Perimenopause: Tips for the Transition

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Perimenopause Tips for the Transition

• By Kimberley Guida, MD
• Pullman Family Medicine, LLP

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Case Presentation

• Annie is a 48 year old white female who comes in
  for her annual exam. She tells me she is just not
  feeling like her usual self. She has been moody
  lately and having trouble sleeping. She has no
  desire for sex, and this is causing problems in
  her marriage. She occasionally has hot flashes.
  She missed a period three months ago, but since
  then they have been regular. Her husband
  suggested that she go to the doctor and get some
  hormones or something. Do I need hormones?,
  she asks, Am I reaching menopause?

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Topics of Discussion

• What is perimenopause?
• Symptoms of perimenopause
• Long term health risks associated with menopause
• Hormone Replacement Therapy
• Complementary therapies
• Lifestyle changes

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What Is Menopause?

• Menopause is defined as the cessation of ovarian
  function, or the cessation of menstrual cycles
• Menopause is a natural process, it is not a
  disease
• The mean age for menopause is 51 years
• One third of womans life occurs after menopause

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What Is Perimenopause?

• Perimenopause is a transition rather than an
  event
• It is the period of time surrounding menopause
  when ovarian function is declining, but has not
  stopped
• Onset of perimenopause is usually 3-5 years
  before the periods stop
• Perimenopause and menopause may last 2-10 years

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Symptoms of Perimenopause

• Hot flashes
• Vaginal dryness
• Breast Tenderness
• Mood disturbances
• Sleep disturbances
• Urinary tract infections/incontinence
• Menstrual changes
• Sexual dysfunction

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Other Physiologic Changes

• Slowing of metabolism
• Weight gain
• Changes in lipids
• Increase in heart disease
• Osteoporosis

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Heart Disease

• Leading cause of death in women
• Higher risk after menopause probably due to
  changes in cholesterol levels when estrogen
  levels decline
• Elevated bad cholesterol (LDL)
• Lower good cholesterol (HDL)
• Elevation in triglycerides (fats)

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Osteoporosis

• 1 out of 2 white women will have an osteoporotic
  fracture in their lifetime
• 24 of patients over age 50 will DIE in the year
  following an osteoporotic hip fracture
• Deaths due to osteoporosis far exceed the numbers
  of deaths due to breast cancer
• Other consequences- physical limitation, chronic
  pain, depression, poor quality of life

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Hormone Replacement Therapy (HRT)

• Treats the symptoms of menopause (hot flashes,
  etc.)
• Prevention of heart disease (40-50 reduction in
  risk)
• Prevention and treatment of osteoporosis
• May help prevent dementia
• May prevent strokes
• Lower mortality rates in women who take estrogen

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Side Effects of HRT

• Blood clots (especially in smokers)
• Gallbladder disease
• May increase risk of breast cancer
• Vaginal bleeding
• Breast tenderness

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A Word on Breast Cancer

• Women fear breast cancer more than any other
  disease
• Most common cause of cancer in women, but most
  women do not die from it
• Lifetime risk is 11
• Analysis of ALL the studies (over 50) show no
  clear cut increase in breast cancer with estrogen
  use
• Womens health initiative- should be the
  definitive study on estrogen in regards to
  breast cancer and heart disease- results
  available in 2007

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HRT Regimens

• Oral formulations- cyclic or continuous
• Vaginal preparations
• Patches
• Injectable forms
• Low dose oral contraceptives

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Low Dose OCPs

• Higher dose of estrogen than HRT (4-6 times as
  much)
• Provides contraception
• Counteracts erratic ovarian function
• Regulates menstrual cycle
• Improves symptoms of perimenopause
• Protects against ovarian and endometrial cancer

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Male Hormones- Can They Help You?

• Androgens are produced in the ovaries and the
  adrenal glands
• Known to increase libido
• Protects bone mass
• Unfavorable effects on cholesterol
• Can cause virilization (unwanted hair growth)

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Complementary Therapies

• Most lack scientific proof of efficacy
• Large placebo effect
• Large financial incentive for marketers
• Dietary supplements- no regulation by FDA
• May be helpful for women who do not choose HRT or
  as adjunctive therapy

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Phytoestrogens

• Phyto means plant
• Examples are isoflavones, coumestans, lignans
• Found in soy products, whole grains, beans
  (lentils, garbanzos)
• 500-1000 times weaker than estrogen found in the
  body
• Effective in relieving hot flashes
• Dose 40-80 mg isoflavone/daily
• Are supplements the same as dietary sources?
  Unknown

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More on Phytoestrogens

• Found to reduce total cholesterol, LDL and
  triglycerides, and raise HDL
• No effect on bone density
• Is this why Asians have a lower incidence of
  heart disease?

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Vitamin E

• Thought to stabilize estrogen levels
• 800-1200 IU/day (higher doses can increase
  bleeding risk)
• May be beneficial for prevention of heart disease
• Foods rich in Vitamin E asparagus, fish,
  safflower oil, sesame oil, mangos, brown rice

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Chaste tree Berry

• Used extensively in Europe
• May affect prolactin or LH (hormones)- no good
  studies
• May regulate menses or help with PMS symptoms
• Dose 20-40 mg/day
• Side effects rash, stomach upset
• Not to be used in breast-feeding or pregnant
  women

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Dong Quai

• Used in Asia for over 2000 years for menstrual
  problems
• Not shown to be helpful for menopausal symptoms
• Side effects rash, essential oil may contain
  carcinogen
• Not to be used in pregnant women
• Benefits not worth the risks

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Natural Progesterone

• Found in yam root- but eating yams wont help
• Topical cream not well absorbed
• Oral formulation Prometrium
• No adverse effects at standard doses

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Black Cohosh

• Marketed in U.S. as Remifemin (40 mg/day)
• Reports indicate it works better than placebo in
  decreasing hot flashes and sleep disturbances
• Has not been tested for longer than 6 months
• Side effects stomach upset, headache, dizziness

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Evening Primrose

• May lower cholesterol
• May help with eczema
• May help with PMS or breast complaints
• Side effects no adverse effects in standard doses

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Acupuncture

• 12 sessions over 8 weeks showed 75 reduction in
  hot flashes
• Cost 40-75 per session
• Improvement in sleep

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Other Options for Hot Flashes

• Clonidine
• Megace
• Effexor
• Prozac

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Lifestyle Approaches to Perimenopause

• Exercise- aerobic, weight-bearing, strengthening
  program
• High fiber, low fat, soy-rich diet
• Maintain regular sexual activity
• Relaxation and stress reduction activities
• Daily sunlight
• Decrease alcohol intake
• Stop Smoking

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Summary

• Perimenopause is a process rather than an event
• Symptoms are common and most women will seek
  treatment
• HRT is the best treatment available for symptoms
  of menopause, and to prevent long term
  consequences of estrogen deficiency
• Complementary therapies may be of some short term
  benefit for symptom control

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Recommendations

• Consider use of HRT for at least 5-10 years in
  the perimenopause
• Watch for more data available in 2007- Womens
  Health Initiative
• Remember that fear of breast cancer is much
  greater than your actual risk
• Make lifestyle changes

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• For more information on Perimenopause or to refer
  back to this presentation, visit our web site at
• www.pullmanfamilymed.com
• Thank You.