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List one possible complication of menopause and some solutions to this complication. Make sure to look in Course Documents for the Turnitin grading rubric…………


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Menopause, Hormone
Therapy And
Part Two
Wendy Bonnar WHNP-BC, MSN
Symptoms of Perimenopause
• Irregular periods
• Hot flashes
• Night sweats
• Alterations in libido
• Insomnia
• Headaches
•  memory &
• Tiredness
• Anxiety
• Mood swings
• Breast tenderness
• Palpitations
• Vaginal Dryness
• Itchy vulvar area
• Bladder symptoms
Vasomotor Symptoms
• Definition:
• Recurrent, transient episodes of flushing
accompanied by a sensation of warmth to
intense heat on the upper body and
• Commonly referred to as “hot flashes” by day
and “night sweats” by night
• Hot flashes can sometimes involve the whole
body (e.g., inside of elbows, back of knees).
Vasomotor Symptoms
• As many as 75% of perimenopausal
women in US report hot flashes
• Number of episodes vary
• Few to multiple episodes daily
• Highest occurrence during perimenopause
and first 2 years of postmenopausal.
Freeman EW Climacteric 2007;10:197-214
Physiologic Mechanisms
• Not completely understood
• Related to small fluctuations in core body
• Triggered when core body temperature rises
above upper (sweating) threshold.
• Shivering occurs when core body temperature
falls from elevated level to a level below the
lower threshold of thermoneutral zone.
Freedman RR Fertil Steril 2002;77487-90; Freedman RR Menopause 2005;12:156-9
Factors Contributing to Hot
• Warm environment, hot drinks, spicy food, stress
• Higher BMI, cigarette smoking, alcohol
• Disease conditions including thyroid disease,
infection, leukemia, pancreatic tumors,
autoimmune disorders, anxiety
• Serum estrogen levels are not predictive of hot
flash frequency or severity.
Other Problems
• Midlife sleeplessness:
• Both men and women report an increase in
sleep disturbances at midlife.
• A higher percentage of women than men
report sleep disturbances at all ages.
• Sleep disturbances are associated with fatigue,
irritability, chronic illness (e.g., CVD), mood
disorders (e.g., depression).
• Abrupt decreases in estradiol, such as those that
occur during menstrual periods and
perimenopause, play a role in the incidence of
• During perimenopause, the prevalence or
intensity of headaches often increases,
especially in women with a history of menstrual
• Frequency of migraines often decreases
Brandes JL JAMA 2006;295:1824-30; Martin VT Headache 2006;46:365-86
Sexual Health
• Libido generally decreases with age.
• Distressing sexual problems peak during midlife
(ages 45-64) and are lowest from age 65 onward.
• Decreased estrogen can result in loss of vaginal
moisture and elasticity.
• Decline in androgens may contribute to a decline
in sexual desire, arousal, and vaginal lubrication
• Vaginal sexual activity and lubricants may help
keep vaginal tissue more moist and elastic.
Basson R J Urol 2000;163:888-93; Gracia CR Menopause 2004;11:144-50; Hartman U Menopause 2004;11:726-40; Shifren JL Obstet Gynecol
• Osteo means “bones”
• Porosis means porous condition (full of
tiny holes).
• Osteoporosis is a disease that can cause
bones to become thin, brittle and more
likely to break.
• Considered the silent disease
• few warning signs
Definition of Osteoporosis
A disease characterized by low bone mass and microarchitectural
deterioration of bone tissue leading to enhanced bone fragility and a
consequent increase in fracture risk
Normal Bone
Pentice A Public Health Nutr 2004;7:227-43; WHO Study Group In Assessement of Facture Risk and Its Application to Screening for Postmenopausal
Osteoporosis. Geneva: WHO, 1994
Osteoporosis – Social Impact
• Osteoporosis causes 1.5 million fractures
each year
• 300,000 of those will be hip fractures
• 700,000 vertebral fractures annually, most common
manifestation of osteoporosis
• 5 – 20% of those women die within the year of that
• 15-25% become permanently disabled
• Cost of these fractures is $10 Billion annually
• 65% of patients post hip fracture never regain
prefracture level of independence.
A Gender-Related Condition
• Osteoporosis is the most common bone
disorder affecting humans.
• The risk of hip fracture doubles for every
5- to 6-year increase in age from ages 6585.
• Of the 10 million Americans estimated to
have osteoporosis, 8 million are women
National Osteoporosis Foundation Accessed 8/24/2012; Kim SH Arthritis Care Res 2012;64:751-7
Osteoporosis: ethnic-related
National Osteoporosis Foundation Accessed 8/28/12
BMD Testing
• The Fracture Risk Assessment Tool (FRAX)
• The FRAX tool was developed by the World Health
Organization to help predict the risk of having a
fracture related to osteoporosis in the next 10
• The tool is meant for people who are not already
being treated with medicine for osteoporosis.
• If you are interested in the tool and it’s components
BMD Testing Recommendations
• All women age 65 and older
• Postmenopausal women younger than age 65
if FRAX score for 10-year risk of major fracture is
≥9.3% (average fracture risk for healthy women)
• Postmenopausal women with medical causes of
bone loss.
• Postmenopausal women with history of fragility
Pfister AK Ann Intern Med 2011;155:275-6
Other Factors
• For postmenopausal women age 50 and older
with one or more of following:
• Previous fracture after menopause
• Thinness (body weight <127 lb [57.7 kg] or BMI <21 kg/m2) • History of hip fracture in a parent • Current smoking • Rheumatoid arthritis • Excessive alcohol intake BMD • Bone density tests (bone mineral density tests) examine bone strength and are used to help diagnose osteoporosis. • Dual energy X-ray absorptiometry (DEXA) DEXA is the most accurate method for measuring bone mineral density. • Two X-ray beams are projected onto the bones. • The amounts of each X-ray beam that is blocked by bone and soft tissue are compared to estimate the bone density. BMD • Bone mineral density results are reported as a T-score. • T-score is the bone density compared with what is normally expected in a healthy young adult of a sex (male or female). • Your T-score is the number of units — called standard deviations — that your bone density is above or below the average. Bone Health: Exercise Is a Key Component • The most important exercise for your bones is developing and maintaining good posture. • No amount of exercise will undo 16 hours of bad posture a day. • Think about sitting and standing as tall as possible, pulling your belly button towards your spine, lowering your shoulders, and gently drawing your shoulder blades together. 3 Types of Exercise for Your Bones • 1. Weight-bearing exercise means carrying your body weight in activities. • Brisk walking, jumping, running • Dance, tennis, soccer • Swimming and biking are very good for your heart, but note that they are not considered weight-bearing exercises to strengthen your bones. 3 Types of Exercise for Your Bones • 2. Strength-training exercises can include the use of resistance machines or inexpensive equipment: • Resistance bands, free weights, or barbells. • 3. Balance work: • Advanced activities include tai chi and yoga, which improve muscle strength, flexibility, and balance. • Note that yoga can be both beneficial and risky in women with osteoporosis. • There is controversy regarding the safety of some of the spinetwisting positions in yoga. Exercise • Goal • 30-40 minutes weight bearing exercise • 3-4 times per week Lifestyle Modifications • Maintain a healthy weight • Eat a balanced diet • Obtain adequate calcium and vitamin D • For calcium: 1,200 mg/d from food (preferably) and/or supplement • For vitamin D: RDA is 600 IU/d until age 70 and 800 IU/d after age 70 • Participate in appropriate exercise • Avoid excessive alcohol consumption • Do not smoke • Institute measures to prevent falls NAMS Menopause 2010;17:25-54 Calcium Needs by Age Group 1-3 years Elemental Calcium Needed per day 50mg 4-8 years 800 mg 9-18 years 1300 mg 19-50 years 1000 mg 50+ years 1200 mg Treatment • Bisphosphonates are the most common medications prescribed for osteoporosis treatment. • These include: • • • • Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva) Zoledronic acid (Reclast) • Biophosphonates work by retarding bone resorption Treatment • Hormones, such as estrogen, and some hormone-like medications approved for preventing and treating osteoporosis, such as raloxifene (Evista), also play a role in osteoporosis treatment. Treatment • Prolia® (denosumab) is a prescription medicine used to treat osteoporosis in women after menopause who: • are at high risk for fracture, meaning women who have had a fracture related to osteoporosis, or who have multiple risk factors for fracture. • cannot use another osteoporosis medicine or other osteoporosis medicines did not work well. Objectives/Study Guide • Name several symptoms of perimenopause/menopause. • Understand when vasomotor symptoms have the highest occurrence. • Name several factors that can contribute to hot flashes. • Describe some other problems associated with midlife. • Discuss the social impact of osteoporosis. • Know the typical sites associated with osteoporosis. • Understand what risk factors are associated for osteoporosis. • Know what age peak bone mass is reached. • Know the 2 main nutrients needed to prevent osteoporosis. • Understand how vitamin D works to prevent bone loss. Objectives/Study Guide • Understand what the FRAX tool is. • Know how to evaluate BMD. • Know the recommended amounts of calcium and vitamin D intake. • Name some treatments for osteoporosis. Menopause, Hormone Therapy And Osteoporosis Part One Wendy Bonnar WHNP-BC, MSN Introduction • In this lecture we will review: • The process of menopause (physiology) • The negative and positive effects menopause can have on a woman’s life. • Hormone use and studies related to it’s use. • Osteoporosis • Nutrition for the older woman. Introduction • Menopause is the point in a woman's life at which she is no longer fertile, and menstrual periods have ceased. • Menopause is a specific event that occurs during midlife years that brings both physical and emotional changes. • Menopause is an important women’s health issue. Introduction • It was not until the 20th century that women that the life expectancy of the U.S. woman reached a point where most women lived much beyond menopause. • Today most women will live one third or more of their lives postmenopausally. Life expectancy at birth SOURCE: CDC/NCHS, Health, United States, 2013, Figure 1. Data from the National Vital Statistics System. Introduction ❑ Age – Population over 65 years old ◼ 1900 4% ◼ 2010 at 13% (CDC) ◼ 2030 20% approx. 58 million ◼ Average life expectancy of women 80.5 years (CDC) ❑ Increase of 32 years since 1900 Introduction • The medical definition of menopause is the cessation of menstrual cycles for one year. • Menopause is a natural biological process and is not a disease. • The transition stage before menopause is called perimenopause: • Changes in menstruation can occur such as heavy and frequent menstrual cycles. • Mood swings • Hot flashes and night sweats. Introduction • Most women enter and complete menopause between the ages of 45 and 55. • The average age being 51. • Early menopause occurs before the age of 40. • Early menopause is a risk factor for cardiovascular disease. • Induced menopause is cessation of menstruation that follows bilateral oophorectomy (with or without hysterectomy), chemotherapy, or pelvic radiation therapy. • Late menopause occurs after age 55. Introduction • Risk factors for early menopause include: • • • • • Smoking Not graduated from college Unemployment Formally married History of heart disease. • Risk factors for late menopause: • History of taking oral contraceptives • Japanese ancestry • Have had a child The Biology of Menopause • Perimenopause: • Definition • Time period when hormone secretion begins to decline as a prelude to menopause • Age of Onset • 39 to 51 (typically mid 40’s) • Duration • 2 to 10 years The Biology of Menopause • Perimenopause Continued: • Decrease in fertility: • # of capable ovarian follicles decline • Menstrual cycles become irregular • Hormone levels begin to shift: •  Follicle Stimulating Hormone (FSH) •  Luteinizing Hormone (LH) •  Estrogen • Pregnancy remains a possibility during this time because ovulation may occur in sporadic intervals. • Eventually  Progesterone & Androgen The Biology of Menopause • Natural menopause occurs when the ovaries fail to respond to LH and FSH. Weight Gain • Many women gain an average of 5 lb (2.27 kg) at midlife related mostly to aging and lifestyle, not menopause or hormone therapy (HT). • However, menopause may be related to changes in body composition and fat distribution. • • Brown WJ Obes Res 2005;13:1431-41; Milewicz A Climacteric 2004;4:273-83; Crawford SI Menopause 2000;7:96-104 Body mass index for women Underweight Normal weight Overweight Obese Morbidly obese <18.5 kg/m2 18.5-24.9 kg/m2 25.0-29.9 kg/m2 30.0-39.9 kg/m2 ≥40.0 kg/m2 National Library of Medicine Accessed 8/22/12 Percent of population Overweight in US • 70% of women ages 55-75 and 65% of women ages 45-55 are overweight • Approximately 40% are obese The Biology of Menopause • Skin: • Estrogen inhibits skin ageing by preventing skin ageing and promoting skin thickness, collagen content and skin moisture. • 30% decline in skin collagen in the first 5 years after menopause, ~2% per year decline over next 20 years. • Estrogen receptors are present in significant numbers in skin. • Brincat M Br Med J 1983;287:1337-8; Verdier-Sevrain S Exp Dermatol 2006;15:83-94 The Biology of Menopause • Muscle: • Several studies have indicated that lower circulating estrogen levels are associated in loss of muscle strength and muscle mass. • The Biology of Menopause • Hair: • Increase in the ratio of androgen to estrogen during the menopause transition may influence hair changes in some women. • Female pattern hair loss (thinning on crown) most common diagnosis. • Large “rogue hairs” can appear on the chin around menopause. The Biology of Menopause • Cardiovascular: • Coronary artery disease is the narrowing or blockage of arteries that surround the heart muscle. • It results when fatty plaque builds up in the artery walls (known as atherosclerosis). This buildup is associated with high levels of cholesterol in the blood. • After menopause, a woman's risk for coronary artery disease increases. The Biology of Menopause • Genitourinary Tract: • Vagina and surrounding tissues require estrogen stimulation to maintain normal structure and function. • Decline in estrogen levels—regardless of the cause— can result in vaginal atrophy and its associated symptoms, such as vaginal dryness, itching, burning, and inadequate lubrication during sexual activity. • Urinary symptoms associated with vaginal atrophy include increased frequency, urgency, and recurrent urinary tract infections, as well as urinary incontinence resulting from pelvic floor relaxation. The Biology of Menopause • Effects of Estrogen Loss: • Bone: Women lose an average of 25 percent of their bone mass from the time of menopause to age 60 due in large part to the loss of estrogen. • Over time, this loss of bone can lead to bone fractures. There are many options, including estrogen therapy, to treat brittle bones. Objectives/Study Guide • Define menopause • Understand the difference between natural menopause and surgical menopause. • Name risk factors for early menopause. • Name risk factors for late menopause. • What age does perimenopause typically start. • Understand the physical changes associated with the perimenopausal period. • Understand the difference between normal body mass index and obesity. • Name several effects estrogen depletion has on a woman’s body. ... Purchase answer to see full attachment

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