- Email: [email protected]
Treatment of the perimenopausal female
HONORABLE MENTION PAPER
TREATMENT OF THE PERIMENOPAUSAL FEMALE Lauren Bales, MD
ELSEVIER
American women are living longer andmanymore women will be entering the climacteric period of their lives than ever before. Menopause occurs at a period when many women are experiencing changing roles, responsibilities, and relationships that accompany aging. Many women experience a smooth transition through their perimenopausal to postmenopausal years, but for some women these changes can be problematic and worrisome. The primary health care provider needs to understand the social, psychologic, and biologic changes that occur during menopause. Osteoporosis, cardiovascular disease, cancer, irregular bleeding, genitourinary complaints, vasomotor symptoms, and sexual dysjunction are prevalent concerns. Patient education about the facts and myths, disease prevention, and screening as well as appropriate medical intervention are essential components when treating this particular population of patients. (Prim Care Update OblGyns 1998;5:90-94.0 1998 Elsevier Science Inc. All rights reserved.)
As the life expectancy of women has steadily increased during the last century, a woman may spend more than one third of her life in a postmenopausal state. This means that many more women are entering the climacteric than ever before. Therefore, an increased awareness and understanding of how to properly treat the perimenopausal woman is From land.
90
the Naval
Medical
Center,
Bethesda.
0 1998
Elsevier
Mary-
Science
essential. Patient education, disease prevention, and screening in addition to appropriate medical treatment during this important milestone are all important components of the total health and management of this special group of patients.
Patient Education The perimenopausal years include those of decreasing ovarian function, including a variable length of time from the loss of regular cyclic menses to the cessation of menses. This is an ideal time to begin educating the patient about expectations and what she can do to help maintain good health and prevent future health problems. Menopause is associated with both positive and negative connotations and often occurs during a time in which a woman may be experiencing many changes in roles, responsibilities, and relationships. Therefore, it is an important time to address her questions, fears, and expectations regarding her health now and beyond because this transition is influenced not only by biologic changes but social and psychological changes as well.’ A Healthy Woman Study performed at the University of Pittsburgh Department of Psychiatry addressed some of the myths and realities many women may face regarding menopause and the following years. They discovered that as many as 80% of women thought that they were likely to get depressed during menopause, 75% thought they would get hot flashes, and almost 70% thought they would “more likely fly off the hanInc.,
all rights
reserved.
1068-607X/98/$19.00
dle.” However, this study showed that the postmenopausal women surveyed reported the same increase in depressive symptoms as their premenopausal controls, a finding contrary to what was expected, while confirming the belief that the menopausal women did have an increase in vasomotor symptoms. Initially, there may be an acute onset of adverse feelings and psychological symptoms as the woman first experiences the onset of vasomotor symptoms; however, as she learns to cope and get treatment when necessary, these feelings tend not to persist.’ Additionally, there is evidence that women who have negative perceptions and expect adverse symptoms and outcomes regarding menopause will indeed have a more troublesome experience. These negative beliefs can, therefore, act as a self-fulfilling prophecy. Patient education and encouragement in conjunction with health maintenance are vital during the perimenopausal period. Another misconception held by many is that there are no significant changes that occur after menopause except for the cessation of menses. It has been shown in several studies that the hypoestrogenic milieu that occurs during menopause is a risk factor for cardiovascular heart disease that approaches that of men, and it is a risk factor for osteoporosis especially in thin, white and Asian, smoking females with a positive family history for osteoporosis.” Genitourinary complaints increase and sexual dysfunction becomes a common problem. Diet, exercise, lifestyle, and medical interventions in the perimenopausal period can
. PI1 SlO68-607X(98)00005-5
Prim
Care
Update
Ob/Gyns
TREATMENT OF THE PERIMENOPAUSAL FEMALE
all help retard or prevent the adverse changes that occur secondary to the hypoestrogenic state of menopause.
Osteoporosis Ravnikar4 has shown that estrogen replacement therapy is the most efficient drug in decreasing bone loss postmenopausally. Perimenopausal women can decrease their risks of this potentially lifethreatening disease while estrogen levels are still within normal range with a balanced diet high in calcium, a regular exercise program, and even low-dose oral contraceptives when indicated. Exercise effects on bone mass are site specific. Aerobic exercise will improve cardiovascular fitness but is not beneficial toward bone preservation. Therefore, an exercise program should provide both weight-bearing and cardiovascular activity. This is especially important in the perimenopausal period as a peak bone mass can be maintained before the hypoestrogenic menopausal state. The same seems to hold true for calcium as a single agent in bone preservation. Calcium intake appears to have its greatest effect in premenopausal women when given alone.5 Therefore, the main benefit of calcium is to improve premenopausal peak bone mass. Postmenopausally, it is an excellent adjunct to estrogen replacement therapy.
Cardiovascular
Disease
Cardiovascular disease is a leading cause of death in postmenopausal women. However, before menopause, women lag behind men in the incidence of coronary heart disease by about 10 years.” There are a number of factors that can account for this change after menopause, such as an increasingly sedentary lifestyle, obesity, increasing cholesterol/high-density lipoprotein ratio, Volume
5. Number
2. 1998
diabetes, and hypoestrogenism. In perimenopausal women, healthy eating habits, a regular aerobic exercise program, and maintenance of ideal body weight are excellent strategies to aid in prevention of heart disease. As a woman gets closer to menopause, the addition of hormone replacement therapy, namely estrogen, is more vital as this can also help maintain a normal lipid profile. These preventive measures are especially important in the diabetic female as her relative risk of myocardial infarction after menopause is roughly twice that of men.
Disease Screening Along with disease prevention, disease screening becomes vital at this time, especially for cancer. As a person ages, the risk of cancer significantly increases. It has been estimated that 30% of the population will develop cancer at some point in their lives and that about 100,000 deaths could be prevented each year by early detection and treatment7 By the time a woman becomes perimenopausal, she usually is older than 40 years of age and should receive an annual cancer-related examination as part of her routine health maintenance. Papanicolaou smears and pelvic examinations should be done on all women who are sexually active or older than age eighteen. However, for those women who have had three or more consecutive, satisfactory normal Papanicolaou smears, the frequency can be decreased to every 2-3 years depending on the patient’s individual risk factors for cervical cancer. Some high-risk factors are sexual intercourse at an early age, multiple sexual partners, smoking, diethylstilbestrol exposure in utero, and exposure to human immunodeficiency virus and human papilloma virus. Mammography, physical examination, and breast self-examination
are all important components in the screening and early detection of breast cancer. It is recommended that mammography screening begin by age 40 and consist of screening every l-2 years. At the age of 50, these examinations should be done annually. Flexible sigmoidoscopy, used in screening for colon cancer, is also an important component of cancer screening beginning in the perimenopausal period. A low-fat, highfiber diet also should be encouraged as an integral component to both a healthy lifestyle and colon cancer prevention, An initial screening flexible sigmoidoscopy is recommended at the age of 50 and then repeated every 3-5 years at the discretion of the physician. Unfortunately, there are no clinically useful or practical screening modalities for ovarian cancer. The American College of Obstetricians and Gynecologists Committee Opinion has stated that the techniques available are not suitable for routine screening for ovarian cancerS8 In high-risk patients with a family history of ovarian cancer, serum tumor markers and transvaginal ultrasonography with color flow Doppler may be indicated. There have been, however, numerous studies that have shown a decreased risk of ovarian cancer in women who have used oral contraceptives, especially in the nulliparous patient. The cancer reduction risk seems to be long lasting; in those patients who have used oral contraceptives for at least 5 years, the decrease is approximately 60% even in patients with a family history of ovarian cancer.”
Common Health Concerns and Their Treatments Education along with disease prevention and screening are very im91
BALES
portant, but many patients may only visit their health care practitioner when “something is wrong.” The perimenopausal period is a time when women may begin to experience and complain of physical signs and symptoms that are common to this transition. Some may just need reassurance, whereas others may require further evaluation to rule out a more serious disease process. Frequent complaints can include irregular bleeding patterns, genitourinary problems, vasomotor symptoms, and sexual dysfunction.
Irregular Bleeding Irregular bleeding patterns are a common occurrence in the perimenopausal patient. There is a significant increase and variability in the intermenstrual interval that is attributed to a shortened follicular phase owing to both the aging of the hypothalamic-pituitary unit and the ovary. Therefore, it is important not only to understand the normal physiologic changes that occur, but also to realize that with aging also comes an increase in pathologic abnormalities of the female reproductive tract that often will present with irregular bleeding. Some bleeding patterns that are of concern include postcoital bleeding, intermenstrual bleeding, and postmenopausal bleeding. It is the responsibility of the clinician to do a thorough investigation to find the source of this abnormal bleeding pattern because cervical and vaginal lesions are not that uncommon and along with uterine leiomyomas, adenomyosis, endometrial polyps, pregnancy, endometrial hyperplasia, and adenocarcinoma can cause abnormal bleeding. Evaluation includes a complete menstrual and reproductive history along with the medical history, which should look for such risk factors as diabetes, hypertension, infertility, a past history of abnor-
mal bleeding, and thyroid, hepatic, renal, or adrenal dysfunction. Papanicolaou smears, colposcopy, endometrial biopsy, hysteroscopy, and dilation and curettage are some tools that can help make the diagnosis. Once organic and systemic causes have been ruled out, medical management of abnormal bleeding can be initiated. For the acutely bleeding patient, a dilation and curettage may be needed for initial hemostasis. Then, acute control can be accomplished by intravenous or high-dose oral estrogen and oral progestins. When the acute situation has been remedied, the patient may need to have her menses suppressed to prevent large drops in hemoglobin levels or to restore levels if this has been a chronic problem. Regimens of medroxyprogesterone acetate at 150 mg given intramuscularly for 3 months, gonadotropin-releasing hormone agonist therapy every month for 3 months, or medroxyprogesterone acetate at 30 mg orally every day can accomplish this.l’ For long-term control, oral contraceptives are used effectively to control irregular menses and menorrhagia. They also have the added benefit of maintaining bone densityll and protecting against endometrial and ovarian cancer as previously mentioned. Menorrhagia also can be successfully treated with nonsteroidal anti-inflammatory agents, which can reduce blood flow by as much as 50%. Cyclic medroxyprogesterone acetate at 10 mg orally on days 16 through 25 of the menstrual cycle also can reduce menstrual 10~s.‘~ Despite these regimens, some women may be unresponsive to long-term medical management. Recurrent heavy bleeding, especially when associated with low hemoglobin levels, may need alternative treatments such as surgical ablation of the endometrium or hysterectomy.
Genitourinary Symptoms Genitourinary complaints increase as women get closer to menopause. The internal urethral sphincter is composed of mucosa, smooth muscle, and a blood supply, all of which are estrogen responsive. Therefore, with the decreasing estrogen levels affecting the perimenopausal female, atrophy of the urethral mucosa, decreased vascular and collagen integrity, and decreased response of urethral smooth muscle to alpha-adrenergic stimulation can cause problems. Associated symptoms include atrophic vaginitis, dysuria, recurrent urinary tract infections, and genuine stress incontinence. Genuine stress incontinence is the most common cause of urinary leakage in the perimenopausal female, but there is also an increase in detrusor instability so that about 9045% of urinary incontinence is caused by genuine stress incontinence, detrusor instability, or a combination of both.‘” When evaluating these patients, it must be remembered that systemic diseases are not an uncommon cause of urinary complaints. Diabetes, neurologic disease, medications, previous gynecologic or urologic surgeries, and pelvic irradiation can all alter bladder function. The initial evaluation usually consists of a history, physical examination, urinalysis with culture and sensitivities, and office cystometrics when incontinence is suspected. Some of these women will require complex urodynamic studies to further define the specific type of incontinence and thus the optimal surgical and medical treatment. After a urinary tract infection has been ruled out, various therapeutic regimens may be employed and tailored to the individual patient. Medical condition, motivation, COinciding pelvic relaxation, and the severity of her complaints all contribute to identifying the most suitPrim
Care
Update
Ob/Gyns
TREATMENT
able management plan. Nonsurgical treatment is the appropriate firstline treatment for most patients. Kegel exercises may improve or cure up to 80% of stress incontinence in the motivated patient. Systemic estrogen and estrogen vaginal cream can alleviate symptoms of urgency, urge incontinence, frequency, nocturia, and dysuria. It can also help with symptoms of incontinence when used in association with phenylpropanolamine. Topical application of estrogen cream also is useful because it can strengthen the vaginal and perineal tissues in women who are planning to undergo continence surgery. Women with urge incontinence also are encouraged to eliminate caffeine from their diet, stop smoking, and adjust medications (with the help of a physician) that may have anticholinergic side effects. These side effects can interfere with detrusor contraction and thus cause urinary retention. On the other hand, the treatment for detrusor instability uses these anticholinergic effects along with alpha and beta adrenergic agonist effects to decrease detrusor tone and increase intraurethral pressure. Tricyclic antidepressants, such as imipramine, display these characteristics and are often prescribed to treat detrusor instability.
Vasomotor
Symptoms
Vasomotor symptoms, or hot flushes or flashes, are probably one of the most common concerns of the perimenopausal female. About 75% of women will experience hot flushes as early as 5 years before actual menopause as their systemic estrogen levels slowly decrease, Obese women are not as likely to experience these symptoms because their estrogen levels are decreased to a lesser extent secondary to increased peripheral conversion by adipose cells. About one third of women will Volume
5. Number
2. 19%
have symptoms severe enough to require medical treatment. The flushes frequently occur at night, awaken the patient, and then cause insomnia. Generally, it is described as sudden in onset with an increase in peripheral skin temperature, heart rate, and circulating norepinephrine and luteinizing hormone levels. These episodes can last from 30 seconds to 5 minutes. It is rare for these symptoms to persist for more than 3-5 years.14 Oral contraceptives are one approach to treating perimenopausal vasomotor symptoms. Alternatively, estrogens at doses of 0.625-1.25 mg for 25 days each month with or without a progestin seem to decrease the frequency and severity of hot flushes. These effects are seen within the first month of treatment, and patients will often report better sleep quality and sense of well-being. Progestins also have been shown to be beneficial in this treatment, but the side effect of vaginal spotting can be problematic for some women. Androgens alone have not been shown to be helpful. Another medication, composed of ergotamine tartrate, belladonna alkaloids, and phenobarbital, was shown in a study by Hirsch et a1.15 to be effective in reducing the frequency and severity of hot flushes in 50% of patients. Unfortunately, because this medication contains phenobarbital, patients need to know that it may be habit forming and sedating. Alpha-adrenergic medications such as clonidine also have been tried. There have been reports of good response rates, but the side effects of dizziness, dry mouth, and insomnia can lead to poor compliance and dissatisfaction.
Sexual Dysfunction Sexual dysfunction is rather prevalent in both men and women and seems to increase with advancing
OF THE PERIMENOPAUSAL
FEMALE
age. Some of the most frequent dysfunctions reported by perimenopausal females are inadequate lubrication with sexual arousal, insertional dyspareunia owing to lack of vaginal lubrication, and decreased sexual interest and desire. The majority of sexual problems associated with the perimenopausal and postmenopausal years are because of the physiologic, anatomic, and behavioral changes that occur from declining gonadal hormone levels. The greatest percentage of sexual dysfunctions reported at this time can be directly or indirectly related to the changes in circulating levels of estrogens and androgens.*‘j An additional cause in the perimenopausal woman may be postoperative sexual dysfunction after a hysterectomy. The uterus may have important psychosexual and sociocultural connotations for some women. Therefore, surgery that alters or changes the female anatomy may affect sexual function. There are several factors that are associated with adverse postoperative sexual function. A prior history of depression, sexual dysfunction, or psychological problems, along with limited education, an unstable sexual relationship, conflict about desire for future child bearing, infrequent coitus, and a nonsupportive spouse, are some of the preoperative problems that are prevalent. There are treatment options available for women with sexual dysfunction during the perimenopausal period. Healthy, nonsmoking women can use lowdose oral contraceptives as this often helps with vaginal lubrication and overall vaginal health. Additionally, it is an effective treatment for menstrual irregularities, mood swings, and insomnia, which can in and of itself help alleviate sexual dilficulties. Hormone replacement therapy also has been shown to be beneficial. As the estrogen levels fall during this period and beyond, the 93
BALES vagina becomes atrophic, poorly lubricated, and alkaline. Estrogens appear to reverse these changes by increasing the vaginal circulation and quantity of vaginal fluid. Problems with decreased sexual desire, arousal, and gratification may be reversed by androgen administration either alone or in conjunction with estrogens. If frequent sexual activity is maintained, the effects of the androgen treatment will be maintained long after the discontinuation of the treatment. Lastly, there also are many over-the-counter vaginal lubricants and moisturizers that can be used alone or in conjunction with any of the previously mentioned treatments. It should be mentioned, however, that sexual problems that seem to be long standing or complex should be considered for further evaluation by a psychiatrist or counselor.
Summary The perimenopausal period may be an emotional and physical milestone in a woman’s life. A multidisciplinary approach to total health care can help make the transition to menopause a positive one. Patient education and support along with preventive care and treatment are
94
used to help ensure that women have healthy, satisfying, and productive lives in the peri- and postmenopausal years.
References 1. Mathews KA. Myths and realities of the menopause. Psychosomatic Med 1992;54:1-9. 2. Mathews KA, et al. Influences of natural menopause on psychological characteristics and symptoms of middle aged healthy women. J Consult Clin Psycho1 1990;58:345-51. 3. Mathews KA, et al. Menopause and risk factors for coronary heart disease. N Engl J Med 1989;321:641-6. 4. Ravnikar V. Hormonal management of osteoporosis. Clin Obstet Gynecol 1992;35:913-22. 5. Elders PJM, Neteslenbos JC, Lips P. Calcium supplementation reduces vertebral bone loss in perimenopausal women: a controlled trial in 248 women between 46 and 55 years of age. J Clin Endocrinol Metab 1991;73:533-40. 6. Ravnikar VA. Diet, exercise, and lifestyle in preparation for menopause. Obstet Gynecol Clin North Am 1993;20:365-78. 7. Runowicz CD, Goldberg GL, Smith HO. Cancer screening for women older than 40 years of age. Obstet Gynecol Clin North Am 1993;ZO: 391-408. 8. American College of Obstetricians and Gynecologists. Report of Task Force on Routine Cancer Screening. Washington (DC): April 1989, ACOG Committee Opinion #68.
9. Center for Disease Control Cancer and Steroid Hormone Study: oral contraceptive use and the risk of ovarian cancer. JAMA 1983;249: 1596. 10. Awaad JT, Toth TL, Schiff I. Abnormal uterine bleeding in the perimenopause. Int J Fertil Menopausal Stud 1993;38:261-9. 11. Corson SL. Oral contraceptives for the protection of osteoporosis. J Reprod Med 1993;38:1015-20. 12. Thorneycroft IH. Medical management of abnormal uterine bleeding in the patient in her 40s. Obstet Gynecol Clin North Am 1993:20: 333-6. 13. Young SB, Pingeton DM. A practical approach to perimenopausal and postmenopausal urinary incontinence. Obstet Gynecol Clin of North Am 1994;21:357-79. 14. Young SB. Hot flashes-physiology, hormonal therapy, and alternative therapies. Obstet Gynecol Clin North Am 1994;21:385-8. 15. Hirsh LB, Montella JM. Bent AE. Detrusor instability. In Ostergard DR, Bent AE, editors. Urogynecology and urodynamics: theory and practice. Baltimore (MD]: Williams & Wilkins; 1991:363. 16. Bachman GA. Sexual function in the perimenopause. Obstet Gynecol Clin North Am 1993;20:378-89. Address correspondence and reprint requests to Lauren Bales, MD, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889-5600.
Prim
Care
Update
ObiGyns
TREATMENT OF THE PERIMENOPAUSAL FEMALE Lauren Bales, MD
ELSEVIER
American women are living longer andmanymore women will be entering the climacteric period of their lives than ever before. Menopause occurs at a period when many women are experiencing changing roles, responsibilities, and relationships that accompany aging. Many women experience a smooth transition through their perimenopausal to postmenopausal years, but for some women these changes can be problematic and worrisome. The primary health care provider needs to understand the social, psychologic, and biologic changes that occur during menopause. Osteoporosis, cardiovascular disease, cancer, irregular bleeding, genitourinary complaints, vasomotor symptoms, and sexual dysjunction are prevalent concerns. Patient education about the facts and myths, disease prevention, and screening as well as appropriate medical intervention are essential components when treating this particular population of patients. (Prim Care Update OblGyns 1998;5:90-94.0 1998 Elsevier Science Inc. All rights reserved.)
As the life expectancy of women has steadily increased during the last century, a woman may spend more than one third of her life in a postmenopausal state. This means that many more women are entering the climacteric than ever before. Therefore, an increased awareness and understanding of how to properly treat the perimenopausal woman is From land.
90
the Naval
Medical
Center,
Bethesda.
0 1998
Elsevier
Mary-
Science
essential. Patient education, disease prevention, and screening in addition to appropriate medical treatment during this important milestone are all important components of the total health and management of this special group of patients.
Patient Education The perimenopausal years include those of decreasing ovarian function, including a variable length of time from the loss of regular cyclic menses to the cessation of menses. This is an ideal time to begin educating the patient about expectations and what she can do to help maintain good health and prevent future health problems. Menopause is associated with both positive and negative connotations and often occurs during a time in which a woman may be experiencing many changes in roles, responsibilities, and relationships. Therefore, it is an important time to address her questions, fears, and expectations regarding her health now and beyond because this transition is influenced not only by biologic changes but social and psychological changes as well.’ A Healthy Woman Study performed at the University of Pittsburgh Department of Psychiatry addressed some of the myths and realities many women may face regarding menopause and the following years. They discovered that as many as 80% of women thought that they were likely to get depressed during menopause, 75% thought they would get hot flashes, and almost 70% thought they would “more likely fly off the hanInc.,
all rights
reserved.
1068-607X/98/$19.00
dle.” However, this study showed that the postmenopausal women surveyed reported the same increase in depressive symptoms as their premenopausal controls, a finding contrary to what was expected, while confirming the belief that the menopausal women did have an increase in vasomotor symptoms. Initially, there may be an acute onset of adverse feelings and psychological symptoms as the woman first experiences the onset of vasomotor symptoms; however, as she learns to cope and get treatment when necessary, these feelings tend not to persist.’ Additionally, there is evidence that women who have negative perceptions and expect adverse symptoms and outcomes regarding menopause will indeed have a more troublesome experience. These negative beliefs can, therefore, act as a self-fulfilling prophecy. Patient education and encouragement in conjunction with health maintenance are vital during the perimenopausal period. Another misconception held by many is that there are no significant changes that occur after menopause except for the cessation of menses. It has been shown in several studies that the hypoestrogenic milieu that occurs during menopause is a risk factor for cardiovascular heart disease that approaches that of men, and it is a risk factor for osteoporosis especially in thin, white and Asian, smoking females with a positive family history for osteoporosis.” Genitourinary complaints increase and sexual dysfunction becomes a common problem. Diet, exercise, lifestyle, and medical interventions in the perimenopausal period can
. PI1 SlO68-607X(98)00005-5
Prim
Care
Update
Ob/Gyns
TREATMENT OF THE PERIMENOPAUSAL FEMALE
all help retard or prevent the adverse changes that occur secondary to the hypoestrogenic state of menopause.
Osteoporosis Ravnikar4 has shown that estrogen replacement therapy is the most efficient drug in decreasing bone loss postmenopausally. Perimenopausal women can decrease their risks of this potentially lifethreatening disease while estrogen levels are still within normal range with a balanced diet high in calcium, a regular exercise program, and even low-dose oral contraceptives when indicated. Exercise effects on bone mass are site specific. Aerobic exercise will improve cardiovascular fitness but is not beneficial toward bone preservation. Therefore, an exercise program should provide both weight-bearing and cardiovascular activity. This is especially important in the perimenopausal period as a peak bone mass can be maintained before the hypoestrogenic menopausal state. The same seems to hold true for calcium as a single agent in bone preservation. Calcium intake appears to have its greatest effect in premenopausal women when given alone.5 Therefore, the main benefit of calcium is to improve premenopausal peak bone mass. Postmenopausally, it is an excellent adjunct to estrogen replacement therapy.
Cardiovascular
Disease
Cardiovascular disease is a leading cause of death in postmenopausal women. However, before menopause, women lag behind men in the incidence of coronary heart disease by about 10 years.” There are a number of factors that can account for this change after menopause, such as an increasingly sedentary lifestyle, obesity, increasing cholesterol/high-density lipoprotein ratio, Volume
5. Number
2. 1998
diabetes, and hypoestrogenism. In perimenopausal women, healthy eating habits, a regular aerobic exercise program, and maintenance of ideal body weight are excellent strategies to aid in prevention of heart disease. As a woman gets closer to menopause, the addition of hormone replacement therapy, namely estrogen, is more vital as this can also help maintain a normal lipid profile. These preventive measures are especially important in the diabetic female as her relative risk of myocardial infarction after menopause is roughly twice that of men.
Disease Screening Along with disease prevention, disease screening becomes vital at this time, especially for cancer. As a person ages, the risk of cancer significantly increases. It has been estimated that 30% of the population will develop cancer at some point in their lives and that about 100,000 deaths could be prevented each year by early detection and treatment7 By the time a woman becomes perimenopausal, she usually is older than 40 years of age and should receive an annual cancer-related examination as part of her routine health maintenance. Papanicolaou smears and pelvic examinations should be done on all women who are sexually active or older than age eighteen. However, for those women who have had three or more consecutive, satisfactory normal Papanicolaou smears, the frequency can be decreased to every 2-3 years depending on the patient’s individual risk factors for cervical cancer. Some high-risk factors are sexual intercourse at an early age, multiple sexual partners, smoking, diethylstilbestrol exposure in utero, and exposure to human immunodeficiency virus and human papilloma virus. Mammography, physical examination, and breast self-examination
are all important components in the screening and early detection of breast cancer. It is recommended that mammography screening begin by age 40 and consist of screening every l-2 years. At the age of 50, these examinations should be done annually. Flexible sigmoidoscopy, used in screening for colon cancer, is also an important component of cancer screening beginning in the perimenopausal period. A low-fat, highfiber diet also should be encouraged as an integral component to both a healthy lifestyle and colon cancer prevention, An initial screening flexible sigmoidoscopy is recommended at the age of 50 and then repeated every 3-5 years at the discretion of the physician. Unfortunately, there are no clinically useful or practical screening modalities for ovarian cancer. The American College of Obstetricians and Gynecologists Committee Opinion has stated that the techniques available are not suitable for routine screening for ovarian cancerS8 In high-risk patients with a family history of ovarian cancer, serum tumor markers and transvaginal ultrasonography with color flow Doppler may be indicated. There have been, however, numerous studies that have shown a decreased risk of ovarian cancer in women who have used oral contraceptives, especially in the nulliparous patient. The cancer reduction risk seems to be long lasting; in those patients who have used oral contraceptives for at least 5 years, the decrease is approximately 60% even in patients with a family history of ovarian cancer.”
Common Health Concerns and Their Treatments Education along with disease prevention and screening are very im91
BALES
portant, but many patients may only visit their health care practitioner when “something is wrong.” The perimenopausal period is a time when women may begin to experience and complain of physical signs and symptoms that are common to this transition. Some may just need reassurance, whereas others may require further evaluation to rule out a more serious disease process. Frequent complaints can include irregular bleeding patterns, genitourinary problems, vasomotor symptoms, and sexual dysfunction.
Irregular Bleeding Irregular bleeding patterns are a common occurrence in the perimenopausal patient. There is a significant increase and variability in the intermenstrual interval that is attributed to a shortened follicular phase owing to both the aging of the hypothalamic-pituitary unit and the ovary. Therefore, it is important not only to understand the normal physiologic changes that occur, but also to realize that with aging also comes an increase in pathologic abnormalities of the female reproductive tract that often will present with irregular bleeding. Some bleeding patterns that are of concern include postcoital bleeding, intermenstrual bleeding, and postmenopausal bleeding. It is the responsibility of the clinician to do a thorough investigation to find the source of this abnormal bleeding pattern because cervical and vaginal lesions are not that uncommon and along with uterine leiomyomas, adenomyosis, endometrial polyps, pregnancy, endometrial hyperplasia, and adenocarcinoma can cause abnormal bleeding. Evaluation includes a complete menstrual and reproductive history along with the medical history, which should look for such risk factors as diabetes, hypertension, infertility, a past history of abnor-
mal bleeding, and thyroid, hepatic, renal, or adrenal dysfunction. Papanicolaou smears, colposcopy, endometrial biopsy, hysteroscopy, and dilation and curettage are some tools that can help make the diagnosis. Once organic and systemic causes have been ruled out, medical management of abnormal bleeding can be initiated. For the acutely bleeding patient, a dilation and curettage may be needed for initial hemostasis. Then, acute control can be accomplished by intravenous or high-dose oral estrogen and oral progestins. When the acute situation has been remedied, the patient may need to have her menses suppressed to prevent large drops in hemoglobin levels or to restore levels if this has been a chronic problem. Regimens of medroxyprogesterone acetate at 150 mg given intramuscularly for 3 months, gonadotropin-releasing hormone agonist therapy every month for 3 months, or medroxyprogesterone acetate at 30 mg orally every day can accomplish this.l’ For long-term control, oral contraceptives are used effectively to control irregular menses and menorrhagia. They also have the added benefit of maintaining bone densityll and protecting against endometrial and ovarian cancer as previously mentioned. Menorrhagia also can be successfully treated with nonsteroidal anti-inflammatory agents, which can reduce blood flow by as much as 50%. Cyclic medroxyprogesterone acetate at 10 mg orally on days 16 through 25 of the menstrual cycle also can reduce menstrual 10~s.‘~ Despite these regimens, some women may be unresponsive to long-term medical management. Recurrent heavy bleeding, especially when associated with low hemoglobin levels, may need alternative treatments such as surgical ablation of the endometrium or hysterectomy.
Genitourinary Symptoms Genitourinary complaints increase as women get closer to menopause. The internal urethral sphincter is composed of mucosa, smooth muscle, and a blood supply, all of which are estrogen responsive. Therefore, with the decreasing estrogen levels affecting the perimenopausal female, atrophy of the urethral mucosa, decreased vascular and collagen integrity, and decreased response of urethral smooth muscle to alpha-adrenergic stimulation can cause problems. Associated symptoms include atrophic vaginitis, dysuria, recurrent urinary tract infections, and genuine stress incontinence. Genuine stress incontinence is the most common cause of urinary leakage in the perimenopausal female, but there is also an increase in detrusor instability so that about 9045% of urinary incontinence is caused by genuine stress incontinence, detrusor instability, or a combination of both.‘” When evaluating these patients, it must be remembered that systemic diseases are not an uncommon cause of urinary complaints. Diabetes, neurologic disease, medications, previous gynecologic or urologic surgeries, and pelvic irradiation can all alter bladder function. The initial evaluation usually consists of a history, physical examination, urinalysis with culture and sensitivities, and office cystometrics when incontinence is suspected. Some of these women will require complex urodynamic studies to further define the specific type of incontinence and thus the optimal surgical and medical treatment. After a urinary tract infection has been ruled out, various therapeutic regimens may be employed and tailored to the individual patient. Medical condition, motivation, COinciding pelvic relaxation, and the severity of her complaints all contribute to identifying the most suitPrim
Care
Update
Ob/Gyns
TREATMENT
able management plan. Nonsurgical treatment is the appropriate firstline treatment for most patients. Kegel exercises may improve or cure up to 80% of stress incontinence in the motivated patient. Systemic estrogen and estrogen vaginal cream can alleviate symptoms of urgency, urge incontinence, frequency, nocturia, and dysuria. It can also help with symptoms of incontinence when used in association with phenylpropanolamine. Topical application of estrogen cream also is useful because it can strengthen the vaginal and perineal tissues in women who are planning to undergo continence surgery. Women with urge incontinence also are encouraged to eliminate caffeine from their diet, stop smoking, and adjust medications (with the help of a physician) that may have anticholinergic side effects. These side effects can interfere with detrusor contraction and thus cause urinary retention. On the other hand, the treatment for detrusor instability uses these anticholinergic effects along with alpha and beta adrenergic agonist effects to decrease detrusor tone and increase intraurethral pressure. Tricyclic antidepressants, such as imipramine, display these characteristics and are often prescribed to treat detrusor instability.
Vasomotor
Symptoms
Vasomotor symptoms, or hot flushes or flashes, are probably one of the most common concerns of the perimenopausal female. About 75% of women will experience hot flushes as early as 5 years before actual menopause as their systemic estrogen levels slowly decrease, Obese women are not as likely to experience these symptoms because their estrogen levels are decreased to a lesser extent secondary to increased peripheral conversion by adipose cells. About one third of women will Volume
5. Number
2. 19%
have symptoms severe enough to require medical treatment. The flushes frequently occur at night, awaken the patient, and then cause insomnia. Generally, it is described as sudden in onset with an increase in peripheral skin temperature, heart rate, and circulating norepinephrine and luteinizing hormone levels. These episodes can last from 30 seconds to 5 minutes. It is rare for these symptoms to persist for more than 3-5 years.14 Oral contraceptives are one approach to treating perimenopausal vasomotor symptoms. Alternatively, estrogens at doses of 0.625-1.25 mg for 25 days each month with or without a progestin seem to decrease the frequency and severity of hot flushes. These effects are seen within the first month of treatment, and patients will often report better sleep quality and sense of well-being. Progestins also have been shown to be beneficial in this treatment, but the side effect of vaginal spotting can be problematic for some women. Androgens alone have not been shown to be helpful. Another medication, composed of ergotamine tartrate, belladonna alkaloids, and phenobarbital, was shown in a study by Hirsch et a1.15 to be effective in reducing the frequency and severity of hot flushes in 50% of patients. Unfortunately, because this medication contains phenobarbital, patients need to know that it may be habit forming and sedating. Alpha-adrenergic medications such as clonidine also have been tried. There have been reports of good response rates, but the side effects of dizziness, dry mouth, and insomnia can lead to poor compliance and dissatisfaction.
Sexual Dysfunction Sexual dysfunction is rather prevalent in both men and women and seems to increase with advancing
OF THE PERIMENOPAUSAL
FEMALE
age. Some of the most frequent dysfunctions reported by perimenopausal females are inadequate lubrication with sexual arousal, insertional dyspareunia owing to lack of vaginal lubrication, and decreased sexual interest and desire. The majority of sexual problems associated with the perimenopausal and postmenopausal years are because of the physiologic, anatomic, and behavioral changes that occur from declining gonadal hormone levels. The greatest percentage of sexual dysfunctions reported at this time can be directly or indirectly related to the changes in circulating levels of estrogens and androgens.*‘j An additional cause in the perimenopausal woman may be postoperative sexual dysfunction after a hysterectomy. The uterus may have important psychosexual and sociocultural connotations for some women. Therefore, surgery that alters or changes the female anatomy may affect sexual function. There are several factors that are associated with adverse postoperative sexual function. A prior history of depression, sexual dysfunction, or psychological problems, along with limited education, an unstable sexual relationship, conflict about desire for future child bearing, infrequent coitus, and a nonsupportive spouse, are some of the preoperative problems that are prevalent. There are treatment options available for women with sexual dysfunction during the perimenopausal period. Healthy, nonsmoking women can use lowdose oral contraceptives as this often helps with vaginal lubrication and overall vaginal health. Additionally, it is an effective treatment for menstrual irregularities, mood swings, and insomnia, which can in and of itself help alleviate sexual dilficulties. Hormone replacement therapy also has been shown to be beneficial. As the estrogen levels fall during this period and beyond, the 93
BALES vagina becomes atrophic, poorly lubricated, and alkaline. Estrogens appear to reverse these changes by increasing the vaginal circulation and quantity of vaginal fluid. Problems with decreased sexual desire, arousal, and gratification may be reversed by androgen administration either alone or in conjunction with estrogens. If frequent sexual activity is maintained, the effects of the androgen treatment will be maintained long after the discontinuation of the treatment. Lastly, there also are many over-the-counter vaginal lubricants and moisturizers that can be used alone or in conjunction with any of the previously mentioned treatments. It should be mentioned, however, that sexual problems that seem to be long standing or complex should be considered for further evaluation by a psychiatrist or counselor.
Summary The perimenopausal period may be an emotional and physical milestone in a woman’s life. A multidisciplinary approach to total health care can help make the transition to menopause a positive one. Patient education and support along with preventive care and treatment are
94
used to help ensure that women have healthy, satisfying, and productive lives in the peri- and postmenopausal years.
References 1. Mathews KA. Myths and realities of the menopause. Psychosomatic Med 1992;54:1-9. 2. Mathews KA, et al. Influences of natural menopause on psychological characteristics and symptoms of middle aged healthy women. J Consult Clin Psycho1 1990;58:345-51. 3. Mathews KA, et al. Menopause and risk factors for coronary heart disease. N Engl J Med 1989;321:641-6. 4. Ravnikar V. Hormonal management of osteoporosis. Clin Obstet Gynecol 1992;35:913-22. 5. Elders PJM, Neteslenbos JC, Lips P. Calcium supplementation reduces vertebral bone loss in perimenopausal women: a controlled trial in 248 women between 46 and 55 years of age. J Clin Endocrinol Metab 1991;73:533-40. 6. Ravnikar VA. Diet, exercise, and lifestyle in preparation for menopause. Obstet Gynecol Clin North Am 1993;20:365-78. 7. Runowicz CD, Goldberg GL, Smith HO. Cancer screening for women older than 40 years of age. Obstet Gynecol Clin North Am 1993;ZO: 391-408. 8. American College of Obstetricians and Gynecologists. Report of Task Force on Routine Cancer Screening. Washington (DC): April 1989, ACOG Committee Opinion #68.
9. Center for Disease Control Cancer and Steroid Hormone Study: oral contraceptive use and the risk of ovarian cancer. JAMA 1983;249: 1596. 10. Awaad JT, Toth TL, Schiff I. Abnormal uterine bleeding in the perimenopause. Int J Fertil Menopausal Stud 1993;38:261-9. 11. Corson SL. Oral contraceptives for the protection of osteoporosis. J Reprod Med 1993;38:1015-20. 12. Thorneycroft IH. Medical management of abnormal uterine bleeding in the patient in her 40s. Obstet Gynecol Clin North Am 1993:20: 333-6. 13. Young SB, Pingeton DM. A practical approach to perimenopausal and postmenopausal urinary incontinence. Obstet Gynecol Clin of North Am 1994;21:357-79. 14. Young SB. Hot flashes-physiology, hormonal therapy, and alternative therapies. Obstet Gynecol Clin North Am 1994;21:385-8. 15. Hirsh LB, Montella JM. Bent AE. Detrusor instability. In Ostergard DR, Bent AE, editors. Urogynecology and urodynamics: theory and practice. Baltimore (MD]: Williams & Wilkins; 1991:363. 16. Bachman GA. Sexual function in the perimenopause. Obstet Gynecol Clin North Am 1993;20:378-89. Address correspondence and reprint requests to Lauren Bales, MD, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889-5600.
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