Menopause! For many women approaching the fifth-decade hearing the word is like slowly grinding a fresh manicure across a dusty chalkboard. Is it the beginning of the end? Is it the end of the beginning? No Virginia! It’s the middle of the beginning! Well you get the picture. Just like your pre and post childhood and adulthood the menopause will be what you make of it. Confucius said, “A journey of 1,000 miles begins with the first step.” On your journey there will be flushes and flashes, big deal; You have had them before many years ago or maybe not so many, young love caused them. He caused them and all it took was a smile, a touch or perhaps a kiss. You had the same flash and flush you’re having now. The same physiologic response, cutaneous blood vessels dilating, heart pounding, hormones cascading, warm red cells welling up from your core washing over you as they race for every pore of your skin. You found it breathtaking back then, fear, hope, flush, breath….thrilling! You’re current flashes and flushes are the same, they lack only the mystery. Hold your breath and try to experience these flashes as you did your first ones. I know it sounds preposterous but many of my patients have done it for years. Even if it doesn’t help it makes them laugh and I believe that’s almost as good! Often it the little things that help you cope. Don’t despise demon menopause, tame then dominate this anathema. Use these guidelines as you would a shield. Keep your mind, body and spirit healthy. Put the demons on notice don’t pass quietly into the night! Yes, of course there will be changes, dry thing may be wet, wet things may be dry, tight things may loosen etc. and yes hair can grow from anywhere! Fear not when landmarks start drifting south, for come to rest they will once more. Now equatorial land marks they be, just not as pointy as before. Now let’s review the guide for the rest of the middle.

What is this menopause? How do we define it? Permanent cessation of menses defines the menopause. It concludes with the final menstrual period. Post-menopause begins at that time, although it is not recognized until after 12 months without a period. In the United States, the median age at which menopause occurs is 52 years, but it can vary between 40 and 58 years of age. With a life expectancy close to 85 years, the average woman is postmenopausal for one third of her life. The incidence of certain conditions such as coronary artery disease, diabetes, breast cancer and colon cancer increases after menopause. Don’t dwell on the previous two lines, information like this can produce “Nirvana interruptus!” Seek your physician’s guidance toward healthy lifestyle choices. You can keep years in your life and life in your years.

Key Clinical Recommendations for Postmenopausal Women:
Extended use of hormone therapy in women who are aware of the risks and benefits and are under medical supervision is acceptable for the following: those who feel that the benefits of menopausal symptom relief outweigh the risks; those who have moderate to severe menopausal symptoms and those with reduced bone mass. All postmenopausal women should have adequate intake of calcium and vitamin D to maintain bone health. Aspirin is recommended in women with high risk of coronary heart disease. Screening for breast cancer every one to two years, beginning at age 40 years. Routine PAP smear for cervical cancer screening in women who have a cervix. Screen for colorectal cancer beginning at age 50 years.

Symptom Management:
I am told some women go through menopause with few if any symptoms. My review of the literature found virtually all these women live in California, have at least one personal trainer and no children. Carrying a tiny dogling as well as a cell phone is considered strenuous activity, and a handful of almonds plus the condensation from a Perrier bottle is a hardy meal. Vasomotor symptoms and vaginal dryness are consistently associated with menopausal transition. Oral hormone therapy is highly effective in relieving hot flashes and night sweats compared with placebo. Various hormonal preparations are available to treat vasomotor symptoms. When estrogen is contraindicated, nonestrogen drugs may be considered. Postmenopausal vaginal symptoms can be treated with topical vaginal estrogen preparations. The WHO found that a small group of women taking combined estrogen and progestin therapy had a slightly higher risk of heart attack and venous thromboembolism after one year, stroke after three years, and breast cancer after five years. However, there is a lower incidence of fractures, colon cancer and dementia in women who take combination hormone therapy continuously for five years. A recent updated analysis of the WHI findings concludes that estrogen alone does not increase the incidence of breast cancer in postmenopausal women with a previous hysterectomy. All women on hormone therapy should be under clinical supervision and aware of the potential risks and benefits. Relatives, friends and husbands of all postmenopausal women not on hormone therapy must also be made aware of their risk. They must be ever vigilant for early signs of Hypohormonomania. The tragic ramifications of which are far beyond the scope of this paper.

Preventive Care Recommendations:
Lifestyle modifications, screenings, early identification, and appropriate intervention prevent many serious chronic conditions that cause disability and death during the postmenopausal years. The following are evidence based recommendations for health maintenance screening in postmenopausal women.

Osteoporosis Screenin:g:
One half of all postmenopausal women will have an osteoporotic fracture during their lifetime. Routine bone mineral density screening is recommended in women older than 65 years. Treatment is recommended.

Calcium and Vitamin D:
Adequate calcium and vitamin D intake reduces bone loss in peri- and postmenopausal women. Calcium also potentiates the effects of exercise on bone mineral density in postmenopausal women. The National Institutes of Health recommends 1,000 mg of calcium per day for postmenopausal women younger than 65 on estrogen and 1,500 mg per day for those over 65. Vitamin D plays a major role in calcium absorption and bone health. Vitamin D is formed in the skin following direct exposure to sunlight. Usually 10 to 15 minutes of exposure of hands, arms, and face two to three times per week satisfies the body's vitamin D requirement. Other sources include vitamin D fortified foods, such as milk, yogurt, cheese, bread, orange juice, and oily fish. The current recommendation for daily vitamin D intake is 800 to 1.000 IU per day.

Exercise:
Regular weight-bearing exercise reduces the risk of developing osteoporotic fractures in postmenopausal women. A recent trial revealed that brisk walking combined with moderate resistance training improved muscle strength, balance, and performance in women who recently went through menopause.

Smoking:
Cigarette smoking has been associated with earlier onset of menopause. The annual risk of death for women who continue to smoke is more than double that of persons who have never smoked in every age group from 45 through 74 years. Postmenopausal women who currently smoke have lower bone mineral density and an increased risk of hip fracture compared with women who do not smoke. Smoking cessation reduces the risk of certain cancers, coronary artery disease, and premature death among women.

Coronary Heart Disease Prevention:
Coronary heart disease is the most common cause of death in women. Approximately one in two women develops, and one in three dies from it. Early mortality following MI is higher and long-term prognosis is worse in women than in men. It is strongly recommended that women 45 years and older be screened for lipid disorders and treated if lipid levels are abnormal. Screening for diabetes with fasting plasma glucose is indicated for women with risk factors for CHD, such as hypertension and hyperlipidemia. Data suggest that smoking cessation after an MI and treatment of hypertension and hyperlipidemia lower the risk for CHD events in women. The American Heart Association recommends aspirin therapy in women at high risk of CHD. Aspirin lowers the risk of ischemic stroke by 24 percent.

Cancer Screening
Breast Cancer:
Breast cancer is the most common non-skin malignancy diagnosed in women and the second leading cause of cancer-related death. The risk of breast cancer increases with age. Screening for breast cancer is recommended every one to two years, with mammography for women 40 years and older. The evidence that screening reduces mortality from breast cancer is strongest for women 50 to 69 years of age.

Cervical Cancer:
There is evidence that early detection through routine Papanicolaou (Pap) testing can lower mortality from cervical cancer. Routine screening with Pap testing for all women who have a cervix is recommended. Screening can be discontinued after 65 if the patient has had 3 normal yearly Pap smears. Screening is not required for women who have had a total hysterectomy for benign indications.

Colorectal Cancer:
Early detection of colorectal cancer improves survival. The five-year survival rate is approximately 91 percent with localized disease, but drops to 6 percent among persons presenting with distant metastasis. Screening is recommended for colorectal cancer in all persons 50 years and older.

Immunizations:
Annual influenza vaccine should be administered to women 50 years and older. A tetanus and diphtheria toxoid (Td) booster is recommended every 10 years after the primary series is completed. Women 65 years and older should also be immunized against pneumococcal disease. A single dose of zoster vaccine is recommended for adults 60 years and older, whether or not they report a previous episode of herpes zoster.

In Summary:
Menopause usually occurs when women reach their early 50s. It is the permanent cessation of menstruation resulting from the loss of ovarian and follicular activity. Vasomotor symptoms and vaginal dryness are frequently reported during menopause. Estrogen is the most effective treatment for management of hot flashes and night sweats. Local estrogen is preferred for vulvovaginal symptoms because of its excellent therapeutic response. Bone mineral density screening should be performed in all women older than 65 years, and should begin sooner in women with additional risk factors for osteoporotic fractures. Adequate intake of calcium and vitamin D should be encouraged for all postmenopausal women to reduce bone loss. Coronary artery disease is the leading cause of death in women. Postmenopausal women should be counseled regarding lifestyle modification, including smoking cessation and regular physical activity. All women should receive periodic measurement of blood pressure and lipids. Appropriate pharmacotherapy should be initiated when indicated. Women should receive breast cancer screening every one to two years beginning at age 40, as well as colorectal cancer screening beginning at age 50. Women younger than 65 years who have a cervix should receive routine cervical cancer screening with Papanicolaou smear. Recommended immunizations for menopausal women include an annual influenza vaccine, a tetanus and diphtheria toxoid booster every 10 years, and a one-time pneumococcal vaccine after age 65 years.

SURVIVING THE CHANGE
Marc J. Crupie, M.D.

Serving Memphis, Cordova, & Surrounding Areas
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901-507-4400