausal women (50-79 y.o.)
Ave age at enrollment = 63 yrs Two arms:
Estrogen + Progestin (Prempro 0.625/2.5), n=8506 Placebo, n=8102
Outcomes measured: Primary : Coronary heart disease (CHD) and invasive
breast cancer Secondary : stroke, pulmonary embolism, DVT,
endometrial CA, colorectal CA, hip and vertebral fractures and death from other causes
Large prospective RCT, 2002, JAMA 16,608 postmenopausal women (50-79 y.o.)
Ave age at enrollment = 63 yrs Two arms:
Estrogen + Progestin (Prempro 0.625/2.5), n=8506 Placebo, n=8102
Outcomes measured: Primary : Coronary heart disease (CHD) and invasive
breast cancer Secondary : stroke, pulmonary embolism, DVT,
endometrial CA, colorectal CA, hip and vertebral fractures and death from other causes
HRT Arm: Stopped Early @ 5.2 yrsHRT Arm: Stopped Early @ 5.2 yrs Invasive Breast Cancer = 38 vs 30/10,000
person yrs (HR 1.26) CHD = 37 vs 30/10,000 (HR 1.29) Stroke = 29 vs 21/10,000 (HR 1.41) Venous Thromboembolic disease = 34 vs
16/10,000 (HR 2.11)
Colorectal cancer = 10 vs 16/10,000 (HR 0.63) Hip fracture = 10 vs 15/10,000 (HR 0.66) Vertebral fracture = 9 vs 15/10,000 (HR 0.66) No change in endometrial and lung cancer
Invasive Breast Cancer = 38 vs 30/10,000 person yrs (HR 1.26)
CHD = 37 vs 30/10,000 (HR 1.29) Stroke = 29 vs 21/10,000 (HR 1.41) Venous Thromboembolic disease = 34 vs
16/10,000 (HR 2.11)
Colorectal cancer = 10 vs 16/10,000 (HR 0.63) Hip fracture = 10 vs 15/10,000 (HR 0.66) Vertebral fracture = 9 vs 15/10,000 (HR 0.66) No change in endometrial and lung cancer
WHI: Estrogen Only vs Placebo
WHI: Estrogen Only vs Placebo
WHI 2004: JAMA 10,739 postmenopausal women
s/p hysterectomy (50-79 y.o.) Ave. age @ enrollment = 63.6 y.o.
Two arms: Estrogen (Premarin 0.625 mg), n=5310 Placebo, n=5429
Outcomes: Primary: CHD and invasive breast cancer Secondary: stroke, pulmonary embolism, DVT,
colorectal cancer, hip/vertebral fractures and death from other causes
WHI 2004: JAMA 10,739 postmenopausal women
s/p hysterectomy (50-79 y.o.) Ave. age @ enrollment = 63.6 y.o.
Two arms: Estrogen (Premarin 0.625 mg), n=5310 Placebo, n=5429
Outcomes: Primary: CHD and invasive breast cancer Secondary: stroke, pulmonary embolism, DVT,
colorectal cancer, hip/vertebral fractures and death from other causes
OutcomesOutcomes Ave. follow up 6.8 years (Hazard Ratio)
Invasive breast Cancer = 26 vs 33/10,000 person yrs (0.77)
CHD = 49 vs 54/10,000 (0.91) Venous Thromboembolic disease = 28 vs
21/10,000 (1.33) Stroke = 44 vs 32/10,000 (1.39)
Fatal = 4 vs 4/10,000 (1.13) Nonfatal = 32 vs 23/10,000 (1.39)
Colorectal cancer = 17 vs 16/10,000 (1.08) Hip fracture = 11 vs 17/10,000 (0.61) Vertebral fracture = 11 vs 17/10,000 (0.62)
Ave. follow up 6.8 years (Hazard Ratio) Invasive breast Cancer = 26 vs 33/10,000
person yrs (0.77) CHD = 49 vs 54/10,000 (0.91) Venous Thromboembolic disease = 28 vs
21/10,000 (1.33) Stroke = 44 vs 32/10,000 (1.39)
Fatal = 4 vs 4/10,000 (1.13) Nonfatal = 32 vs 23/10,000 (1.39)
Colorectal cancer = 17 vs 16/10,000 (1.08) Hip fracture = 11 vs 17/10,000 (0.61) Vertebral fracture = 11 vs 17/10,000 (0.62)
Clinical EventHazard Ratio, 95% confidence interval
HERS E+P WHI E+P WHI E alone
CHD Events 0.99 (0.80-1.22)
1.29 (1.02-1.63) 0.91 (0.75-1.12)
Stroke 1.23 (0.89-1.70)
1.41 (1.07-1.85) 1.39 (1.10-1.77)
Pulm. Embolism
2.79 (0.89-8.75)
2.13 (1.39-3.25) 1.34 (0.87-2.06)
Breast Cancer 1.30 (0.77-2.19)
1.26 (1.00-1.59) 0.77 (0.59-1.01)
Colon Cancer 0.69 (0.32-1.49)
0.63 (0.43-0.92) 1.08 (0.75-1.55)
Hip Fracture 1.10 (0.49-2.50)
0.66 (0.45-0.98) 0.61 (0.41-0.91)
Death 1.08 (0.84-1.38)
0.98 (0.82-1.18) 1.04 (0.88-1.22)
Global Index - 1.15 (1.03-1.28) 1.01 (0.89-1.70)
Menopausal Complaints: Treatments
Menopausal Complaints: Treatments
Hormones vs non-hormones vs herbals Efficacy
Hormones vs non-hormones vs herbals Efficacy
Hormones ContraindicatedHormones Contraindicated Breast CA Endometrial CA Undiagnosed vaginal bleeding CHD Venous thrombosis Stroke Pregnancy What is not here, that is a CI on OCP’s?
Breast CA Endometrial CA Undiagnosed vaginal bleeding CHD Venous thrombosis Stroke Pregnancy What is not here, that is a CI on OCP’s?
Normal Physiologic Changes of Aging
Normal Physiologic Changes of Aging
DemographicsDemographics
34 million elderly now 69 million in 2030
Gerontology Health in the aged
Absence of ds Maintain function and comfort Presence of satisfactory support systems
34 million elderly now 69 million in 2030
Gerontology Health in the aged
Absence of ds Maintain function and comfort Presence of satisfactory support systems
Body Composition and Homeostasis
Body Composition and Homeostasis
Decrease muscle mass Increase body fat Changes volume of distribution
Impaired baroreceptor Orthostatic hypotension
Impaired thermoregulation
Decrease muscle mass Increase body fat Changes volume of distribution
Impaired baroreceptor Orthostatic hypotension
Impaired thermoregulation
CardiovascularCardiovascular
Decrease LV compliance Increased reliance on atria
More LVH Stiffer arteries
Decreased beta-adrenergic responsiveness Decreased max. HR with exercise
Decrease LV compliance Increased reliance on atria
More LVH Stiffer arteries
Decreased beta-adrenergic responsiveness Decreased max. HR with exercise
PulmonaryPulmonary
Decreased elastic recoil, airways collapse earlier
Decreased forced vital capacity, functional residual capacity, residual volume, FEV1
Decreased ventilatory response and chemoreceptor function Increased hypoxia and hypercapnia
Decreased elastic recoil, airways collapse earlier
Decreased forced vital capacity, functional residual capacity, residual volume, FEV1
Decreased ventilatory response and chemoreceptor function Increased hypoxia and hypercapnia
RenalRenal Decreased mass, # of glomeruli Increased glomerulosclerosis GFR slowly decreases CrCl maintains
Decreased Na+ rentention, decreased responsiveness to AVP; less concentration of urine
Decreased thirst and drink response Increased dehydration
Decreased mass, # of glomeruli Increased glomerulosclerosis GFR slowly decreases CrCl maintains
Decreased Na+ rentention, decreased responsiveness to AVP; less concentration of urine
Decreased thirst and drink response Increased dehydration
EndocrineEndocrine
Decreased glucose tolerance Independent of obesity and inactivity FG decreases 1 mg/dL/decade
Increased insulin resistance Decreased GH, IGF-1
Give elderly men GH, increases lean body mass
Decreased glucose tolerance Independent of obesity and inactivity FG decreases 1 mg/dL/decade
Increased insulin resistance Decreased GH, IGF-1
Give elderly men GH, increases lean body mass
ImmunologicImmunologic
Decreased T-cell activity Decreased Ab response to foreign
antigen Increased autoantibodies
Decreased T-cell activity Decreased Ab response to foreign
antigen Increased autoantibodies
Specific Geriatric IssuesSpecific Geriatric Issues
Other assessments to be made.
Other assessments to be made.
Cognitive FunctionCognitive Function
Normal decline Dementia
Alzheimer’s Vascular Others
Depression Medications EtOH
MMSE
Normal decline Dementia
Alzheimer’s Vascular Others
Depression Medications EtOH
MMSE
SensorySensory
Visual Auditory Balance
Visual Auditory Balance
IncontinenceIncontinence
Types Risk factors Assess Tests Treatment
Types Risk factors Assess Tests Treatment
Types of IncontinenceTypes of Incontinence
Urge Stress Functional Overflow Mixed
Urge Stress Functional Overflow Mixed
Fall RisksFall Risks
Intrinsic Person oriented issues… Mobility “Get up and go” test
Extrinsic Environment
Intrinsic Person oriented issues… Mobility “Get up and go” test
Extrinsic Environment
PolypharmacyPolypharmacy
Medication List Drug-drug interactions Altered pharmacokinetics,
pharmacodynamics Herbals OTC
Medication List Drug-drug interactions Altered pharmacokinetics,
pharmacodynamics Herbals OTC
OsteoporosisOsteoporosis
Screening Risk Factors Treatments
Screening Risk Factors Treatments
OthersOthers
Abuse Sexuality Vaccinations Financial Support System Driving
Abuse Sexuality Vaccinations Financial Support System Driving
ScreeningScreening
Thyroid Cancer
Sxs Pap Mammogram Colonoscopy
Lipids
Thyroid Cancer
Sxs Pap Mammogram Colonoscopy
Lipids
Questions???Questions???
Thank you very much for your participation!!
Good luck on your shelf!
Thank you very much for your participation!!
Good luck on your shelf!