Perimenopause and Menopause Changing with Grace! Heather Shannon, MS, CNM, NP, MPH Upstate Midwifery Program

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1 Perimenopause and Menopause Changing with Grace! Heather Shannon, MS, CNM, NP, MPH Upstate Midwifery Program

2 Disclosure I do not have any financial relationships with any commercial organizations.

3 Midlife What is it? Video

4 Midlife Stage years Time of transition Increased feelings of physical and emotional wellbeing Greater sense of control over their lives Establish new goals More free time New career Go back to school New hobbies

5 Midlife Physical changes Health conditions Weight gain Muscle loss Visual changes Sexuality changes Menstrual changes

6 Most Common Changes Insomnia Hot Flashes Weight Gain Vaginal Dryness Sexual Response Emotional Concerns Cardiovascular Disease Osteoporosis Lifestyle Changes Menstruation

7 Insomnia 61% experience Up to 80% experience fatigue Keep regular schedule Eat regular meals at regular times Limit caffeine Bloodstream for up to 6 hours Coffee Tea Chocolate Cola drinks Avoid nightcaps Alcohol = drowsy Affects REM and non-rem sleep Wake up often Exercise regularly Not within 3 hours of bedtime

8 Hot Flashes 90% reported (75% night sweats) Begin 1-2 years prior last period Lasts up to 15 years Pinpoint triggers Hot drinks Spicy foods Alcoholic drinks Stress Hot weather Warm room

9 How to Cope! Dress in layers Thermostat low Fan Exercise regularly Fewer and less intense hot flashes HRT

10 Weight Gain 90% will have a 10-20lb weight gain Result of slowing metabolism Requiring less calories Estrogen deficiency

11 Vaginal Changes Thinner and dryer (40-60%) Dysparunia (Painful sex) ERT Water-soluble or silicone-based lubricants Regular sex Active sex life increases blood flow to the genitals

12 Sexual Response Decreased libido (desire) Most common sexual concern (20-40%) Lack of desire before having sex is normal for some women Usually becomes aroused when in the act Lack of sexual desire also can be a sign of depression Desire is often present in new relationships Tends to decrease Changes in sexual response changes Arousal takes longer Talk with your partner regarding feelings and your likes/dislikes Foreplay or try new positions Not just sexual intercourse Many other activities Kissing Fondling Oral sex Mutual masturbation

13 The Oops Factor!

14 Emotional Concerns Constant change of hormone levels affect emotions Mood swings or symptoms of depression (50%) Age: x more likely to experience depression Gallop poll (1998) sense of happiness 50-65: 51% 40s: 16% 30s: 17% 20s: 10% Memory lapses and poor concentration Changing hormone vs. natural effects of aging

15 How to Cope! Unsteady emotions or mental lapses Talk to your health care provider Not going crazy Dealing with symptoms of perimenopause at midlife Therapies Regular exercising Stress-control methods Get more sleep Antidepressants» Even out moods Just knowing what is wrong

16 Cardiovascular Disease Largest killer than any other cause of death Accounts for >33% of all deaths in women each year More deaths from heart disease and stroke than from all forms of cancer combined 450,000 women die from cardiovascular disease each year 72,000 from lung cancer 40,500 from breast cancer Risk of heart disease and stroke increases Natural estrogen protective Less estrogen increase risk Midlife is increased risk factors for heart disease High cholesterol High blood pressure Smoking A high-fat diet Diabetes Physically inactive Overweight

17 Cardiovascular Disease Heart disease is 2X as likely to strike inactive people Best exercises to strengthen your heart and lungs are Brisk walking Running Swimming

18 Bones Always changing Old bone is broken down and new bone is formed Childhood 30 years Bone is formed faster than it is broken down Bones become larger and denser 30+ years Process begins to reverse» Bone is broken down faster than it is made» Process continues for the rest of your life A small amount of bone loss after age 35 normal usually not problematic Rapid bone loss 4 8 years after menopause 33% >50 will fracture bone from osteoporosis

19 How to Cope! Just as muscles get stronger with regular exercise, so do bones. Active women have higher bone density than women who do not exercise. Regular weight-bearing exercise, done three to four times a week, is a good way to strengthen bones and slow bone loss. Calcium supplementation Vita D

20 How to Cope! years 1,000 mg of calcium a day 51+ years 1,200 mg of calcium a day Milk and other dairy foods are good sources Daily calcium supplement Vitamin D helps absorb calcium Vitamin D 5 through15 minutes of sunlight each day Ability to make vitamin D from sunlight decreases with age international units of vitamin D daily Sources of vitamin D are fatty fish such as salmon and tuna

21 Lifestyle Changes Losses, new demands, and changes in routines Children are getting older time of challenges Decade of closeness Pull away Talk with you less openly Act in a way that is moody or hostile Unsettling Independent children Feel less needed

22 Lifestyle Changes 2.5% of all babies born in the United States aged 40+ Baby at midlife Big adjustment Juggling a job Child care Household chores Feedings at 3 am Caring for aging parents Roles reverse- parenting your parents 22 million Americans caring for aging parents Childless or never married women face midlife changes Concerned of future Lack support

23 How to Cope! Reach out for help Talking with others Open up to a friend Facing fears and stresses Counseling and support groups

24 Ah! A Positive! Despite these challenges, midlife often is still a rewarding phase of life Better equipped emotionally to handle problems Wisdom Manage things Reveal strengths

25 How Menopause Happens

26 Menstruation Your Menstrual Cycle Monthly changes in two hormones estrogen and progesterone Estrogen and progesterone - ovaries Ovaries male hormone testosterone Ovaries thousands of eggs Egg matures and released by an ovary ovulation About 400 eggs are released over a woman s lifetime Rest are absorbed into the body

27 Menstruation

28 Menstruation In your 40s, Hormone levels changes = menstrual cycle changes Number of days between periods Increase or decrease Periods Shorter or longer Menstrual bleeding Heavier or lighter Skip periods Irregular release of eggs

29 Menstruation Abnormal bleeding means call your provider Bleeding between periods Bleeding after sex Spotting at anytime in the menstrual cycle Bleeding that is heavier or lasts for more days than usual Bleeding after menopause

30 What is it? Perimenopause

31 Perimenopause Beginning mid-40s lasts from age 45 years to age 55 years Transition phase Perimenopause Gradual change in hormone levels and menstrual cycles Ovaries get smaller and produce less estrogen

32 Perimenopause»Menopause Menopause Absence of menstrual periods > 1 year Average age American women 51 years Perimenopause and menopause are natural events Same basic changes Feels and copes with these changes differently Best approach to menopause is to be fully informed Knowing what to expect Ease symptoms Prevent future health problems

33 Symptoms and Effects

34 Hormone Therapy (HRT) Helpful for treating the symptoms of perimenopause Risks and benefits of HRT Many of the risks are related to a woman s health and family history Important to learn as much as you can Discuss your options with your health care provider

35 Types of Hormone Therapy Hormone therapy can be given in different ways: Orally (by mouth) Vaginally (cream, pill, suppository, or ring) Transdermally (through the skin with a patch, gel, or spray) Sublingually (a pill placed under the tongue) By troche (a lozenge that is placed between the cheek and gum until it dissolves) Under the skin (pellets)

36 Types of Hormone Therapy Not had a hysterectomy Two types of hormone therapy: Continuous-combined therapy Estrogen and progestin are taken every day» Irregular bleeding the first few months» Bleeding decreases with time» Stops within 6 months Cyclic therapy Estrogen and progestin are taken cyclically, either together or separately, with 1 week during which no hormones are taken» Estrogen is taken alone» May have some bleeding

37 Benefits of Hormone Therapy Estrogen with or without progestin relieves Hot flashes Night sweats Sleep problems Low doses estrogen cream relieve Vaginal dryness and irritation Estrogen with or without progestin prevents Bone loss (osteoporosis) Prevent hip and spine fractures Combined hormone therapy Reduce the risk of colon cancer

38 Risks of Hormone Therapy Increase the risk of certain types of cancer Uterine cancer Estrogen therapy bulks lining of the uterus Adding progestin decreases the risk Breast cancer (first 2-3 years) Both progesterone and estrogen have been linked Estradiol (ovary) increase breast cancer Estriol (pregnancy) protective against breast cancer Estrone (fat cells) increases risk of breast cancer

39 Risks of Hormone Therapy Increase the risk of other conditions Small increased risk of heart attack Estrogen therapy with or without progestin Estradiol and Estrone increases risks Related to age, existing medical conditions, timing of HRT In good heart health are at low risk of heart attack in early menopause Consider combined hormone therapy for the relief of menopause symptoms

40 Risks of Hormone Therapy Estrogen therapy with or without progestin is associated with: Small increased risk of stroke Low doses of estrogen do not cause an increased risk of stroke Deep vein thrombosis (DVT) Non-pill forms (patches, sprays, rings, and others) have less risk of causing DVT Small increased risk of gallbladder disease Greatest with pill forms

41 Risks of Hormone Therapy Estrogen therapy with or without progestin is associated with: Small increased risk of stroke Low doses of estrogen do not cause an increased risk of stroke Deep vein thrombosis (DVT) Non-pill forms (patches, sprays, rings, and others) have less risk of causing DVT Small increased risk of gallbladder disease Greatest with pill forms

42 Risks of Hormone Therapy Combine HRT Small increase risk of breast cancer Risk increases the longer on hormone therapy Increased risk goes away when a woman stops the therapy Estrogen-only therapy may not increase the risk of breast cancer, but research results are conflicting

43 Side Effects Combined HRT may cause: Vaginal spotting Heavier bleeding like that of a menstrual period Adjust your dosage to minimize bleeding Fluid retention Breast soreness Usually lasts for a short time

44 Alternatives to Hormone Therapy Antidepressants Called selective serotonin reuptake inhibitors (SSRIs) Lessen mood symptoms Added benefit of helping to relieve hot flashes in some women Gabapentin (Neurontin) Used to treat seizures Reduce hot flashes

45 Alternatives to Hormone Therapy Plant Based Therapies: Soy isoflavone Isoflavone is a phytoestrogen - plant estrogen Plant estrogens act like a weak form of estrogen Help reduce hot flashes and other menopause symptoms Research results are conflicting about their effectiveness Same risks as other types of estrogens Role in preventing bone loss after menopause

46 Alternatives to Hormone Therapy Black cohosh North American plant Hot flashes Sleep disorders Depression Wild yam Extracts, tablets, and creams No proof that yams can relieve symptoms of menopause Hormone-like substance found in some yams, a woman would have to eat a large amount of raw yam to reach a level that would relieve symptoms

47 Alternatives to Hormone Therapy Bioidentical Hormones Plant based hormones combined together Compounded by a pharmacist Ordered by a licensed provider Same risks as hormone therapies approved by the U.S. Food and Drug Administration

48 Bioidentical (Compound) Hormones Bioidentical hormones Plant-derived hormones Chemically similar or structurally identical to the body Commercially available products approved by the U.S. Food and Drug Administration (FDA) Micronized progesterone and estradiol

49 Knowledge Know your symptoms Know your risks Family Personal Talk to your provider Learn about HRT Conventional Compounded

50 Work Up Complete physical exam Cholesterol Pelvic exam Breast exam Imaging studies Blood work to evaluate your current hormone levels

51 Work Up FSH LH DHEA/DHEAs Free and Total Testosterone Estrone Estradiol Estriol TSH ft4/ft3 CBC Lipid panel Cortisol Progesterone

52 Maintenance Reevaluate labs and symptoms in 3 mos Adjust if needed Every year evaluate the need for adjustment

53 Upstate Midwifery & Gynecology 4900 Broad Ave Ste 4H Syracuse, NY

54 References ACOG (2013). Midlife transitions: perimenopause to menopause. ABO13, January ACOG (2013). The menopause years. APO47, January 2013.

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