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The perimenopausal period
THEPERIMENOPAUSALPERIOD Implications
for Nurse-Midwifery
Practice
Marianne Scharbo-DeHaan, CNM, MN, and May C. Brucker. CNM,
fied anddi&ed.
.
Ewy year for the next 10 years ap proximately 4 million women will turn 40.’ A large number of these women have prevfoudy sought the care of certified nurse-midwives for their obstetric care. Now they may seek similar suppoti education, and g-eneralhealth management for the midyears surrounding menopause. Therefore, it is timely to review current information concerning this pedcd, the perimenopause.
DEFINITIONS “Menopause” is a word d-at is derived from two Greek words, one tneanfng “month” and the other “to stop.“-According to the World Health Omanfzation. menopa”se is the cemilon of menstruation rer;ulting from loss of ovarian activity. By definition it must be a retrospective diagnosis, because 12 months of amenorrhea must f&xv the last menses in order to safely as-
permanent
DNSC
wme that p&ds have ceased.* Because menopause actually encompassesa single event. another term, the “perimenopausal period,” has begun to gain popularity. Unlike a single event. the perimenopausal period is loosely defined as time around rnenopaure. both before and after. The pedmenopausal period is often used to desctibe the time in which women begin to experience symptoms associated with menooause. Sherman noted that oti~nall~ ihe pelimenopausal period v&en& =ioned as a short period of lime, but current evidence indicates that it is a protracted period lasting for as long as 15 years3 Harper suggestedthat the period may extend for a quarter century, from ages 35 to 60.’ Thus women in their early 4Os, although not experiencing symptoms, need anticipatory guidance. Two additional tem~ are imwrtan*to be recognixd for the m&e woman. “Climacteric” Is derived from Greek and means “rung oi the ladder.” It is essenUall~synonymws with the petimenopausalperiod. The other is the ‘Lpostmenopausal prtod,” which fs the period dating from met~qxiuse.~
experdce it after 50. Re&r nxmstluatfon pe.,tsb w2u into the sixth decade for sane women. Premature ovarian failure k deBtledmcasaLi.mdme~bebre age4naccomQa&dbyfnaeased gonsdotroptns and hypoestrogenkm. The etfokxy remains tmCbarandisCEonddered by-to be an autoimmune ttIwx&l aso&ted with c.ilcubuw antlbodbs to
tion of other factors such as familial ptterns, age at menarche, race, use of oral contraceptives.nutrition, and even M&, have resulted in unclear or cor&&tory findings.’ T&v. amxoximatelv one third of the “ion’; female &p&ion k poshnenopausal. As the average life expectancy for a female in the United States approaches SO years, a woman will Find herself spending a Full 40% of her life in the perimenopausal or pc%tmenopsusalperiods.5 THE IMAGE OF MENOPAUSE In the sock! and cultural context of today. ysuth is valued for strength and beauly. Menopause k intimately intertwined with aging, not a desirable state in this culture. Motaphsrs used in common language include the pejomtive phrase, “the change,” which suggestsa metamorphosisinto a genderless state. It has not been until recently, when celebrity role models have emerwd. that more mature women still &Id sexual
and
powerful
be seen as individuals.
even though they continue to appear in the minority. Parallel to contemporay cid:ure. health care providers also have ewsioned menopause and menopausal women in a poor light. Fink discussed medical myths of the menopause. He suggestedthat the odentation toward menopause in medi-
tine has been influenced by 1) the lack of quality scientific research in the area, 2) the preponderance of male physicians, and 3) the use of the diagnosis of menopause for a wide range of complaints of women between the ages of 40 and 65. sometimes to the physical and psy cholcgical debiment of the women.’ As Hamer stated. medicine has traditionaily viewed menopause and :he perimenopausal periods as evidence of pathology. It is not uncommon to Find a discussion of menopause in a gynecologic text under the heading of a disease of estrogen deprivation or of endoxinopathy. It is an appropriate time to view menopause from an alternative perspective. An analogy could be made with pregnancy. It can be argued that pregnancy is a pathologic state. Certainly pregnancy has been viewed as such within the medical Framework of the past. During pregralcy. there eat sQnif,cantph& psychological, psychosexual, and 50. cial variations from the “normal” nonpregnant state. However, most nurse-midwives view pregnancy as a normal life event. A similar view can exist for menopause. Significant vadations are associated with menopwse: physiologic, psychological. psychosexual. and social. Just as a normal pregnancy warrants obsewaiion. suppmt. anticipatory guidance, and, occasionally, intenrentton, so does the pertmenopausal period. The commonalities between pregnancy and menopause are Illustrated in Table 1. For a nuw-midwife to care competently for a woman and provide the needed management, support. and education. the clinician should also be aware of the underlying physiologic changes that occur during this time. HORMONE6 IN TRANSITFON Three major estrogensexist during a woman’s life. These are estmns. estradiol. and estrkal. The last is pm&csd exclusively during pregnancy. The principal estrogen for the pre-
TABLE 1 Comparlwn of Menopause and Premwmcy Me”opa”se
Pregnsney
Myihs and tears Major hommnalchanges Estrogen( t ) wK%enfl) Common discomforts ControvetiesI” management and screening Need for educationand support menopawal reproductive wmnan k esiradiol. Esimdiol is also the most potent of the estrogens, having approximately 10 times the patency of estrow5 It is produced preddminantlv in the o-.&tow follicle durinq Wh-CyCk. The number of potential ovulatow follicles far excee& the actual cm&. Accordins to Sherman. at 20 weeks of geskbbn. the female fetus has the potential for several million caa3 But even at that point, ovarian aging begins so that by menarche, a woman has the potential for 400,ooO ova. During the average reprcductive life cycle, she will release fewer than 500 mahue ova. The remainder undergo a&e&t. Thus, it is atresia, not ovulation. that is the dominant processin ovarian aging. is loss of ovulatory function by atresia that causes the eventual cessation of menses. Because estradiol k produced primarily in the ovulatoy follicle, at&a results in diminished production of eslmdiol. After the age OF35. the lossof wxytes and fcllicles results in gradual diminution of estmgen and inhibin, an ovarian hormone. This results in increased FSH, which induces rapid follicular development that results in shortening of the menstlual c&z, one of the first clinical evidences of the paimenopause. Ps the numbers of Follicles are Furtherdecreased, estrogen production falls to a level not compatible with an LH surge so that ovulation may cease or become irregular.5 The second major naturally occurring estrogen is eshone, the predominant postmenopausal estmgen. Un-
It
Journal of Nurse-Midwifery . Vd. 36, No. 1. JanuarglFebruary1991
like eslradiol, estrone has hvo major sources of production: from metabolism of &radio1 and also from aromatization of androstenedione in adipose tissue. As estradiol decrwsw, so does e&one to sane degree. However, because of the second production site in fat cells, estrone is still produced. As Wentz suggested, because adiposity remains unchanged or may even increase during the perimenopausal o&cd. estmne remains ool” slishtl” iess than during the preme~opausal wricd.5 As ilk&&d in Table 2. esbone,a less potent estrogen than estradiol, becomes the dominant estrogen of the postmenopausal woman. FSH levels gradually increase oe,tmenopausallvand remain at high levels postme~opausally.3 The so-called deficiencv state of menopause does not indicate total lack of estrogen, but rather a change in the production site. type of estrogen produced, and overall decrease ir. circulating levels. Some reqard menopause, then, as a physio&ic phenomenon that is protective in nature rather than a deficiency disease. The protection, accordingto Wentz. is from undesirable wpro-
COMMON DISCOMFORTS OF THE PERfMENOPAUSAL PERIOD Cellular estiogen receptors are located in organs throughout the body so that the decline in estrogen levels results in a multitude of clinicalmanifestations, Although many of the clinical manifestations are commonly known as “menopausal comolainls.” tbev are more apprOPiat& ;ecognized& diwomfort-associated with the decreasins eshadiol levels of the pedmenopa&l pet=&. The degree of diqomfoti to a woman depends upon many factors including. among others, the age of the woman, the rapidity with which her &radio1 levels decrease, her body adiposity, and her interpretation of the symptoms. These variations account for the tide disparity to clinical
expressions of common discornforts.8 Among the most commonly reported symptoms are those of “asomotor instability, genitourinary alterations, alterations of the skin, hair, and bones. and psychogenic complaints. It should be recognized that many discomforts are commonly treated with estrogen replacement therapy. An accompan~ngpaper in this issue by Lichtman (see page 30) addresses the specifics of hormonal therapy in detail. Vasomotor Instability The single most obvious, and often the first, discomfort of the climacteric is “asomotor instability. Manifestations of the instability can be divided into three different entities: hot flash, hot flush. and niqht sweats. Although the usual term iy patien!r End providers alike is “hot flash.” Harper reviewed the phenomena and suggested that a hot flash is actually the sudden sensation of warmth, usually in the head, neck, and chest; this is a symptom o! varying intensity and duration. A hot flush is the changein the skin temperature or flushing of the skin that follows the hot flash: it is an observablesign as opposed to the svmotom of hot flash. Night sweats &e hot tlashes that o&while the woman sleeps, usually awakening ha4 The incidence of hot flashes/ flushes reported in the literature varies. Klehky and Borenstein reported an incidence of 50%. whereas Sperofi et al reported an incidenceof 85%.s.9 Regardless of the range. hot flushes and flashes constitute a discomfon for a large number of perimenopausal women. They may be triggered by a variety of stimuli. such as alcohol, spicy foods, hot weather. emotional distress. or even a “JarIn roan. The etiology of hot flashes remains unclear. Hot flashes coincide with an LH surge.8 It is speculated that alterations in the feedback mechanism of the menstrual cycle interact with the gonadotropin-re-
Journal of Nurse-Midwifery l Vol. 36. No. 1. JanuzuyiFebrua~ 1991
leasing hormone neurons of the hyp4alamus. These neumns. in close proximitv to the thermoreculatow initiatethe fl&h. kother factor thought to be invohwd is the effect of increasing instablity of catecholamines amciated with declining estmdiil levels. The vasodilatinq effects of pmstaqlandinrelease may-&0 &?a-the Msomotcr situa-
&ers,ernay
tion. Hormonal replacement therapy has been widely and successfully used as a twatmeot modality for vasomotor instability. Both estrogen and medroxyprogesterone acetate have significantly reduced the frequency of hot flashe~.‘~ Alternative treatments have often been suggested, but not widely researched. Among the alternative modalities have been the chartingof hot flash= in order to belter educate the paimenopausal woman about her body and allow her to cope with the symptoms.” Other nonintewentive therapies have included use of relaxation methods and guided tmagey. Nut,itional treatments have included the use of alternative diets or supplementation of tihmins E, 6 compfa, or C or of zinc4 Homeopathic remedies have suggestedgjnseng tea, bee pollen, or cohash.‘* Anectodal re‘pa* of S”CCe55of alternative treatments abound perhaps due to the effectiveness of these nontraditional treatments, or the biologic vadations of individuals using them, or even the time-limited nature of the complaints. However, sctentific data is l&.illg. Urogenital Variations The linings of the vagfnaand urethra are rich with eshcgen receptor5 and thus are extremely sensitive to the decreasing estradiol levels of the wrimenooausal wriod. As eshown ievels de&se, ‘so does the thickwas of the vaoinal eoithaliurr.. C!inlally, a maturation index may demonetmte thls changeGth an increase in pambasal and intermediate cel!s and a decrease in superficial cells. Table 3 illmtes this shift to the left.
_
I1
TABLE2 Hormonal Concentrations PrelW%?XUSll
EstradiOlIpgirnLI EstmneftimL) FSH lmlU/mLI
50-M) 30-40 1.2
As the squamous eptthelium decreases, the glycogen in the cells diminishes, culminating in an increased vagtnal PH. Therefore, the patmenopausal woman may expelience vaginal discomforts such as dynes, irritation. and dy_pawunia. The changesin va@nal pH may make her more prone b vaginit& or leukorrhea. External genitalia may also change in appeamnce. As noted by 8ergman and Brenner, the thinning hair and loss of subcutaneous fat and tissue of the pudenda is related to both aging and lack of es~~~n.‘~ However it may cause concern about body’image for the woman involved. Common treatment for the vaginal and vulvular alterations have been oral or toplcal hormonal repbcement therapy. Among alternative treatments proposed have been dietary manipulation to ensure meeting the RDA recommendation of 15 mg of zinc dail~,~ as well as the usual nonpharmaceutical treatments for vagtnitis (eg, cotton underwear, sitz baths, yogurt douche). Acidophilus tab!& have been suggested as another alternative theraw for vaginitis according to Cobb.12 Unfortunately, as with most alternative therapies and herbal remedies. wide variations in treatment regimens exist, and no scientific data Is available to allow evaluation of efficxy. Similar to the vaginal mucosa, the urethral mumsa c&s are estrogen sensitiven Thus. as estmdiol levels decrease, a ped&nopausal woman may expertence variations in the urinary system. In addition to udnay hequency and sbessincontinence, a
hmtng,
12
300~5Oa 15%3w 10
5-2.5 20-M) I-100
particular phenomenon related to this period is urge incontinence. Because of cellular changes, reststence to urine is lessened and urine flow is difficult to controt.l3 In addition to hormonal redacement therapy, general recon&ndattons for well-being of the urinary system are in order. Frequent voidings, drinking water, and avoiding urinary initants are always good advice. Kegel exercisesprovide relief for sane casesof stressinconttnance. although their use in treating urge incontinence is limited, Panty liners may provide an e&a protection for women who fear loss of a few drops of lutne. Skin Changes Sktn charwee associated with aging occur in both men and women. It is difficult to differentiate changes attributable solely to aging from those associated with estnx-en deftciencv. Pertmenopausal women may co& plain of focal hyperpigmentation, depigmentation, dytng of the skin, decrease in restHence.and bruktng. In spite of the fact that cosmeticcornpanies tend to blame aging alone, Greenwood summadzed current sctenttfic knowledge in asserting that major factors involved with wrinkles are neither aging nor menopause, but the potentially preventable
factors of smoking and sun exposure.‘4 Treatments for dy skin may include lotions and oils without an alcoholic base. Little is written wg9estin.athe use of hormonal redacetherapy to prevent skin’wdnklins or other dtsorden. altbouoh it has-been suggested that skincollagen content and skin thickness may be increased with such therapy. The buccal muco~a also is rich in estrogen receptors. Some pefinlenopausal women report an unusuauy dry mouth and increased salivary viscosity. Go4 dental hygiene. gum massage. and use of mink or other agents can be recommended to a &man for some relief. Voda and Tucker reported two other discomforts of the perimenooausal wiod. In their research. thev iound &men who reported fonnl’ cations, or the sensation of something crawling on one’s skin. A woman might casually attribute the sensation to an insect, but be unable to find such a creature. Voda and Tucker suggested antictpatory guidance and reassuranceas treatments. Restless or “jumpy legs” was another symptom reported by women in their studies. They suggested treatment by activity or massage as well as the aforementioned anttcipatoy guidance and reassurance.~’
&nt
Hair Asswiated with declining &radio1 levels and increased adrenocorikal activity, there exists the tendency to have thicker and coarser hair grow on the chin, lip, chest, and abdomen. Once hair folltclesare stimulated they tend to continue to grow. Hair removal by electrolysis or top ical treatments depends upon the choice of the woman. If a woman
TABLE 3 Maturation Index Cell Count 100
Journal of Nurse-MidwHey . Vol. 36. No. 1. Janvay,Febmay
,991
has alopecia.it is likely that it will increase in sevellty during this period. Few studies have discussed nonpbarroaceutical treatment methods for these symptoms. Bones Peak bone mass has been achieved before a woman enters the perimenopausal period. However, bones continue to undergo continual dynamic changesof basic remineralization and demineralization. Through complex physiologic interrelationships among calcium, calcitonin, vitamins A and D. pamthyroid hormones. and estrw.wn. a level of homeostasis is es&ally maintained. As estradiol decreases, the dynamics begin to change, allowing demineralizationto occur at a greater degree than remineraltttion. Therefore. loss of bone density results. Eventually. for some women, the bone mass may become so fragile that fractures occur with minimal trauma. This pathologic ccxdttion, called osteoporosis, is more prevalent among certain subgroups of women. As outlined by Johnson. plincipal risk factors are age. female gender, caucasianand oriental races, slender bodv. and beins ~ostmenopausal. He identified se&ndaly lisk factors of 11 calcium deficiencv. 21 protein excess, 3) substance abuses bf alcohol, tobacco, and coffee, 31 family history or 4) any medical disease associated with bone 10~s.‘~ The optimum approach to osteoporosis -is prevehilon. Adequate bone mass developed in young adulthood will help the woman as she reech~~the pertmenopausalperiod. Identification of those risk factors that can be ameliorated is important. Diagnosis of osteoporosis is usually accomplished by a radiographic technique, hopefully before fracture. The most common diagnostic techniques are dual photon absorptiometry, quantitative cornputed tomcgraphy. and dual photon x-ray quantitative dual x-ray. These
methods use a small amcxnt of tadtation and assess density, usudliy in the vertebrae or hip. It has b&n estimated that they may identify bone losses of as small as 2% or 3%.16 The most effective method to retard bone loss or reverse it moderately is estrcgen supplemenhtionwplacement. Moderate exerc;se has been suggested to aid in slowing bone mass loss, but associations are not clear.‘5 Calcium supplements have been shown to be effective in building bones and slowing bone loss but not sufficient alone in preventing osteoporosis. A dietay program emphasizing magnesium instead of calcium has been shown to rebuild bone mass postmenopausally, and the “se of etidronate has also been shown to be effective in the treatment of osteoporo~is”~‘~ Additional research is warranted in all areas of osteoporosis 1) prevention of the disease, 2) diagnosis, especially to increase accessibility and decrease cost, and 3) treatments. particularly nonhormonal alternatives. Psyibogenic Complaints Accompanyingthe physical changes of the perimenopausal period are issues of bodv image and self-esteem. As menfioned before, there is a societal view that menopause and the years thereafter signal “an inevttable slide into seniiity.“~14 It is important to note that these external societal opinions occur at a point when a woman is also most likely to be experiencing mternal personal changes. Fink stimmarized these midlife changes as the “empty nest, the struggle over career, the unhappy and sometimes adulterous husband, the illness and death of parents. the disappointments of past and present and the fear of the fut~re.“~ Dufly noted in her research that the higher the level of self-esin the midlife woman, the higher her health promotion behaviors.‘9 Therefore, self-esteem needs to be supported and pro-
teem
Journal of Nurse-Midwifery . Vol. 36. No. 1. JanuaxyFebmary 1991
m&d during this pried of life to effect overall health Sexuality also can change during the p&menopausal period. Lieblum and Bachmann summarized previ01!5 stub of sexuality of tbe dmacteric trnman. They found that there was a general-decrease in sexual interest for women afta their Rfth decade.However, it was difficult to extrapolate from the data if this finding was linked to menopause or asscciated with a general decline in both sexes as they age.= It was d& covered that women who did cmtinue sexual activity had less vaginal atrophy. and a suggestion existed that hot flashes ma” be reduced through an unclear r&tionship be tween coitus and gw.dotrop+ release.7 Psychogenic complaints are not easily remedied by hormonal replacementi~eahnent They reflect internal and external influences. Cetified nurse-midwives would be well advised to support positive imagesof matutity as well as to SUpQoIt individual women with realistic and accurate infomxltion. ContinlMtiOr~ Of sexual activity in different forms throughout the life cycle should be viewed as normal. Sensitivity about the taboos regardingsexuaitty would allow the professional to impart education and support in an appropriate manner. Table 4 identifies additional self-help measures for the middle years.=
Wbtle supporting the woman in her desire to rem;in sexually acttve, the nurse-mldwife must also be aware that contraception should also be considered. Kaew reported in 1989 that, without contraception, conception could occur amongan estimated 86% of the 10.1 million women aged35-39; 78% of the 8.9 million v,omen aged 40-44; and 69% of the 7.1 million aged 45-49.= Therefore, more than 20 million women exist who are potennauyfecund ov;r the age of 35. Moreover. these women are less likely than 13
TABLE 4
Self.Help Measures for Middle Years Women Remedy
Need Knowledce of middle !!ears
Preparation and support by knowledgeable health providers
Health maintenance
Monthly breast selfaaminatfon Appropriate nutrition and exercise Yearly Pap smears and breast examinations by a health care prodder REguf3.rstwl guaiac tests Eliminate smoking and use alcohol moderately
Hot flashes
Wear layered clothing vitmin E Action: Prevents excess& FS” and LH production Dietary sources: Wheat gam, whole grains, vegetable oils, soybeans. peanuts. rpinach Dose: Vanes with individual’s nubidonal status. Usually begin with 100 IU increasing over weeks or a month or two. to Mx) IU until relief of symptoms Note Inges, after me& with fat 01 take wtth tecitbin (contatns phmphoms) to aid absorp+ion. Medical supervision needed for those with hypertension. heart disease. and diabetes. Sometimes used in combination v&h ginseng. Taker 2-6 weeks to be effective Ginseng ,herb, Action: Unknown. Said to increase feelings of well-being. and changes in bcdy metabolism Dow: Vanes with bcdy weight Note: Take on empty stomach before or between meals. Should not be taken with vitamin C. Difficult to be sure of purcbajmg pure ~weng. Contains small amounts d estrogen. has a component closely resembling digitoxtn. and appears to affect blood leve!~ of 9kxoso BF.~ 9lyccgen levels in liver and mu&. Use questhmable by diabetfEs and those takfn9 cardiac glycxxides. May be pack& with mandrake mot (contains scopolamine) and snakeroot lcontains reseelpkle) Vftamin B compfex Actton: Aids in detoxification and elimination of FSH and LH by llwr Dietary SDUMI: Whole @ins, wheat gzrm. yogurt. brewer’s yeast milk Dose: one to tv.0 daily after meals
Vaginaldlyness
Continued intercourre and/or masturbation aids ckculation and helps keep hues Lubrication: water-soluble jelly, vegetable atl. or if necessary. esbgen aearn
Osteopomsb preuention
Exercise: Any that puts traction on long banes as walking. tennis. dancing. bicycle riding Increase calcium intake
flexible.
Supplements available as calcium lactate, carbonate or 9luwnate Dose: Sufftcient (with dietary sources) to equal 1 g/day beginning age 25, 1.5 glday pasLme”ap3”sal years
Nervousness.,mtability,
Vitamin E6, 5-25 m9 daily (Do not exceed 100 mgl Dietan, ~)uce.s: Brewers’ yeast. bran. wheat germ. organ meats. malasses. wafnutr. peanuts. brown rice
“feeling blue” Insomnia
.Wa’arm milk at bedtime (contatns typtophsnl. Calcium at bedtime. No coffee. tea, chocolate or cola after evain meal Chamomile tea Caution: can cause hypersznsitity for people allergk to ragweed, asters, chrysanthemums Vaferian tea &on9 cdorl. Both teas slow dig&ton if u=d daily
Pelvic relaxation
Weight loss if overweight Kegel exerctsesto increase muscle tone
Muscle cramps
Caldum tablets or calcium-magnesium
Prevention of urinary tract infection
Incre~~reul~I
younger
a preg-
nancy.
women
to Want
However.
21% of women
approximately
in the United
States
between the ages of 40 and 44 use
14
products such as dolomite
void frequently. urinate after intermurse, maintain gacd hygiene, wem cotton
no method percentage
of contraception.
This
is higher than any other
age group. including adolescents. Fomey susgested that this h&h per-
Journal Of Nurse-Midwifery
centaw
ts due to limited contracep-
tfve ;ptfons
available
this age gr~up.~ Recently IIEW
to women
thoughts
. Vol. 36. No. 1. danua@Febnmy
bf
have
1991
emerged about the use of oral contraceptives amons women over the age if 35. An advisoiy group to the Food and Dram Administration has recommended that age limits on the use of oral contraceptives by healthy, nonsmoking women be removed.= In common practice. many providers now continue to prescribe birth control pills to women in their 40s. However, no studies have been conducted regarding oral contraceptives and the perimenopausal woman. For most women, use of oral contraceptiveshelps prevent the common complaint of irregularities of the menstrual cycle. A difficulty occurs when the woman and clinician decide to implement hormonal replacement therapy. The estrogen in combination pills can be up to five times the amount in estrogenlhormane replacement therapy, and there seems to be no intermediary pill between the oral contraceptive and replacemec! therapy. Suggested manasement has included vearlv evaluation of FSH levels starting at the aoe of 50. FSH IeveL are confour&d by oral contraceptive usage. mandating discontinuation for a pedod of time starting at the age of 50 with resumption of oral contraceptives d FSH levels are not elevated. However, once elevated, oral contraceptives could be permanently discontinued and replacement therapy initiated. Other clinicians have advocated using the age of 50 as an arbitrarv dme w witch &alar-
fll~C~“tlCdlS.~~
Other methods that are available to the pedmenopavsal woman include stetilization [male or female), banier methods, and the inhautetine device (IUD). Although the IUD is the second most popular reversible method for women aged 40-44 (the most popular is the condom), it is as sociated with menstrual bleeding problems and dysmenorrhea that could be compounded by fibroids or pedmenopaueal menorrhagia. The feru!ity awareness method is also more problematic during the pedmenopausal years because of the
menstrual cycle irregularities. As always, contraceptive care InUS, be individualized. However, more research is needed in the area of pertmenopausal contraception and more options are needed so appropriate individualization can be accomplished.
GENERAL G!J!DELlNES FOR MANAGEMENT In order to educate women aboui the normalcy of the climactedc, it is optimal to care for her before she has developed any of the common discomforts.Byny outlined a plan to maintain health and prevent disease. These recommendations were designed to provide a fomm to educate the woman about her health, promote behavioral changes, and screen for risk factors or early signs of cardiovascular disease, cancer, or infectiowz5 Following Byny’s guidelines. a well woman would be seen annually. Evey year from the climactedc on, she would have a histoy (especially to screen for risk factors in general and substanceabuse in particular), a general physical that includes assessment of height, weight, breasts. pelvis, and rectum, and vision and hearing assessments. A woman should have routine tetanusldlphtheria booster every 10 years and, startino at ase 60. she should have a pneumwax-immunization euely five years end xl xx-a! in:xnza imm:: r;ine:ion. Starting at age 40. a woman should be screened for occult blood annually and lipoproteins profile evey fzw years. At age 60. thyroid assessments are recammended eve?, two years, as wdl as an annual hematoait or hemoglobin test. A base!ine mammogram &ould be wrfon-ned at age 35, wfonned pexiodically under age- 50. and yearly thereafter. Tonome!ry and fundoscopy is recommended every five years after age 40. Pmctosigmoidoscopy is suggestedevery four years starting at age 48. These guidelines were developed for the
buma! ofNurse.Midwifew . Vo!. 36. No. 1. Januaryifebm&
1991
low-risk woman and should be individualized as needed.=
SUMMARY
Women during the pmimenopausal period present both a challenge and an opportunity for certified nursemidwives. To best deliver care to women during this time, a nwsemidwife must be familiar with the normal vattationsassaiated with decreasing &radio1 levels. Moreover. the professionalmust also appreciate the cultural and social context of menopause and agina Use of an organized plan for delivery of care allows the certified nurse-midurife to target risk factors and prwide an organized approach to maximize health during this prime time of life. REFERENCE8 1. Wegg RB: Demography, in Mishell DR fed), Menopause:Physiolw and Phannacolq,. Chicago.Year Book MedicalPublishers.1987. 2. World Health Oiganization: Researchon the menopause.WHO Technical Report X670. Geneva, WHO. 1951. 3. ShermanBM: Endoninolc@cand menstmual alterations,in MishellDR (ed,, Menopause: Physiology and Phamxcology Chicago, Year Book Medical publisher, 1987. 4. Harper D: Perimenopauseand aging, in Lichtman R. Papem S (eds). Gynecology: Well-woman Care. East Norwalk. Connecticut, Appleton & Lange. 1990. 5. Wenb AC: Managementof the menopause,in Jones HW, Wenb AC, Bum& LS feds). Novak’sTextbookof Gynecology, 11th ed. Baltimore, Williams& WIuCins, 1988. p. 397. 6. Da,,,ewwd MD: What factonundedle premahlre ovarian failure? Contemp ‘Xstet Gyoecol35:31, 1990. 7. Fink PJ: Psychiatric myths of menopause,b Eskin BA (cd). Menopause: Comprehensive Management, 2nd ed. New York, Macmllan, 1988. 8. Sperofl L, GlassR KaseN: Clinical mmecologic endcatnol~ and infertility. 4th ed. Baltimore. Willlams & Wilkins.1989. 15
9. Kkkky 0, Borenrtein R: Varomotor instability of the menopause, in M&hell DR fed), Menopause: Pbysiolosy and Pharmacology. Chicago. Year Baok Medical Publishers 1987.
10. No& B, Jones M. Crilly R. et ak A p!acebc..contro”edtrtal of ethinyl of% tmdiol and no,rtbesterone in dimactatc women. Matudtas 2:247-251.1980. 11. Vc& A. Tucker J: Menapause: Me and you. Salt Lake City, Universityof Utah, 1984. 12. Cobb J: Aitematiwr to hormone use, in A Friend Indeed 515). Montreal, A Mend indeed Publicabcms.1988. 13. Bergman A. Brenner P: Alterations in urogenital system.in Mishell DR fed). Meno0aw.e: Phtialwv and Phar-
14. Greenwood SA: Menopause “at-
16
umlly Preparing for the second half of life. Volcano, CA, Vokano. 1989. 15. Johnson CC: Osteoporosis, in E&t” BA ledl. Merwpawz Comprehensive Management. 2nd ed. New York. MacmiUa”. 19%. 16. Mflkr p: Advancer in osteopwasis manwanent. Cantemp Obstet Gynecol 6:31-46. 1988. 17. Abraham GE. Grewal H: A total dietary pmgmm emphasting magnesium instead of c&turn. J Reprod Med 35. 503-507.1990 18 watts NB. et al lntelmitte”t cyclical etidronate tratment of pastmenopausal osteoporosis. N Engl J Med 323:73-79. 1990. 19. Dutfy ME- Determinants of health promotion in midlife women. Nurs Res 37:35S-362. 1988. 20. Lieblum 5. Bachmann G: The
sexuaUtv of the cltmachtic woman. in E&n i led), Menopause: Comp&nsive Management, 2nd ed. New York. Macmillan, 1988.
21. Adams BN: The middle years woman: Educatton for health promoSo” and maintenance. in Littlefield VM (ed). Health Education for Women: A Guide for Nurses and Other Health Professionals.Notwalk, Connecttcu~ AppletonCentury-Crofts. 1986. pp 336-337. 22. Kaeser L: Reconsideling the age limits 0” pill we. Fam Plan” Perspect 21:273-274, 1989. 23. Fomey J: canhaceptio” in Amertcan women 40 and over. Fam Plann Perspat 19:32-35.1987 24. Clinicians devising pmtccols for perk”enopa”sal oc users. Contracept Techno, update 11:81-92, ls9Ll. 25 qwnu R: Establishin” ouiddines for preve%e medicine. C%mp Obstet Gynecol31:43-49, 1988.
dwrnal of Nurse-Midwifery . Vol. 36. No. 1. danua,y/Feb,,w,
1991
for Nurse-Midwifery
Practice
Marianne Scharbo-DeHaan, CNM, MN, and May C. Brucker. CNM,
fied anddi&ed.
.
Ewy year for the next 10 years ap proximately 4 million women will turn 40.’ A large number of these women have prevfoudy sought the care of certified nurse-midwives for their obstetric care. Now they may seek similar suppoti education, and g-eneralhealth management for the midyears surrounding menopause. Therefore, it is timely to review current information concerning this pedcd, the perimenopause.
DEFINITIONS “Menopause” is a word d-at is derived from two Greek words, one tneanfng “month” and the other “to stop.“-According to the World Health Omanfzation. menopa”se is the cemilon of menstruation rer;ulting from loss of ovarian activity. By definition it must be a retrospective diagnosis, because 12 months of amenorrhea must f&xv the last menses in order to safely as-
permanent
DNSC
wme that p&ds have ceased.* Because menopause actually encompassesa single event. another term, the “perimenopausal period,” has begun to gain popularity. Unlike a single event. the perimenopausal period is loosely defined as time around rnenopaure. both before and after. The pedmenopausal period is often used to desctibe the time in which women begin to experience symptoms associated with menooause. Sherman noted that oti~nall~ ihe pelimenopausal period v&en& =ioned as a short period of lime, but current evidence indicates that it is a protracted period lasting for as long as 15 years3 Harper suggestedthat the period may extend for a quarter century, from ages 35 to 60.’ Thus women in their early 4Os, although not experiencing symptoms, need anticipatory guidance. Two additional tem~ are imwrtan*to be recognixd for the m&e woman. “Climacteric” Is derived from Greek and means “rung oi the ladder.” It is essenUall~synonymws with the petimenopausalperiod. The other is the ‘Lpostmenopausal prtod,” which fs the period dating from met~qxiuse.~
experdce it after 50. Re&r nxmstluatfon pe.,tsb w2u into the sixth decade for sane women. Premature ovarian failure k deBtledmcasaLi.mdme~bebre age4naccomQa&dbyfnaeased gonsdotroptns and hypoestrogenkm. The etfokxy remains tmCbarandisCEonddered by-to be an autoimmune ttIwx&l aso&ted with c.ilcubuw antlbodbs to
tion of other factors such as familial ptterns, age at menarche, race, use of oral contraceptives.nutrition, and even M&, have resulted in unclear or cor&&tory findings.’ T&v. amxoximatelv one third of the “ion’; female &p&ion k poshnenopausal. As the average life expectancy for a female in the United States approaches SO years, a woman will Find herself spending a Full 40% of her life in the perimenopausal or pc%tmenopsusalperiods.5 THE IMAGE OF MENOPAUSE In the sock! and cultural context of today. ysuth is valued for strength and beauly. Menopause k intimately intertwined with aging, not a desirable state in this culture. Motaphsrs used in common language include the pejomtive phrase, “the change,” which suggestsa metamorphosisinto a genderless state. It has not been until recently, when celebrity role models have emerwd. that more mature women still &Id sexual
and
powerful
be seen as individuals.
even though they continue to appear in the minority. Parallel to contemporay cid:ure. health care providers also have ewsioned menopause and menopausal women in a poor light. Fink discussed medical myths of the menopause. He suggestedthat the odentation toward menopause in medi-
tine has been influenced by 1) the lack of quality scientific research in the area, 2) the preponderance of male physicians, and 3) the use of the diagnosis of menopause for a wide range of complaints of women between the ages of 40 and 65. sometimes to the physical and psy cholcgical debiment of the women.’ As Hamer stated. medicine has traditionaily viewed menopause and :he perimenopausal periods as evidence of pathology. It is not uncommon to Find a discussion of menopause in a gynecologic text under the heading of a disease of estrogen deprivation or of endoxinopathy. It is an appropriate time to view menopause from an alternative perspective. An analogy could be made with pregnancy. It can be argued that pregnancy is a pathologic state. Certainly pregnancy has been viewed as such within the medical Framework of the past. During pregralcy. there eat sQnif,cantph& psychological, psychosexual, and 50. cial variations from the “normal” nonpregnant state. However, most nurse-midwives view pregnancy as a normal life event. A similar view can exist for menopause. Significant vadations are associated with menopwse: physiologic, psychological. psychosexual. and social. Just as a normal pregnancy warrants obsewaiion. suppmt. anticipatory guidance, and, occasionally, intenrentton, so does the pertmenopausal period. The commonalities between pregnancy and menopause are Illustrated in Table 1. For a nuw-midwife to care competently for a woman and provide the needed management, support. and education. the clinician should also be aware of the underlying physiologic changes that occur during this time. HORMONE6 IN TRANSITFON Three major estrogensexist during a woman’s life. These are estmns. estradiol. and estrkal. The last is pm&csd exclusively during pregnancy. The principal estrogen for the pre-
TABLE 1 Comparlwn of Menopause and Premwmcy Me”opa”se
Pregnsney
Myihs and tears Major hommnalchanges Estrogen( t ) wK%enfl) Common discomforts ControvetiesI” management and screening Need for educationand support menopawal reproductive wmnan k esiradiol. Esimdiol is also the most potent of the estrogens, having approximately 10 times the patency of estrow5 It is produced preddminantlv in the o-.&tow follicle durinq Wh-CyCk. The number of potential ovulatow follicles far excee& the actual cm&. Accordins to Sherman. at 20 weeks of geskbbn. the female fetus has the potential for several million caa3 But even at that point, ovarian aging begins so that by menarche, a woman has the potential for 400,ooO ova. During the average reprcductive life cycle, she will release fewer than 500 mahue ova. The remainder undergo a&e&t. Thus, it is atresia, not ovulation. that is the dominant processin ovarian aging. is loss of ovulatory function by atresia that causes the eventual cessation of menses. Because estradiol k produced primarily in the ovulatoy follicle, at&a results in diminished production of eslmdiol. After the age OF35. the lossof wxytes and fcllicles results in gradual diminution of estmgen and inhibin, an ovarian hormone. This results in increased FSH, which induces rapid follicular development that results in shortening of the menstlual c&z, one of the first clinical evidences of the paimenopause. Ps the numbers of Follicles are Furtherdecreased, estrogen production falls to a level not compatible with an LH surge so that ovulation may cease or become irregular.5 The second major naturally occurring estrogen is eshone, the predominant postmenopausal estmgen. Un-
It
Journal of Nurse-Midwifery . Vd. 36, No. 1. JanuarglFebruary1991
like eslradiol, estrone has hvo major sources of production: from metabolism of &radio1 and also from aromatization of androstenedione in adipose tissue. As estradiol decrwsw, so does e&one to sane degree. However, because of the second production site in fat cells, estrone is still produced. As Wentz suggested, because adiposity remains unchanged or may even increase during the perimenopausal o&cd. estmne remains ool” slishtl” iess than during the preme~opausal wricd.5 As ilk&&d in Table 2. esbone,a less potent estrogen than estradiol, becomes the dominant estrogen of the postmenopausal woman. FSH levels gradually increase oe,tmenopausallvand remain at high levels postme~opausally.3 The so-called deficiencv state of menopause does not indicate total lack of estrogen, but rather a change in the production site. type of estrogen produced, and overall decrease ir. circulating levels. Some reqard menopause, then, as a physio&ic phenomenon that is protective in nature rather than a deficiency disease. The protection, accordingto Wentz. is from undesirable wpro-
COMMON DISCOMFORTS OF THE PERfMENOPAUSAL PERIOD Cellular estiogen receptors are located in organs throughout the body so that the decline in estrogen levels results in a multitude of clinicalmanifestations, Although many of the clinical manifestations are commonly known as “menopausal comolainls.” tbev are more apprOPiat& ;ecognized& diwomfort-associated with the decreasins eshadiol levels of the pedmenopa&l pet=&. The degree of diqomfoti to a woman depends upon many factors including. among others, the age of the woman, the rapidity with which her &radio1 levels decrease, her body adiposity, and her interpretation of the symptoms. These variations account for the tide disparity to clinical
expressions of common discornforts.8 Among the most commonly reported symptoms are those of “asomotor instability, genitourinary alterations, alterations of the skin, hair, and bones. and psychogenic complaints. It should be recognized that many discomforts are commonly treated with estrogen replacement therapy. An accompan~ngpaper in this issue by Lichtman (see page 30) addresses the specifics of hormonal therapy in detail. Vasomotor Instability The single most obvious, and often the first, discomfort of the climacteric is “asomotor instability. Manifestations of the instability can be divided into three different entities: hot flash, hot flush. and niqht sweats. Although the usual term iy patien!r End providers alike is “hot flash.” Harper reviewed the phenomena and suggested that a hot flash is actually the sudden sensation of warmth, usually in the head, neck, and chest; this is a symptom o! varying intensity and duration. A hot flush is the changein the skin temperature or flushing of the skin that follows the hot flash: it is an observablesign as opposed to the svmotom of hot flash. Night sweats &e hot tlashes that o&while the woman sleeps, usually awakening ha4 The incidence of hot flashes/ flushes reported in the literature varies. Klehky and Borenstein reported an incidence of 50%. whereas Sperofi et al reported an incidenceof 85%.s.9 Regardless of the range. hot flushes and flashes constitute a discomfon for a large number of perimenopausal women. They may be triggered by a variety of stimuli. such as alcohol, spicy foods, hot weather. emotional distress. or even a “JarIn roan. The etiology of hot flashes remains unclear. Hot flashes coincide with an LH surge.8 It is speculated that alterations in the feedback mechanism of the menstrual cycle interact with the gonadotropin-re-
Journal of Nurse-Midwifery l Vol. 36. No. 1. JanuzuyiFebrua~ 1991
leasing hormone neurons of the hyp4alamus. These neumns. in close proximitv to the thermoreculatow initiatethe fl&h. kother factor thought to be invohwd is the effect of increasing instablity of catecholamines amciated with declining estmdiil levels. The vasodilatinq effects of pmstaqlandinrelease may-&0 &?a-the Msomotcr situa-
&ers,ernay
tion. Hormonal replacement therapy has been widely and successfully used as a twatmeot modality for vasomotor instability. Both estrogen and medroxyprogesterone acetate have significantly reduced the frequency of hot flashe~.‘~ Alternative treatments have often been suggested, but not widely researched. Among the alternative modalities have been the chartingof hot flash= in order to belter educate the paimenopausal woman about her body and allow her to cope with the symptoms.” Other nonintewentive therapies have included use of relaxation methods and guided tmagey. Nut,itional treatments have included the use of alternative diets or supplementation of tihmins E, 6 compfa, or C or of zinc4 Homeopathic remedies have suggestedgjnseng tea, bee pollen, or cohash.‘* Anectodal re‘pa* of S”CCe55of alternative treatments abound perhaps due to the effectiveness of these nontraditional treatments, or the biologic vadations of individuals using them, or even the time-limited nature of the complaints. However, sctentific data is l&.illg. Urogenital Variations The linings of the vagfnaand urethra are rich with eshcgen receptor5 and thus are extremely sensitive to the decreasing estradiol levels of the wrimenooausal wriod. As eshown ievels de&se, ‘so does the thickwas of the vaoinal eoithaliurr.. C!inlally, a maturation index may demonetmte thls changeGth an increase in pambasal and intermediate cel!s and a decrease in superficial cells. Table 3 illmtes this shift to the left.
_
I1
TABLE2 Hormonal Concentrations PrelW%?XUSll
EstradiOlIpgirnLI EstmneftimL) FSH lmlU/mLI
50-M) 30-40 1.2
As the squamous eptthelium decreases, the glycogen in the cells diminishes, culminating in an increased vagtnal PH. Therefore, the patmenopausal woman may expelience vaginal discomforts such as dynes, irritation. and dy_pawunia. The changesin va@nal pH may make her more prone b vaginit& or leukorrhea. External genitalia may also change in appeamnce. As noted by 8ergman and Brenner, the thinning hair and loss of subcutaneous fat and tissue of the pudenda is related to both aging and lack of es~~~n.‘~ However it may cause concern about body’image for the woman involved. Common treatment for the vaginal and vulvular alterations have been oral or toplcal hormonal repbcement therapy. Among alternative treatments proposed have been dietary manipulation to ensure meeting the RDA recommendation of 15 mg of zinc dail~,~ as well as the usual nonpharmaceutical treatments for vagtnitis (eg, cotton underwear, sitz baths, yogurt douche). Acidophilus tab!& have been suggested as another alternative theraw for vaginitis according to Cobb.12 Unfortunately, as with most alternative therapies and herbal remedies. wide variations in treatment regimens exist, and no scientific data Is available to allow evaluation of efficxy. Similar to the vaginal mucosa, the urethral mumsa c&s are estrogen sensitiven Thus. as estmdiol levels decrease, a ped&nopausal woman may expertence variations in the urinary system. In addition to udnay hequency and sbessincontinence, a
hmtng,
12
300~5Oa 15%3w 10
5-2.5 20-M) I-100
particular phenomenon related to this period is urge incontinence. Because of cellular changes, reststence to urine is lessened and urine flow is difficult to controt.l3 In addition to hormonal redacement therapy, general recon&ndattons for well-being of the urinary system are in order. Frequent voidings, drinking water, and avoiding urinary initants are always good advice. Kegel exercisesprovide relief for sane casesof stressinconttnance. although their use in treating urge incontinence is limited, Panty liners may provide an e&a protection for women who fear loss of a few drops of lutne. Skin Changes Sktn charwee associated with aging occur in both men and women. It is difficult to differentiate changes attributable solely to aging from those associated with estnx-en deftciencv. Pertmenopausal women may co& plain of focal hyperpigmentation, depigmentation, dytng of the skin, decrease in restHence.and bruktng. In spite of the fact that cosmeticcornpanies tend to blame aging alone, Greenwood summadzed current sctenttfic knowledge in asserting that major factors involved with wrinkles are neither aging nor menopause, but the potentially preventable
factors of smoking and sun exposure.‘4 Treatments for dy skin may include lotions and oils without an alcoholic base. Little is written wg9estin.athe use of hormonal redacetherapy to prevent skin’wdnklins or other dtsorden. altbouoh it has-been suggested that skincollagen content and skin thickness may be increased with such therapy. The buccal muco~a also is rich in estrogen receptors. Some pefinlenopausal women report an unusuauy dry mouth and increased salivary viscosity. Go4 dental hygiene. gum massage. and use of mink or other agents can be recommended to a &man for some relief. Voda and Tucker reported two other discomforts of the perimenooausal wiod. In their research. thev iound &men who reported fonnl’ cations, or the sensation of something crawling on one’s skin. A woman might casually attribute the sensation to an insect, but be unable to find such a creature. Voda and Tucker suggested antictpatory guidance and reassuranceas treatments. Restless or “jumpy legs” was another symptom reported by women in their studies. They suggested treatment by activity or massage as well as the aforementioned anttcipatoy guidance and reassurance.~’
&nt
Hair Asswiated with declining &radio1 levels and increased adrenocorikal activity, there exists the tendency to have thicker and coarser hair grow on the chin, lip, chest, and abdomen. Once hair folltclesare stimulated they tend to continue to grow. Hair removal by electrolysis or top ical treatments depends upon the choice of the woman. If a woman
TABLE 3 Maturation Index Cell Count 100
Journal of Nurse-MidwHey . Vol. 36. No. 1. Janvay,Febmay
,991
has alopecia.it is likely that it will increase in sevellty during this period. Few studies have discussed nonpbarroaceutical treatment methods for these symptoms. Bones Peak bone mass has been achieved before a woman enters the perimenopausal period. However, bones continue to undergo continual dynamic changesof basic remineralization and demineralization. Through complex physiologic interrelationships among calcium, calcitonin, vitamins A and D. pamthyroid hormones. and estrw.wn. a level of homeostasis is es&ally maintained. As estradiol decreases, the dynamics begin to change, allowing demineralizationto occur at a greater degree than remineraltttion. Therefore. loss of bone density results. Eventually. for some women, the bone mass may become so fragile that fractures occur with minimal trauma. This pathologic ccxdttion, called osteoporosis, is more prevalent among certain subgroups of women. As outlined by Johnson. plincipal risk factors are age. female gender, caucasianand oriental races, slender bodv. and beins ~ostmenopausal. He identified se&ndaly lisk factors of 11 calcium deficiencv. 21 protein excess, 3) substance abuses bf alcohol, tobacco, and coffee, 31 family history or 4) any medical disease associated with bone 10~s.‘~ The optimum approach to osteoporosis -is prevehilon. Adequate bone mass developed in young adulthood will help the woman as she reech~~the pertmenopausalperiod. Identification of those risk factors that can be ameliorated is important. Diagnosis of osteoporosis is usually accomplished by a radiographic technique, hopefully before fracture. The most common diagnostic techniques are dual photon absorptiometry, quantitative cornputed tomcgraphy. and dual photon x-ray quantitative dual x-ray. These
methods use a small amcxnt of tadtation and assess density, usudliy in the vertebrae or hip. It has b&n estimated that they may identify bone losses of as small as 2% or 3%.16 The most effective method to retard bone loss or reverse it moderately is estrcgen supplemenhtionwplacement. Moderate exerc;se has been suggested to aid in slowing bone mass loss, but associations are not clear.‘5 Calcium supplements have been shown to be effective in building bones and slowing bone loss but not sufficient alone in preventing osteoporosis. A dietay program emphasizing magnesium instead of calcium has been shown to rebuild bone mass postmenopausally, and the “se of etidronate has also been shown to be effective in the treatment of osteoporo~is”~‘~ Additional research is warranted in all areas of osteoporosis 1) prevention of the disease, 2) diagnosis, especially to increase accessibility and decrease cost, and 3) treatments. particularly nonhormonal alternatives. Psyibogenic Complaints Accompanyingthe physical changes of the perimenopausal period are issues of bodv image and self-esteem. As menfioned before, there is a societal view that menopause and the years thereafter signal “an inevttable slide into seniiity.“~14 It is important to note that these external societal opinions occur at a point when a woman is also most likely to be experiencing mternal personal changes. Fink stimmarized these midlife changes as the “empty nest, the struggle over career, the unhappy and sometimes adulterous husband, the illness and death of parents. the disappointments of past and present and the fear of the fut~re.“~ Dufly noted in her research that the higher the level of self-esin the midlife woman, the higher her health promotion behaviors.‘9 Therefore, self-esteem needs to be supported and pro-
teem
Journal of Nurse-Midwifery . Vol. 36. No. 1. JanuaxyFebmary 1991
m&d during this pried of life to effect overall health Sexuality also can change during the p&menopausal period. Lieblum and Bachmann summarized previ01!5 stub of sexuality of tbe dmacteric trnman. They found that there was a general-decrease in sexual interest for women afta their Rfth decade.However, it was difficult to extrapolate from the data if this finding was linked to menopause or asscciated with a general decline in both sexes as they age.= It was d& covered that women who did cmtinue sexual activity had less vaginal atrophy. and a suggestion existed that hot flashes ma” be reduced through an unclear r&tionship be tween coitus and gw.dotrop+ release.7 Psychogenic complaints are not easily remedied by hormonal replacementi~eahnent They reflect internal and external influences. Cetified nurse-midwives would be well advised to support positive imagesof matutity as well as to SUpQoIt individual women with realistic and accurate infomxltion. ContinlMtiOr~ Of sexual activity in different forms throughout the life cycle should be viewed as normal. Sensitivity about the taboos regardingsexuaitty would allow the professional to impart education and support in an appropriate manner. Table 4 identifies additional self-help measures for the middle years.=
Wbtle supporting the woman in her desire to rem;in sexually acttve, the nurse-mldwife must also be aware that contraception should also be considered. Kaew reported in 1989 that, without contraception, conception could occur amongan estimated 86% of the 10.1 million women aged35-39; 78% of the 8.9 million v,omen aged 40-44; and 69% of the 7.1 million aged 45-49.= Therefore, more than 20 million women exist who are potennauyfecund ov;r the age of 35. Moreover. these women are less likely than 13
TABLE 4
Self.Help Measures for Middle Years Women Remedy
Need Knowledce of middle !!ears
Preparation and support by knowledgeable health providers
Health maintenance
Monthly breast selfaaminatfon Appropriate nutrition and exercise Yearly Pap smears and breast examinations by a health care prodder REguf3.rstwl guaiac tests Eliminate smoking and use alcohol moderately
Hot flashes
Wear layered clothing vitmin E Action: Prevents excess& FS” and LH production Dietary sources: Wheat gam, whole grains, vegetable oils, soybeans. peanuts. rpinach Dose: Vanes with individual’s nubidonal status. Usually begin with 100 IU increasing over weeks or a month or two. to Mx) IU until relief of symptoms Note Inges, after me& with fat 01 take wtth tecitbin (contatns phmphoms) to aid absorp+ion. Medical supervision needed for those with hypertension. heart disease. and diabetes. Sometimes used in combination v&h ginseng. Taker 2-6 weeks to be effective Ginseng ,herb, Action: Unknown. Said to increase feelings of well-being. and changes in bcdy metabolism Dow: Vanes with bcdy weight Note: Take on empty stomach before or between meals. Should not be taken with vitamin C. Difficult to be sure of purcbajmg pure ~weng. Contains small amounts d estrogen. has a component closely resembling digitoxtn. and appears to affect blood leve!~ of 9kxoso BF.~ 9lyccgen levels in liver and mu&. Use questhmable by diabetfEs and those takfn9 cardiac glycxxides. May be pack& with mandrake mot (contains scopolamine) and snakeroot lcontains reseelpkle) Vftamin B compfex Actton: Aids in detoxification and elimination of FSH and LH by llwr Dietary SDUMI: Whole @ins, wheat gzrm. yogurt. brewer’s yeast milk Dose: one to tv.0 daily after meals
Vaginaldlyness
Continued intercourre and/or masturbation aids ckculation and helps keep hues Lubrication: water-soluble jelly, vegetable atl. or if necessary. esbgen aearn
Osteopomsb preuention
Exercise: Any that puts traction on long banes as walking. tennis. dancing. bicycle riding Increase calcium intake
flexible.
Supplements available as calcium lactate, carbonate or 9luwnate Dose: Sufftcient (with dietary sources) to equal 1 g/day beginning age 25, 1.5 glday pasLme”ap3”sal years
Nervousness.,mtability,
Vitamin E6, 5-25 m9 daily (Do not exceed 100 mgl Dietan, ~)uce.s: Brewers’ yeast. bran. wheat germ. organ meats. malasses. wafnutr. peanuts. brown rice
“feeling blue” Insomnia
.Wa’arm milk at bedtime (contatns typtophsnl. Calcium at bedtime. No coffee. tea, chocolate or cola after evain meal Chamomile tea Caution: can cause hypersznsitity for people allergk to ragweed, asters, chrysanthemums Vaferian tea &on9 cdorl. Both teas slow dig&ton if u=d daily
Pelvic relaxation
Weight loss if overweight Kegel exerctsesto increase muscle tone
Muscle cramps
Caldum tablets or calcium-magnesium
Prevention of urinary tract infection
Incre~~reul~I
younger
a preg-
nancy.
women
to Want
However.
21% of women
approximately
in the United
States
between the ages of 40 and 44 use
14
products such as dolomite
void frequently. urinate after intermurse, maintain gacd hygiene, wem cotton
no method percentage
of contraception.
This
is higher than any other
age group. including adolescents. Fomey susgested that this h&h per-
Journal Of Nurse-Midwifery
centaw
ts due to limited contracep-
tfve ;ptfons
available
this age gr~up.~ Recently IIEW
to women
thoughts
. Vol. 36. No. 1. danua@Febnmy
bf
have
1991
emerged about the use of oral contraceptives amons women over the age if 35. An advisoiy group to the Food and Dram Administration has recommended that age limits on the use of oral contraceptives by healthy, nonsmoking women be removed.= In common practice. many providers now continue to prescribe birth control pills to women in their 40s. However, no studies have been conducted regarding oral contraceptives and the perimenopausal woman. For most women, use of oral contraceptiveshelps prevent the common complaint of irregularities of the menstrual cycle. A difficulty occurs when the woman and clinician decide to implement hormonal replacement therapy. The estrogen in combination pills can be up to five times the amount in estrogenlhormane replacement therapy, and there seems to be no intermediary pill between the oral contraceptive and replacemec! therapy. Suggested manasement has included vearlv evaluation of FSH levels starting at the aoe of 50. FSH IeveL are confour&d by oral contraceptive usage. mandating discontinuation for a pedod of time starting at the age of 50 with resumption of oral contraceptives d FSH levels are not elevated. However, once elevated, oral contraceptives could be permanently discontinued and replacement therapy initiated. Other clinicians have advocated using the age of 50 as an arbitrarv dme w witch &alar-
fll~C~“tlCdlS.~~
Other methods that are available to the pedmenopavsal woman include stetilization [male or female), banier methods, and the inhautetine device (IUD). Although the IUD is the second most popular reversible method for women aged 40-44 (the most popular is the condom), it is as sociated with menstrual bleeding problems and dysmenorrhea that could be compounded by fibroids or pedmenopaueal menorrhagia. The feru!ity awareness method is also more problematic during the pedmenopausal years because of the
menstrual cycle irregularities. As always, contraceptive care InUS, be individualized. However, more research is needed in the area of pertmenopausal contraception and more options are needed so appropriate individualization can be accomplished.
GENERAL G!J!DELlNES FOR MANAGEMENT In order to educate women aboui the normalcy of the climactedc, it is optimal to care for her before she has developed any of the common discomforts.Byny outlined a plan to maintain health and prevent disease. These recommendations were designed to provide a fomm to educate the woman about her health, promote behavioral changes, and screen for risk factors or early signs of cardiovascular disease, cancer, or infectiowz5 Following Byny’s guidelines. a well woman would be seen annually. Evey year from the climactedc on, she would have a histoy (especially to screen for risk factors in general and substanceabuse in particular), a general physical that includes assessment of height, weight, breasts. pelvis, and rectum, and vision and hearing assessments. A woman should have routine tetanusldlphtheria booster every 10 years and, startino at ase 60. she should have a pneumwax-immunization euely five years end xl xx-a! in:xnza imm:: r;ine:ion. Starting at age 40. a woman should be screened for occult blood annually and lipoproteins profile evey fzw years. At age 60. thyroid assessments are recammended eve?, two years, as wdl as an annual hematoait or hemoglobin test. A base!ine mammogram &ould be wrfon-ned at age 35, wfonned pexiodically under age- 50. and yearly thereafter. Tonome!ry and fundoscopy is recommended every five years after age 40. Pmctosigmoidoscopy is suggestedevery four years starting at age 48. These guidelines were developed for the
buma! ofNurse.Midwifew . Vo!. 36. No. 1. Januaryifebm&
1991
low-risk woman and should be individualized as needed.=
SUMMARY
Women during the pmimenopausal period present both a challenge and an opportunity for certified nursemidwives. To best deliver care to women during this time, a nwsemidwife must be familiar with the normal vattationsassaiated with decreasing &radio1 levels. Moreover. the professionalmust also appreciate the cultural and social context of menopause and agina Use of an organized plan for delivery of care allows the certified nurse-midurife to target risk factors and prwide an organized approach to maximize health during this prime time of life. REFERENCE8 1. Wegg RB: Demography, in Mishell DR fed), Menopause:Physiolw and Phannacolq,. Chicago.Year Book MedicalPublishers.1987. 2. World Health Oiganization: Researchon the menopause.WHO Technical Report X670. Geneva, WHO. 1951. 3. ShermanBM: Endoninolc@cand menstmual alterations,in MishellDR (ed,, Menopause: Physiology and Phamxcology Chicago, Year Book Medical publisher, 1987. 4. Harper D: Perimenopauseand aging, in Lichtman R. Papem S (eds). Gynecology: Well-woman Care. East Norwalk. Connecticut, Appleton & Lange. 1990. 5. Wenb AC: Managementof the menopause,in Jones HW, Wenb AC, Bum& LS feds). Novak’sTextbookof Gynecology, 11th ed. Baltimore, Williams& WIuCins, 1988. p. 397. 6. Da,,,ewwd MD: What factonundedle premahlre ovarian failure? Contemp ‘Xstet Gyoecol35:31, 1990. 7. Fink PJ: Psychiatric myths of menopause,b Eskin BA (cd). Menopause: Comprehensive Management, 2nd ed. New York, Macmllan, 1988. 8. Sperofl L, GlassR KaseN: Clinical mmecologic endcatnol~ and infertility. 4th ed. Baltimore. Willlams & Wilkins.1989. 15
9. Kkkky 0, Borenrtein R: Varomotor instability of the menopause, in M&hell DR fed), Menopause: Pbysiolosy and Pharmacology. Chicago. Year Baok Medical Publishers 1987.
10. No& B, Jones M. Crilly R. et ak A p!acebc..contro”edtrtal of ethinyl of% tmdiol and no,rtbesterone in dimactatc women. Matudtas 2:247-251.1980. 11. Vc& A. Tucker J: Menapause: Me and you. Salt Lake City, Universityof Utah, 1984. 12. Cobb J: Aitematiwr to hormone use, in A Friend Indeed 515). Montreal, A Mend indeed Publicabcms.1988. 13. Bergman A. Brenner P: Alterations in urogenital system.in Mishell DR fed). Meno0aw.e: Phtialwv and Phar-
14. Greenwood SA: Menopause “at-
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umlly Preparing for the second half of life. Volcano, CA, Vokano. 1989. 15. Johnson CC: Osteoporosis, in E&t” BA ledl. Merwpawz Comprehensive Management. 2nd ed. New York. MacmiUa”. 19%. 16. Mflkr p: Advancer in osteopwasis manwanent. Cantemp Obstet Gynecol 6:31-46. 1988. 17. Abraham GE. Grewal H: A total dietary pmgmm emphasting magnesium instead of c&turn. J Reprod Med 35. 503-507.1990 18 watts NB. et al lntelmitte”t cyclical etidronate tratment of pastmenopausal osteoporosis. N Engl J Med 323:73-79. 1990. 19. Dutfy ME- Determinants of health promotion in midlife women. Nurs Res 37:35S-362. 1988. 20. Lieblum 5. Bachmann G: The
sexuaUtv of the cltmachtic woman. in E&n i led), Menopause: Comp&nsive Management, 2nd ed. New York. Macmillan, 1988.
21. Adams BN: The middle years woman: Educatton for health promoSo” and maintenance. in Littlefield VM (ed). Health Education for Women: A Guide for Nurses and Other Health Professionals.Notwalk, Connecttcu~ AppletonCentury-Crofts. 1986. pp 336-337. 22. Kaeser L: Reconsideling the age limits 0” pill we. Fam Plan” Perspect 21:273-274, 1989. 23. Fomey J: canhaceptio” in Amertcan women 40 and over. Fam Plann Perspat 19:32-35.1987 24. Clinicians devising pmtccols for perk”enopa”sal oc users. Contracept Techno, update 11:81-92, ls9Ll. 25 qwnu R: Establishin” ouiddines for preve%e medicine. C%mp Obstet Gynecol31:43-49, 1988.
dwrnal of Nurse-Midwifery . Vol. 36. No. 1. danua,y/Feb,,w,
1991