Menopause

    Menopausal Symptoms

    Vasomotor Symptoms
    • 10% have extreme symptoms (soak bed sheets, need to change 5x/night)
    • 10% have no symptoms at all, and 80% in between
    •  
    Abnormal Uterine Bleeding
    Decline in Fertility
    Vaginal Symptoms (dyness, discomfort, itching, odour, dyspareunia).
     - Frequent Sex
     - Lubricants
    Urinary Incontinence (bladder and urethra have estrogen receptors)
    Sleep Problems
    Mood changes (23%)
    Weight gain (2-4lb)
    Osteoporosis

    Treatment of Symptoms

       General Notes:
    • Do Not monitor LH/FSH (fluctuate too much to diagnose menopause)
     

    Hormone Replacement Therapy (HRT)

    • Indicated for vasomotor symptoms ONLY + must be freshly menopausal (<1yr)
    • Osteoporosis: Works well (reduces hip fractures by 40%), but use other drugs
    • Dose: as low as possible, as short duration as possible (<5years)
    • Often comes with progesterone to reduce risk of endometrial ca.
    • Adverse effects:
      • CVA, Stroke (only worry if >70yo)
      • Breast Cancer
    • Benefits:
      • Reduces colon cancer risk
    • Generally safe if used short term.  CVA/Stroke risk present, but extremely low.

    • Risk Factors (50-70yo)  Baseline Risk /100  Additional Cancers
      /100
      No HRT (Baseline)  4.5  0.0
       5 years of HRT  4.5  0.2
       10 years of HRT  4.5  0.6
       15 years of HRT  4.5  1.2
       Late Menopause  4.5  1.3
       BMI (per 10 kg/m2 increase)  4.5  1.4
       Alcohol (2drinks/d)  4.5  2.7
       Lack of exercise (<4h/w)  4.5  2.7
       Weight Gain after menopause (>20kg)  4.5  4.5
    (SOGC/HRT "Lets Talk" series

    Venlafaxine (Effexor)

    • Small doses 35.5-75mg for vasomotor symptoms
     

    OCP

    • Treats anovulatory menses (irregular bleeding and/or heavy bleeding)
    • Treat 6-12mo (hopefully enough to take them through the transition)
    • 3 possible results when stop:
      • 1. No more bleeding
      • 2. Return to irregular menses (anovulatory)
      • 3. Odd oligomenorrhea
    • Still need to do endometrial biopsy
     

    Bisphosphonates

    • Significant GI symptoms (dyspepsia).  In the past required to sit upright x30min after ingestion. Still developed esophageal cancer.
    • Recent formulations weekly + monthly.
    • Can cause osteonecrosis of the jaw.
     
    Selective Estrogen Receptor Modulators (SERMs)
    • Were popular in the past.
    • Decrease Estrogen, and can increase vasomotor symptoms and VTE risk
    • Used for bone health, 
    • Endometrial Cancer can be perpetuatd by SERMS (unopposed estrogen), but apparently some do not affect endometrium (i.e. raloxifene)
     
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