Learning Outcome

1. Describe the symptoms of menopause
2. Summarize the management of menopause
3. List the complications of menopause
4. Advise lubricants to improve sexual performance

Introduction

Menopause is the permanent cessation of menses for 12 months resulting from estrogen deficiency and is not associated with a pathology. The median age of menopause is 51. Most women experience vasomotor symptoms, but menopause affects many other areas of the body, such as urogenital, psychogenic, and cardiovascular. This article will review hormonal and non-hormonal treatments, as well as complications of menopause. Patients are living longer, and women are spending up to one-third of their lives in post-menopause.

Nursing Diagnosis

• Altered sleep
• Irritable
• Depressed mood
• Thinning bones
• Low libido
• Low self-esteem
• Muscle and joint pain
• Excess sweating
• Skin dryness
• Painful sexual intercourse
• Anxiety
• Hot flashes
• Mood swings

Causes

As women grow older, their ovarian follicles diminish in number. There is a decline in granulosa cells of the ovary, which were the main producers of estradiol and inhibin, with the lack of inhibition from estrogen and inhibin on gonadotropins, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) production increases. FSH levels are usually higher than LH levels because LH is cleared from the blood faster. The decline in estrogen levels disrupts the hypothalamic-pituitary-ovarian axis. As a result, a failure of endometrial development occurs, causing irregular menstrual cycles until they stop altogether.

Menopause may occur due to surgical procedures such as a hysterectomy with bilateral oophorectomy. Menopause can be caused via treatment for certain conditions, like endometriosis and breast cancer with antiestrogens, and other cancers due to chemotherapy medications.

Risk Factors

In the United States, approximately 1.3 million women become menopausal each year. It typically begins between the ages of 51 and 52. However, about 5% of women experience early menopause between the ages of 40 and 45. Additionally, 1% of women experience premature menopause before the age of 40 due to permanent ovarian failure associated with sex chromosome abnormalities.

Assessment

The history will include symptoms related to estrogen deficiency. The obvious symptom is the cessation of menses typically heralded by changes in the menstrual cycle.

Vasomotor Symptoms

Approximately, 75% of women experience vasomotor symptoms. These symptoms include hot flashes, night sweats, palpitations, and migraines. Hot flashes often last approximately three to four minutes at unpredictable intervals. They may be worsened by alcohol, eating, emotional stress, and exertion. Migraines may change in intensity and severity. Migraines without aura are more common than migraines with aura. Migraines with aura have an increased risk of stroke, especially if women smoke or use oral contraceptives. Other types of headaches such as cluster and tension headaches may also increase with a change in hormone levels.

Urogenital Symptoms

Approximately 60% of women experience urogenital symptoms. These symptoms include vaginal atrophy, urethral atrophy, and sexual dysfunction (i.e., a decline in libido).  Vaginal atrophy results in dryness, pruritus, and dyspareunia (painful intercourse). Urethral atrophy results in stress incontinence, frequency, urgency, and dysuria.  

Psychogenic Symptoms

Approximately 45% of women experience psychogenic symptoms. These symptoms include anger/irritability, anxiety/tension, depression, sleep disturbance, loss of concentration, and loss of self-esteem/confidence. 

Physical Examination

Should include measurement of blood pressure, weight and height, breast palpation, vaginal examination, and Pap smear. 

• Blood Pressure: Elevated blood pressure may be noted resulting from arterial vasoconstriction.  
• Weight and Height: Weight gain may be noted, as many women report some degree of weight gain during menopause. The North American Menopause Society stated women gained an average of five pounds over the menopause transitional period. Additionally, a decrease in height may be noted, associated with osteoporosis and spine fractures. 
• Breast and vagina: Breast palpation usually notes decreased breast size. The vaginal examination notes vaginal dryness and urogenital atrophy. Abnormal uterine bleeding is an indication to perform a pap smear.

Evaluation

Generally, no laboratory tests are required to diagnose menopause. The diagnosis is clinically based on the patient's age, symptoms, and ruling out other conditions for patients older than 45 years old. Furthermore, symptoms may precede changes in laboratory values. However, an elevated serum FSH (greater than 40 mIU/mL) can be indicative of menopause (via ovarian failure), although it is insensitive. Additionally, drugs like estrogens, androgens, and hormonal contraceptives may alter lab results.

The United States Preventive Services Tasks Force suggests starting screening for osteoporosis at age 65 if normal risk factors are present. If osteoporosis is a concern (i.e., falls, fractures, medications), a dual-energy x-ray absorptiometry (DEXA) scan can be done. A T-score on DEXA of 1.0 to 2.5 is indicative of osteopenia, while a T-score greater than 2.5 is indicative of osteoporosis.

Medical Management

Menopause treatment and management revolve around minimizing disruptive symptoms and preventing long-term complications.

Hormonal Treatment

Hormone therapy can treat vasomotor symptoms and prevent vaginal/urogenital atrophy, as well as preserve an advantageous lipoprotein profile and prevent bone loss. It can be given in various forms (i.e., tablets, creams, patches), in different modalities (i.e., continuous versus cyclic), and is available as systemic estrogen, estrogen-progestin, estrogen-bazedoxifene, progestin alone, or combined oral contraceptives. The use of unopposed estrogen may cause uterine hyperplasia and uterine cancer, therefore, should be avoided in women with a uterus. The cyclical administration of combination estrogen-progestin therapy is recommended for women with an intact uterus.  It significantly decreases the severity and frequency of hot flashes and improves urogenital atrophy and sleep disturbances. It is also useful in preventing osteoporosis and associated fractures. However, hormone therapy should only be used for the shortest duration of time and at its lowest effective dose, as it increases the relative risk of breast cancer, ovarian cancer, thromboembolism, stroke, and coronary heart disease. There is an increased breast cancer risk after 3 to 5 years with estrogen-progestin and 7 years with estrogen only. It is contraindicated in those with a history of breast cancer, endometrial cancer, deep vein thrombosis, pulmonary embolism, liver disease, unexplained vaginal bleeding, and coronary heart disease. For atrophic vaginitis, in particular, systemic or vaginal estrogen can be utilized; however, localized estrogen therapy at very low doses is preferable when there are no other systemic symptoms. The use of localized estrogen therapy (via vaginal rings, creams, or tablets) has been shown to enhance blood flow and reverse vaginal atrophy. However, this also carries a small risk of venous thromboembolism. 

Selective Estrogen Receptor Modulators (SERMs)

Selective estrogen receptor modulators, such as raloxifene, bazedoxifene, and ospemifene have the ability to modulate estrogen action, without stimulating endometrial growth or increased risk of cancer. SERMs have the same outcome as hormone therapy in preventing bone loss and promoting beneficial lipoprotein levels. Raloxifene acts as an estrogen agonist (pro-estrogen) on bone and lipids, and like an estrogen antagonist (anti-estrogen) on the uterus and breast. Thus, it is effective in preventing/treating mild osteoporosis and decreasing serum LDL. Having a similar profile to raloxifene, bazedoxifene when combined with estrogen, does not influence the endometrium (i.e., women with a uterus do not need to take progestin). Thus, when combined with estrogen, it is effective in treating vasomotor symptoms, like hot flashes. Ospemifene is a newer SERM, which is effective in treating urogenital symptoms, such as vaginal dryness.

Non-Hormonal Treatment

Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, and clonidine. These treatments can be used for short durations (a few months) for menopause symptoms. SSRIs and SNRIs, like paroxetine and venlafaxine, are antidepressants that treat vasomotor symptoms, such as hot flashes and result in one fewer hot flashes a day. Paroxetine, in particular, is the only FDA-approved drug for this indication, and symptoms diminish within a week of initiating treatment. While neither is FDA-approved for the treatment of vasomotor symptoms, both gabapentin and clonidine have been shown to reduce hot flashes in menopausal women. Gabapentin reduces hot flashes by up to 2 hot flashes per day; and clonidine is most effective in mild hot flashes, as it is less effective than SSRIs/SNRIs and gabapentin.

Osteoporosis-Specific

For menopausal women experiencing osteoporosis alone, bisphosphonates, denosumab, and supplementation with calcium and vitamin D can be utilized. Bisphosphonates inhibit osteoclast action and resorption of bone. They have been shown to be safe and efficacious in treating osteoporosis. However, at high doses and over a prolonged period, there may be a risk of developing adynamic bone. For this reason, periodic discontinuation of this drug is recommended, as bone density is retained for quite a few years. Denosumab is an antibody to RANKL. It inhibits the osteoclasts and their activity, such that bone resorption is decreased and bone density is increased. In turn, it is reducing the risk of fractures in menopausal women with osteoporosis (via biannual subcutaneous treatment).

Nonprescription Remedies

Complementary and alternative treatments include phytoestrogens, vitamin E, and omega-3 fatty acids. Vitamin E and omega-3 fatty acids have been used to treat the vasomotor symptoms of menopause. They are generally safe; however, studies have shown that they are no better than placebo. Phytoestrogens like soy, red clover, and black cohosh have also been safely used to treat menopause symptoms. Though studies on black cohosh have shown mixed results when treating hot flashes, soy and red clover have been shown to be effective in treating osteoporosis and high cholesterol.

Nursing Management

• Assess vitals
• Assess sleep pattern
• Take the appropriate history 
• Evaluate mood and depression
• Educate the patient on menopause
• Encourage a healthy diet
• Encourage calcium and vitamin D supplements
• Teach patient stress-relieving methods
• Encourage hydration
• Encourage good sleep hygiene
• Encourage patient to exercise
• Encourage abstinence from alcohol
• Encourage use of lubricants during sex
• Educate patient on kegel exercise

Health Teaching and Health Promotion

• Patients should be encouraged to stop smoking, especially if considering starting hormone therapy.
• Women should try to obtain 150 minutes of cardiovascular exercise per week and 2 to 3 days of weight-bearing exercise.
• Women should eat a healthy diet to maintain a healthy weight.
• Sexual activity is normal, and women should feel comfortable speaking to a health provider if having painful intercourse.  
• Contraception is recommended for 1 year after the last menstrual period while having irregular menses.
• If having menopausal symptoms discuss with a provider because of the many treatment options available.

Discharge Planning

Even though menopause is a physiological condition and not a disease, it has significant morbidity. Besides the increased risk of osteoporosis and fractures, the women also regain their risk for heart disease. In addition, the symptoms of menopause are poorly tolerated and lead to poor quality of life. The majority of these women are seen in clinical practice by the nurse practitioner, primary care provider, or the internist.

Healthcare workers including the nurse and pharmacist should educate the patient on the physiology of menopause. Only those who are not able to tolerate the symptoms should be treated. It appears that many clinicians have started to use menopause as an opportunity to prescribe all sorts of treatments without solid evidence. If there is osteoporosis, a better option is the use of bisphosphonates. Hormonal agents should only be used for short periods and at the lowest dose to avoid complications.

The nurse should educate the patient on the increased risk of heart disease and emphasize prevention. The women should be encouraged to exercise regularly, eat a healthy diet, discontinue smoking and maintain a healthy weight. Since menopause can also result in mood changes, a mental health nurse should offer counsel. Clinicians should ensure that women undergo a bone scan and eat a diet rich in calcium and vitamin D. The pharmacist should urge women not to take untested products and seek guidance from clinicians. Only with an interprofessional team approach can the morbidity of menopause be lowered.