Menopause - Management of Normal and Altered Female Physiologic Processes

MENOPAUSE

Menopause is the permanent physiologic cessation of menses as-sociated with declining ovarian function; during this time, re-productive function diminishes and ends. Postmenopause is the period beginning from about 1 year after menses cease. Menopause is associated with some atrophy of breast tissue and genital organs, loss in bone density, and vascular changes.

Menopause starts gradually and is usually signaled by changes in menstruation. The monthly flow may increase, decrease, be-come irregular, and finally cease. Often, the interval between pe-riods is longer; a lapse of several months between periods is not uncommon.

Changes signaling menopause begin to occur as early as the late 30s, when ovulation occurs less frequently, estrogen levels fluctuate, and FSH levels rise in an attempt to stimulate estrogen production.

Clinical Manifestations

Because of these hormonal changes, some women notice irregu-lar menses, breast tenderness, and mood changes long before menopause occurs. The hot or warm flashes and night sweats re-ported by some women are directly attributable to hormonal changes. Hot flashes, which denote vasomotor instability, may vary in intensity from a barely perceptible warm feeling to a sen-sation of extreme warmth accompanied by profuse sweating, causing discomfort, sleep disturbances and subsequent fatigue, and embarrassment.

Other physical changes may include atrophic changes and osteoporosis (decreased bone density), resulting in decreasedstature and bone fractures. About 1.5 million new fractures due to osteoporosis occur yearly in the United States (NIH Consen-sus Statement, 2001). The entire genitourinary system is affected by the reduced estrogen level. Changes in the vulvovaginal area may include a gradual thinning of pubic hair and a slow shrinkage of the labia. Vaginal secretions decrease, and the woman may report dyspareunia (discomfort during intercourse). The vaginal pH rises during menopause, predisposing the woman to bacterial infections (atrophic vaginitis). Discharge, itching, and vulvar burning may result.

Some women report fatigue, dizziness, forgetfulness, weight gain, irritability, trouble sleeping, feeling “blue,” and feelings of panic. Menopausal complaints need to be evaluated carefully as they may indicate other disorders.

Psychological Considerations

Women’s reactions and feelings related to loss of reproductive capacity may vary (Jacob’s Institute of Women’s Health, 2000). For women with grown families, menopause may result in role confusion or feelings of sexual and personal freedom. Women may be relieved that the childbearing phase of their lives is over. Each woman’s circumstances will affect her response and must be considered on an individual basis. Nurses need to be aware of and sensitive to all possibilities and take their cues from the patient.

Medical Management

As stated earlier, menopause may be characterized by decreased vaginal secretions, hot flashes, changes in the urinary tract, and mood swings. Decreased vaginal lubrication may cause dyspareu-nia in the menopausal woman; this may be prevented by the use of a water-soluble lubricant (eg, K-Y jelly, Replens, Astro-Glide, or contraceptive foam or jelly). A vaginal cream containing estro-gen or an estrogen-containing vaginal ring may be prescribed.

Women approaching menopause often have many concerns about their health. Some have concerns based on a family history of heart disease, osteoporosis, or breast cancer. Each woman should discuss her concerns and feelings with her primary health care provider so that she can make an informed decision about managing menopausal symptoms and maintaining her health.

PHARMACOLOGIC THERAPY

Hormone Replacement Therapy. 

HRT reduces or eliminates per-sistent and severe hot flashes, reduces bone loss, decreases the risk for colon cancer, and improves lipoproteins and lowers fibrino-gen levels (Hulley, Grady, Bush, et al., 1998). Despite these find-ings, the more recent Women’s Health Initiative controlled trial of HRT in over 16,600 women demonstrated that the risks of HRT outweigh the benefits (Writing Group of the Women’s Health Initiative Investigators, 2002). This study was halted after 5.2 years rather than continuing it for the planned duration of 8.5 years because women receiving HRT had a higher risk for in-vasive breast cancer than the group receiving placebo. Although the absolute risk of breast cancer is low for an individual woman taking HRT, the risks were considered contrary to its intended effect, which is to preserve health and prevent disease. Because of these findings, many women have elected to discontinue HRT, and many of those who previously would have taken HRT have refused or are reluctant to consider it. Some women and their health care providers have elected to begin or continue use of HRT to treat menopausal symptoms because of its benefits. Nurses need to be knowledgeable about the issues associated with HRT use if they are to provide appropriate health care to peri-menopausal and menopausal women.

Risks and Benefits of HRT. 

The changes that occur during meno-pause have adverse effects on women, placing them at increased risk for atherosclerosis, angina, and coronary artery disease. The effectiveness of HRT in reducing the risk for some of these con-ditions has not been supported, and the American Heart Associ-ation has recommended against initiating HRT for primary and secondary prevention of cardiovascular disease or stroke (American Heart Association, 2002). HRT is contraindicated in women with a history of breast cancer, vascular thrombosis, active liver disease or chronically impaired liver function, some cases of uterine cancer, and undiagnosed abnormal vaginal bleeding. The risk of thromboembolic phenomena is slightly elevated. Women who elect to take HRT despite these risks should be taught the signs and symptoms of deep vein thrombosis and pulmonary embolism and should be instructed to report these signs and symptoms im-mediately. Nurses should assess for leg redness, tenderness, chest pain, and shortness of breath in patients who take HRT. Further, women taking HRT need to be informed about the need for follow-up and monitoring. For women who decide to take HRT, regular follow-up care, including a yearly physical examination and mammogram, is important. An endometrial biopsy is indi-cated for women with any irregular bleeding during treatment. Because the risk of complications increases the longer HRT is used, HRT should be used for the shortest time necessary (American Heart Association, 2002).

Making a Decision About HRT. 

The decision of whether to useHRT has been a difficult one for many women. Although the re-sults of the Women’s Health Initiative trial may make the deci-sion easier for some women, it is likely to remain a difficult decision for those who may benefit from its use because of very disruptive symptoms of menopause and evidence of bone loss. Women often want to learn about alternatives to HRT use; there-fore, nurses should address other strategies that women can use to promote their health in the perimenopausal period.

Method of HRT Administration. 

There are several different ap-proaches for use of hormone replacement. Some women take both estrogen and progestin daily; others take estrogen for 25 consecu-tive days each month, with progestin taken in cycles (eg, 10 to 14 days of the month). Progestin is taken to prevent proliferation of the uterine lining and hyperplasia in women who have not had their uterus removed. Women who take hormones for 25 days often experience bleeding after completing the progestin. Other women take estrogen and progesterone every day and usually ex-perience no bleeding. They occasionally have irregular spotting, which should be evaluated by their health care provider.

Estrogen patches, which are replaced once or twice weekly, are another option but require a progestin along with them if the woman still has a uterus. Vaginal treatment with an estrogen cream, suppository, or an estradiol vaginal ring (Estring) may be used for vaginal dryness or atrophic vaginitis. Estring is a small, flexible vaginal ring that slowly releases estrogen in small doses over 3 months.

Alternatives to HRT. 

Women may benefit from learning aboutalternatives to HRT, including diet, vitamins, and exercise. They need to know that these approaches to menopause have not been examined thoroughly through research. Osteoporosis, a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, occurs with menopause and leads to en-hanced bone fragility and increased risk for fracture. Other fac-tors that increase a woman’s risk for osteoporosis include a thin body frame, race (Caucasian or Asian), family history of osteo-porosis, nulliparity, early menopause, moderate to heavy alcohol ingestion, smoking, caffeine use, sedentary lifestyle, and a diet low in calcium. Women should be advised to remain active or to begin an exercise program of weight-bearing activity, such as walking; to take a calcium supplement; to decrease or stop smok-ing; and to discuss the use of pharmacologic agents (bisphospho-nates, calcitonin, parathyroid hormone, HRT) to reduce bone loss with their health care provider (NIH Consensus Statement, 2001; National Osteoporosis Foundation, 1999). Selective es-trogen receptor modulators (SERMs) such as raloxifene (Evista) provide another alternative to HRT for the prevention and treat-ment of osteoporosis. These medications do not appear to in-crease the risk for breast cancer; indeed, the risk of breast and uterine cancer may be reduced. Their use may increase hot flashes. No long-term studies exist on these medications because of their recent development.

Problematic hot flashes have been treated with venlafaxine (Effexor), paroxetine (Paxil), gabapentin (Neurontin), and cloni-dine (Catapres). These medications have been found to reduce hot flashes and are alternatives for women who do not wish to use HRT. The web site of the North American Menopause Society (http://www.menopause.org) provides additional suggestions.

Vitamin B in doses of less than 200 mg has been found to relieve some distressing menopausal symptoms. Vitamin E has been ef-fective in decreasing hot flashes for many women. Some women are interested in alternative treatments (eg, natural estrogens and progestins, black cohosh, ginseng, dong quai, soy products, and several other herbal preparations); however, few scientific data exist about the safety or effectiveness of these remedies. Assessment of menopausal patients should include their use of complementary and alternative therapies and supplements. Medications, including alendronate (Fosamax), raloxifene (Evista), and calcitonin, for the treatment of osteoporosis have given women another option in pre-venting or treating this major health problem.

The American Heart Association (2002) suggests the use of established methods of treatment to lower heart disease risk in women. These include lifestyle changes and behavioral strate-gies. Pharmacologic therapy (eg, aspirin, beta blockers, statins, angiostatin-converting enzyme inhibitors) may be indicated in women who have cardiovascular disease or are at high risk for it.

BEHAVIORAL STRATEGIES

Regular physical exercise, including weight-bearing exercise, raises the heart rate, increases high-density lipoprotein (HDL) levels, and helps to maintain bone mass. It may also reduce stress, enhance well-being, and improve self-image. Loss of muscle tis-sue is mediated by exercise; weight-bearing exercise (eg, walking, jogging) at least four times a week is recommended.

NUTRITIONAL THERAPY

Women should also be encouraged to decrease caloric intake, de-crease fat intake, and increase intake of whole grains, fiber, fruit, and vegetables. Women of all ages are urged to include high-calcium food in their diets daily. For example, 1 cup of milk contains about 300 mg of calcium, and 1 cup of nonfat yogurt provides 415 mg of calcium. Other sources of dietary calcium include most green leafy vegetables, seafood, and calcium-fortified foods.

Calcium supplementation may be helpful in reducing bone loss and preventing the morbidity associated with fractures sec-ondary to osteoporosis. Bones serve as a storehouse of the body’s calcium, and bone density decreases with age. When calcium levels in the blood are low, the bones give up calcium to main-tain homeostasis. Women of all age groups often ingest less than the recommended amount of calcium. The average calcium in-take is 300 to 500 mg/day, whereas the recommended amount is 1,300 mg/day for adolescents and young adults, 1,000 mg/day for adults 19 to 50 years of age, 1,200 mg/day for adults 51 years of age and older (including menopausal women taking HRT), and 1,500 mg/day for women who are menopausal and not taking HRT (National Osteoporosis Foundation, 1999; NIH Consen-sus Statement, 2001).

Nursing Management

Nurses can encourage women to view menopause as a natural change resulting in freedom from menses and symptoms related to hormonal changes. No relationship exists between menopause and mental health problems; however, social circumstances (eg, adolescent children, ill partners, and dependent or ill par-ents) that usually coincide with menopause may produce stress.

Measures should be taken to promote general health. The nurse can explain to the patient that cessation of menses is a phys-iologic function that is rarely accompanied by nervous symptoms or illness. The current expected life span after menopause for the average woman is 30 to 35 years, which may encompass as many years as the childbearing phase of her life. Menopause is not a complete change of life, however. Normal sexual urges continue, and women retain their usual response to sex long after meno-pause. Many women enjoy better health after menopause than before, especially those who have experienced dysmenorrhea. The individual woman’s evaluation of herself and her worth, now and in the future, is likely to affect her emotional reaction to meno-pause. Patient teaching and counseling regarding healthy lifestyles, health promotion, and health screening are of paramount im-portance (Chart 46-9).