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Management of the Menopause
Management of the Menopause MARY DEWlTT PETTIT, M.D., F.A.C.S.*
A KNOWLED9E of the proper management of the so-called menopause or female climacteric is important to almost every medical practitioner and specialist. There is still a tendency on the part of many physicians to blame all the symptoms occurring in women over the age of 35 on the "change of life." Women themselves tend to believe all sorts of stories told to them by friends and relatives. As a result of this combination of physician and patient credulity, important organic lesions may be missed in their early stages and quantities of estrogenic substance have been administered to patients without good reason. It is important, therefore, to think out a rational approach to this problem and to set up some reasonable plans for definitive therapy where this is indicated. WHAT CONSTITUTES THE CLIMACTERIC SYNDROME AND HOW DO WE RECOGNIZE IT?
The classical picture of the menopause entails: (1) decreasing or absent menstrual periods with developing atrophic change, (2) increasing sensitivity of the autonomic nervous system often indicated by "hot flashes" or severe sweats, and (3) emotional and nervous instability. Emotional and Vasomotor Instability
The unavoidable aging process is feared deeply by certain persons, both men and women. It may be accompanied by worries about insecurity and lessened efficiency that lead at times to true panic. The possibility of losing physical attractiveness, the emphasis on youth in popular magazines and in employment offices, fears concerning the stability of a marriage-all contribute to this unhappy state. Persons with immature personalities have real difficulty in facing these problems which must come to all people. It therefore behooves the physician to start with the premise that the woman who comes for help in her late 30's and early 40's often needs an explanation of her difficulty more than an injection of hormone. This takes time and understanding on the part of the physician.
* Professor of Gynecology, Woman's Medical College of Pennsylvania; Chief of Department of Gynecology, Hospital of The Woman's Medical College of Pennsylvania; Visiting Chief, Philadelphia General Hospital, Philadelphia. 1725
1726
Mary DeWitt Pettit
A thorough history will give the examiner many clues to the patient's personality as well as to her physical difficulty. Evidence of vasomotor instability during the interview frequently indicates a labile vasomotor system in that individual. There is no doubt that many premenopausal women give evidence of increasing nervous tension and psychosomatic disturbance especially in the premenstrual stage of the menstrual cycle. To give these women estrogen is a mistaken notion. Many of them already have a relative hyperestrinism and their difficulty is one of upset balance in the cycle. Ovarian function does not stop all at once. Defective ovulation and lack of ovulation result in a poorly secreting or absent corpus luteum. This results in upsets in water balance with fluid retention premenstrually. Patients will develop mastodynia a;nd many of them show exacerbations of cystic disease of the breasts. Headache, arthralgia and severe emotional tension also result. These may be strikingly relieved by fluid reduction, salt limitation, diuretics such as ammonium chloride and suitable substitution endocrine therapy. Some women will have none of these symptoms. If and when they occur, and not until they do, they may be dealt with. One must remember that hyperthyroidism and various neuropsychiatric states may mimic this syndrome. From all points of view, a thorough physical examination with urinalysis, blood count and other indicated studies should always precede treatment. This thoroughness, which must include examination of thyroid, breasts, pelvic organs and rectum, will set the stage psychologically to persuade the patient to cooperate with any needed treatment. The Age of the Menopause
Chronological age is not always helpful in making the diagnosis of climacteric. The average age of cessation of menses in this climate is between 48 and 50 years of age. Slight disturbance in endocrine balance may precede the outward and visible evidence of menopause by five to ten years. There will be an increasing number of anovulatory cycles or defective corpora lutea. Estrogen production is the last part of the follicle development to fail. The normal pattern of cessation should be one of decreasing amount of bleeding and lengthening intervals between periods. Any excessive or frequent bleeding is abnormal, as is recurrence of bleeding following a long period of amenorrhea. Women who have undergone unilateral oophorectomy or partial removal of ovaries can expect their climacteric on an average of five to ten years early. It must be remembered that removal of the uterus removes one-half the blood supply to the ovaries. These individuals, even with ovarian conservation, can expect an earlier menopause than their sisters. Any woman who has received irradiation to her pelvic organs even in subcastrating dosage will have had some destruction of primordial ovarian follicles. Because patients have such individual reactions to depriva-
Management of the Menopause
1727
tion of estrogen, we have not treated them until they have actually developed symptoms. We have not routinely used implantation of pellets or other long-acting hormones in surgical castrates. The administration of both testosterone and estrogen by oral preparation is exceedingly satisfactory and one can easily maintain a steady blood level with this form of medication. Women with uterine leiofibromyomas will often have a delayed menopause. One does not know the exact cause of uterine fibroids but it is certain that estrogenic substance either taken as medicine or endogenous in origin will increase their rate of growth. There is a definite familial trend in the age of climacteric uncomplicated by obvious pathologic states. It is worth while, therefore, to inquire into the ages at which maternal aunts, mother, grandmother and sisters of the patient experienced the menopause. Atrophic and Pathophysiologic Changes
All women will eventually have obvious atrophic change in skin and mucous membranes as a result of estrogen deprivation. This comes on at varying intervals after spontaneous cessation of menses. Some women have persistent estrogen activity for many years after cessation of menstrual flow. Early changes in vaginal and cervical mucosa are characterized by a shiny, thinned out, pale appearance. Instead of pink velvety mucosa and elastic vulvovaginal tissues, there is attentuation of tissue with loss of support and the tissues crack and bleed with minimal trauma. This gives rise to dyspareunia and is another very upsetting factor in the emotional adjustment to aging. Cytologic smears from the vaginal mucosa will reveal the basal type of epithelial cell and often many leukocytes. These women need reassurance, advice on proper lubrication of the vaginal tract and local use of estrogenic substance. They will have difficulty in overcoming infestations such as candidiasis or trichomonas vaginitis without replacement of estrogen. As the ovaries fail and production of estrogen deereases, examination of blc)Qd levels will show inereased pituitary activity and increased concentration of gonadotrophie hormones. It is most interesting that one cannot correlate these levels or the presence of changes in the vaginal smear with the symptoms of the patient either vasomotor or emotional. The well adjusted, happy and usually busy woman may have only the objective evidence of lack of menses to notify her of the end of her reproductive life. Most women have a few transient vasomotor phenomena and some emotional upset and pass these off with philosophical calm. There are many, however, whose nervous systems are really out of balance, whose profuse sweating and reddened faces are a real cause of discomfort and embarrassment. Severe headache, pains in joints and muscles, upsets in gastrointestinal pattern and all sorts of vague aches and pains may develop. One must realize that arthralgia may be due to
Mary DeWitt Pettit
1728
estrogen deprivation, headache may be due to pituitary swelling and change in water balance. Osteoporosis should not be overlooked and correction of defects in protein, mineral and vitamin content of the diet as well as hormone replacement must be planned. Skeletal x-rays should be taken when symptoms indicate this difficulty. DEFINITIVE THERAPY
Psychotherapy
After careful general physical examination and history, the physician is in a position to give specific advice. As far as the usual psychological and emotional difficulties are concerned, the psychotherapy resulting from the careful procedures outlined above may be sufficient. The fact should be stressed that the menopause is a transition phase and is se1£limited. The woman should know that the best thing you as a physician can do is to help her attain her new glandular balance easily and painlessly. She should be told that she will enter a period of physical wellbeing to which she can look forward and enjoy. It should be explained that a happy marriage with continued sexual activity may indeed become happier. Both individuals should be more mature, more thoughtful and they may actually need one another more than they did when their young children and the stresses of business and social life were more demanding. Fear of pregnancy has inhibited the sexual pleasure of many women and this barrier to marital happiness has gone. For the woman who has never had time to develop interests and skills beyond her routine home making, the time has now come to indulge in any activity which will keep her busy and make her feel useful. This last is a fundamental human need. It is a tragedy to see some women succumb to the feeling that their lives are over because children are grown and away, their husbands are busy and they have no resources within themselves. This is apt to happen just when the nervous and psychogenic instability of their menopause is at its height and they are least able to cope with their difficulties. Improvement of the Physical State
It is the physician's duty to explain and encourage. Everything must be done to improve the physical state so that the patient will feel like rehabilitating herself. Reduction of weight and stimulation of interest in her own appearance will often start her off. Proper diet, vitamins, minerals, exercise and rest are essential. The hypertensive patient must cut down on weight and physical activity. The underweight and listless person may benefit by more exercise and increased appetite. What sedation is advisable? One can evaluate the patient's needs while her studies are being done. Small doses of barbiturates or bromides for tense patients, amphetamine or one of its derivatives for the depressed patient may
Management of the Menopause
1729
work miracles. Insomnia certainly accentuates the unpleasant vasomotor manifestations. Thyroid substance where indicated will help the fatigue and general lack of desire for effort common in this group. Vitamin E has been tried to control vasomotor symptoms. In our clinic, we have not had much success with this medication. Weight Reduction
Obesity is a problem all its own but is a serious one in this age group. We must understand and if possible get the patient to face the fact that people do not get fat unless they are consuming more calories than they are metabolizing. When these people need psychological solace they eat large meals and nibble between meals. The very obese person is as much an addict to calories as any alcoholic is to alcohol. Unless this patient really wants to lose weight and gets enough pleasure from seeing progress occur until new eating habits are formed, very little can be accomplished. If there is some degree of hypothyroidism, the administration of thyroid substance is most helpful. Periodic weighing, a good diet sheet and use of the various appetite depressants will encourage the patient and get her started. The development of hypertensive disease and even diabetes mellitus may be delayed or averted in susceptible individuals. Hormonal Therapy
After the simple remedies described above have been tried, after examination of breasts and pelvis has ruled out malignant disease or other organic difficulty, hormonal therapy may be planned. Again, one must know what one can expect of each hormone and what are its limitations. Estrogenic substance will depress pituitary overactivity and usually correct the vasomotor symptoms. The vaginal smear will again become cornified, the cervical glands will secrete mucus, the endometrium will proliferate. If excessive or ill-planned dosage is given, uterine bleeding will recur and breast tissue become stimulated to proliferative changes. If the patient is developing a malignant tumor, estrogenic substance may increase its rate of growth. The dose of the hormone varies with the individual. I believe that oral medication with either synthetic (diethylstilbestrol 1 to 5 mg. daily; ethinyl estradiol 0.01 to 0.05 mg. daily) or natural estrogens (conjugated equine estrogens 1.25 mg. daily) is the treatment of choice. In special instances one may fortify this with injections at the beginning of treatment until a satisfactory blood level has been attained. Irregular medication results in sharp changes in blood estrogen levels. We then see the withdrawal bleeding so distressing to patient and physician. Some schedule of administration such as one tablet daily for 20 days, omit for ten days and repeat, will be satisfactory for many women.
1730
Mary DeWitt Pettit
There is now much evidence that the administration of a combination of estrogen 1 to 2 mg. and testosterone 5 to 10 mg., both of which will depress pituitary overactivity, will give improved therapeutic results. Each tends to neutralize the unpleasant side effects of the other. A smaller dosage of each may be given than would be effective for one alone (0.01 mg. ethinyl estradiol plus 5 to 10 mg. methyltestosterone daily). It is well known that the adrenal gland, which must take over endogenous hormone production during the menopause, normally produces both hormones. The androgenic hormone produces a feeling of well-being, enhanced libido and definite improvement in utilization of protein. When atrophic changes in vagina or vulva must be treated, the use of estrogenic substance in suppositories or creams locally may be most helpful. One may enhance this by oral medication below the level necessary to cause recurrence of bleeding. Vitamins A and D have been advised also, both for local application and by mouth. When fear of malignancy is a factor or when one fears reactivation of endometriosis, growth of fibroid tumors or recurrence of endometrial hyperplasia, one may give androgenic hormone in a cyclic fashion fortified with mild continuous barbiturate, as phenobarbital 16 mg. (~ grain) four times daily. Testosterone in the form of peroral (linguet) tablet, 10 mg., may be taken daily for 14 days, omitted for 14 days and repeated. This will often be most successful. SUMMARY AND CONCLUSIONS
1. Management of the menopausal patient may be exceedingly simple or may require all the ingenuity with which the physician is endowed. 2. A thorough history and complete physical examination including tlil.e thyroid, breasts and pelvic organs must precede all therapy. 3. Adequate and sympathetic handling of the patient's fears, vasomotor and emotional problems is most important in this group. 4. Physical defects, dietary peculiarities and vitamin deficiencies must be investigated and treated. 5. It is worth while to try the simple remedies of sedation, general hygiene, weight reduction and administration of thyroid substance where needed, before any other hormone therapy is planned. 6. Where indicated, judicious use of estrogens, androgens or a combination thereof is most successful and satisfactory. 7. It must be emphasized to each patient that her difficulty is a transient one of adjustment. She must be encouraged to take as much medicine as she needs for comfort but as little as she needs to control her symptoms. In this way she will not slow up the reestablishment of her own pituitary-thyroid-adrenal balance. She will get past this uncomfortable state if she can weather the immediate storm. Reassurance is very important to her.
Management of the Menopause
1731
REFERENCES Delaplaine, R. W., Bottomy, J. R., Blatt, M., Wiesbader, H. and Kupperman, H. S.: Effective Control of Surgical Menopause by Estradiol Pellet Implantation at the Time of Surgery. Surg., Gynec. & Obst. 94: 323 (March) 1952. Farell, D. M.: Dangers in the Mapagement of the Climacteric. M. CLIN. NORTH AMERICA 32: 1523 (Nov.) 1948. Freedman, N.: Influence of Vitamin D on Vaginal Epithelium of Menopause and Post Menopause. Am. J. Obst. & Gynee. 62: 1273 (Dec.) 1951. Goldzieher, J. W. and Goldzieher, M. A.: Clinical Evaluation of Long-Acting Steroid Hormones. New York J. Med. 53: 2853 (Dec. 1) W53. Greenblatt, R. B.: Newer Concepts in Management of the Menopause. Geri:;t,trics 7: 263 (Sept.) 1952. Grody, M. H., Lampe, E. H. and Masters, W. H.: Estrogen-Androgen Substitution Therapy in the Aged Female. Obst. & Gynec. 2: 36 (July) 1953. Lang, W. R. and Rakoff, A. E.: Vaginitis in Menopausal and Postmenopausal Woman. J. Am. Geriat. Soc. 1: 520 (July) 1953. Squires, A. H. and Cannell, D. E.: The Menopausal Patient. M. CLIN. NORTH AMERICA 36: 519 (March) 1952. 1930 Spruce Street Philadelphia 3, Pennsylvania
A KNOWLED9E of the proper management of the so-called menopause or female climacteric is important to almost every medical practitioner and specialist. There is still a tendency on the part of many physicians to blame all the symptoms occurring in women over the age of 35 on the "change of life." Women themselves tend to believe all sorts of stories told to them by friends and relatives. As a result of this combination of physician and patient credulity, important organic lesions may be missed in their early stages and quantities of estrogenic substance have been administered to patients without good reason. It is important, therefore, to think out a rational approach to this problem and to set up some reasonable plans for definitive therapy where this is indicated. WHAT CONSTITUTES THE CLIMACTERIC SYNDROME AND HOW DO WE RECOGNIZE IT?
The classical picture of the menopause entails: (1) decreasing or absent menstrual periods with developing atrophic change, (2) increasing sensitivity of the autonomic nervous system often indicated by "hot flashes" or severe sweats, and (3) emotional and nervous instability. Emotional and Vasomotor Instability
The unavoidable aging process is feared deeply by certain persons, both men and women. It may be accompanied by worries about insecurity and lessened efficiency that lead at times to true panic. The possibility of losing physical attractiveness, the emphasis on youth in popular magazines and in employment offices, fears concerning the stability of a marriage-all contribute to this unhappy state. Persons with immature personalities have real difficulty in facing these problems which must come to all people. It therefore behooves the physician to start with the premise that the woman who comes for help in her late 30's and early 40's often needs an explanation of her difficulty more than an injection of hormone. This takes time and understanding on the part of the physician.
* Professor of Gynecology, Woman's Medical College of Pennsylvania; Chief of Department of Gynecology, Hospital of The Woman's Medical College of Pennsylvania; Visiting Chief, Philadelphia General Hospital, Philadelphia. 1725
1726
Mary DeWitt Pettit
A thorough history will give the examiner many clues to the patient's personality as well as to her physical difficulty. Evidence of vasomotor instability during the interview frequently indicates a labile vasomotor system in that individual. There is no doubt that many premenopausal women give evidence of increasing nervous tension and psychosomatic disturbance especially in the premenstrual stage of the menstrual cycle. To give these women estrogen is a mistaken notion. Many of them already have a relative hyperestrinism and their difficulty is one of upset balance in the cycle. Ovarian function does not stop all at once. Defective ovulation and lack of ovulation result in a poorly secreting or absent corpus luteum. This results in upsets in water balance with fluid retention premenstrually. Patients will develop mastodynia a;nd many of them show exacerbations of cystic disease of the breasts. Headache, arthralgia and severe emotional tension also result. These may be strikingly relieved by fluid reduction, salt limitation, diuretics such as ammonium chloride and suitable substitution endocrine therapy. Some women will have none of these symptoms. If and when they occur, and not until they do, they may be dealt with. One must remember that hyperthyroidism and various neuropsychiatric states may mimic this syndrome. From all points of view, a thorough physical examination with urinalysis, blood count and other indicated studies should always precede treatment. This thoroughness, which must include examination of thyroid, breasts, pelvic organs and rectum, will set the stage psychologically to persuade the patient to cooperate with any needed treatment. The Age of the Menopause
Chronological age is not always helpful in making the diagnosis of climacteric. The average age of cessation of menses in this climate is between 48 and 50 years of age. Slight disturbance in endocrine balance may precede the outward and visible evidence of menopause by five to ten years. There will be an increasing number of anovulatory cycles or defective corpora lutea. Estrogen production is the last part of the follicle development to fail. The normal pattern of cessation should be one of decreasing amount of bleeding and lengthening intervals between periods. Any excessive or frequent bleeding is abnormal, as is recurrence of bleeding following a long period of amenorrhea. Women who have undergone unilateral oophorectomy or partial removal of ovaries can expect their climacteric on an average of five to ten years early. It must be remembered that removal of the uterus removes one-half the blood supply to the ovaries. These individuals, even with ovarian conservation, can expect an earlier menopause than their sisters. Any woman who has received irradiation to her pelvic organs even in subcastrating dosage will have had some destruction of primordial ovarian follicles. Because patients have such individual reactions to depriva-
Management of the Menopause
1727
tion of estrogen, we have not treated them until they have actually developed symptoms. We have not routinely used implantation of pellets or other long-acting hormones in surgical castrates. The administration of both testosterone and estrogen by oral preparation is exceedingly satisfactory and one can easily maintain a steady blood level with this form of medication. Women with uterine leiofibromyomas will often have a delayed menopause. One does not know the exact cause of uterine fibroids but it is certain that estrogenic substance either taken as medicine or endogenous in origin will increase their rate of growth. There is a definite familial trend in the age of climacteric uncomplicated by obvious pathologic states. It is worth while, therefore, to inquire into the ages at which maternal aunts, mother, grandmother and sisters of the patient experienced the menopause. Atrophic and Pathophysiologic Changes
All women will eventually have obvious atrophic change in skin and mucous membranes as a result of estrogen deprivation. This comes on at varying intervals after spontaneous cessation of menses. Some women have persistent estrogen activity for many years after cessation of menstrual flow. Early changes in vaginal and cervical mucosa are characterized by a shiny, thinned out, pale appearance. Instead of pink velvety mucosa and elastic vulvovaginal tissues, there is attentuation of tissue with loss of support and the tissues crack and bleed with minimal trauma. This gives rise to dyspareunia and is another very upsetting factor in the emotional adjustment to aging. Cytologic smears from the vaginal mucosa will reveal the basal type of epithelial cell and often many leukocytes. These women need reassurance, advice on proper lubrication of the vaginal tract and local use of estrogenic substance. They will have difficulty in overcoming infestations such as candidiasis or trichomonas vaginitis without replacement of estrogen. As the ovaries fail and production of estrogen deereases, examination of blc)Qd levels will show inereased pituitary activity and increased concentration of gonadotrophie hormones. It is most interesting that one cannot correlate these levels or the presence of changes in the vaginal smear with the symptoms of the patient either vasomotor or emotional. The well adjusted, happy and usually busy woman may have only the objective evidence of lack of menses to notify her of the end of her reproductive life. Most women have a few transient vasomotor phenomena and some emotional upset and pass these off with philosophical calm. There are many, however, whose nervous systems are really out of balance, whose profuse sweating and reddened faces are a real cause of discomfort and embarrassment. Severe headache, pains in joints and muscles, upsets in gastrointestinal pattern and all sorts of vague aches and pains may develop. One must realize that arthralgia may be due to
Mary DeWitt Pettit
1728
estrogen deprivation, headache may be due to pituitary swelling and change in water balance. Osteoporosis should not be overlooked and correction of defects in protein, mineral and vitamin content of the diet as well as hormone replacement must be planned. Skeletal x-rays should be taken when symptoms indicate this difficulty. DEFINITIVE THERAPY
Psychotherapy
After careful general physical examination and history, the physician is in a position to give specific advice. As far as the usual psychological and emotional difficulties are concerned, the psychotherapy resulting from the careful procedures outlined above may be sufficient. The fact should be stressed that the menopause is a transition phase and is se1£limited. The woman should know that the best thing you as a physician can do is to help her attain her new glandular balance easily and painlessly. She should be told that she will enter a period of physical wellbeing to which she can look forward and enjoy. It should be explained that a happy marriage with continued sexual activity may indeed become happier. Both individuals should be more mature, more thoughtful and they may actually need one another more than they did when their young children and the stresses of business and social life were more demanding. Fear of pregnancy has inhibited the sexual pleasure of many women and this barrier to marital happiness has gone. For the woman who has never had time to develop interests and skills beyond her routine home making, the time has now come to indulge in any activity which will keep her busy and make her feel useful. This last is a fundamental human need. It is a tragedy to see some women succumb to the feeling that their lives are over because children are grown and away, their husbands are busy and they have no resources within themselves. This is apt to happen just when the nervous and psychogenic instability of their menopause is at its height and they are least able to cope with their difficulties. Improvement of the Physical State
It is the physician's duty to explain and encourage. Everything must be done to improve the physical state so that the patient will feel like rehabilitating herself. Reduction of weight and stimulation of interest in her own appearance will often start her off. Proper diet, vitamins, minerals, exercise and rest are essential. The hypertensive patient must cut down on weight and physical activity. The underweight and listless person may benefit by more exercise and increased appetite. What sedation is advisable? One can evaluate the patient's needs while her studies are being done. Small doses of barbiturates or bromides for tense patients, amphetamine or one of its derivatives for the depressed patient may
Management of the Menopause
1729
work miracles. Insomnia certainly accentuates the unpleasant vasomotor manifestations. Thyroid substance where indicated will help the fatigue and general lack of desire for effort common in this group. Vitamin E has been tried to control vasomotor symptoms. In our clinic, we have not had much success with this medication. Weight Reduction
Obesity is a problem all its own but is a serious one in this age group. We must understand and if possible get the patient to face the fact that people do not get fat unless they are consuming more calories than they are metabolizing. When these people need psychological solace they eat large meals and nibble between meals. The very obese person is as much an addict to calories as any alcoholic is to alcohol. Unless this patient really wants to lose weight and gets enough pleasure from seeing progress occur until new eating habits are formed, very little can be accomplished. If there is some degree of hypothyroidism, the administration of thyroid substance is most helpful. Periodic weighing, a good diet sheet and use of the various appetite depressants will encourage the patient and get her started. The development of hypertensive disease and even diabetes mellitus may be delayed or averted in susceptible individuals. Hormonal Therapy
After the simple remedies described above have been tried, after examination of breasts and pelvis has ruled out malignant disease or other organic difficulty, hormonal therapy may be planned. Again, one must know what one can expect of each hormone and what are its limitations. Estrogenic substance will depress pituitary overactivity and usually correct the vasomotor symptoms. The vaginal smear will again become cornified, the cervical glands will secrete mucus, the endometrium will proliferate. If excessive or ill-planned dosage is given, uterine bleeding will recur and breast tissue become stimulated to proliferative changes. If the patient is developing a malignant tumor, estrogenic substance may increase its rate of growth. The dose of the hormone varies with the individual. I believe that oral medication with either synthetic (diethylstilbestrol 1 to 5 mg. daily; ethinyl estradiol 0.01 to 0.05 mg. daily) or natural estrogens (conjugated equine estrogens 1.25 mg. daily) is the treatment of choice. In special instances one may fortify this with injections at the beginning of treatment until a satisfactory blood level has been attained. Irregular medication results in sharp changes in blood estrogen levels. We then see the withdrawal bleeding so distressing to patient and physician. Some schedule of administration such as one tablet daily for 20 days, omit for ten days and repeat, will be satisfactory for many women.
1730
Mary DeWitt Pettit
There is now much evidence that the administration of a combination of estrogen 1 to 2 mg. and testosterone 5 to 10 mg., both of which will depress pituitary overactivity, will give improved therapeutic results. Each tends to neutralize the unpleasant side effects of the other. A smaller dosage of each may be given than would be effective for one alone (0.01 mg. ethinyl estradiol plus 5 to 10 mg. methyltestosterone daily). It is well known that the adrenal gland, which must take over endogenous hormone production during the menopause, normally produces both hormones. The androgenic hormone produces a feeling of well-being, enhanced libido and definite improvement in utilization of protein. When atrophic changes in vagina or vulva must be treated, the use of estrogenic substance in suppositories or creams locally may be most helpful. One may enhance this by oral medication below the level necessary to cause recurrence of bleeding. Vitamins A and D have been advised also, both for local application and by mouth. When fear of malignancy is a factor or when one fears reactivation of endometriosis, growth of fibroid tumors or recurrence of endometrial hyperplasia, one may give androgenic hormone in a cyclic fashion fortified with mild continuous barbiturate, as phenobarbital 16 mg. (~ grain) four times daily. Testosterone in the form of peroral (linguet) tablet, 10 mg., may be taken daily for 14 days, omitted for 14 days and repeated. This will often be most successful. SUMMARY AND CONCLUSIONS
1. Management of the menopausal patient may be exceedingly simple or may require all the ingenuity with which the physician is endowed. 2. A thorough history and complete physical examination including tlil.e thyroid, breasts and pelvic organs must precede all therapy. 3. Adequate and sympathetic handling of the patient's fears, vasomotor and emotional problems is most important in this group. 4. Physical defects, dietary peculiarities and vitamin deficiencies must be investigated and treated. 5. It is worth while to try the simple remedies of sedation, general hygiene, weight reduction and administration of thyroid substance where needed, before any other hormone therapy is planned. 6. Where indicated, judicious use of estrogens, androgens or a combination thereof is most successful and satisfactory. 7. It must be emphasized to each patient that her difficulty is a transient one of adjustment. She must be encouraged to take as much medicine as she needs for comfort but as little as she needs to control her symptoms. In this way she will not slow up the reestablishment of her own pituitary-thyroid-adrenal balance. She will get past this uncomfortable state if she can weather the immediate storm. Reassurance is very important to her.
Management of the Menopause
1731
REFERENCES Delaplaine, R. W., Bottomy, J. R., Blatt, M., Wiesbader, H. and Kupperman, H. S.: Effective Control of Surgical Menopause by Estradiol Pellet Implantation at the Time of Surgery. Surg., Gynec. & Obst. 94: 323 (March) 1952. Farell, D. M.: Dangers in the Mapagement of the Climacteric. M. CLIN. NORTH AMERICA 32: 1523 (Nov.) 1948. Freedman, N.: Influence of Vitamin D on Vaginal Epithelium of Menopause and Post Menopause. Am. J. Obst. & Gynee. 62: 1273 (Dec.) 1951. Goldzieher, J. W. and Goldzieher, M. A.: Clinical Evaluation of Long-Acting Steroid Hormones. New York J. Med. 53: 2853 (Dec. 1) W53. Greenblatt, R. B.: Newer Concepts in Management of the Menopause. Geri:;t,trics 7: 263 (Sept.) 1952. Grody, M. H., Lampe, E. H. and Masters, W. H.: Estrogen-Androgen Substitution Therapy in the Aged Female. Obst. & Gynec. 2: 36 (July) 1953. Lang, W. R. and Rakoff, A. E.: Vaginitis in Menopausal and Postmenopausal Woman. J. Am. Geriat. Soc. 1: 520 (July) 1953. Squires, A. H. and Cannell, D. E.: The Menopausal Patient. M. CLIN. NORTH AMERICA 36: 519 (March) 1952. 1930 Spruce Street Philadelphia 3, Pennsylvania