Continuing Education

Guiding your patients through menopause

Defined as the permanent end of ovulation and menses, menopause is a natural and normal event—not a disease or disorder. Yet menopause symptoms may significantly affect quality of life. This time in a wo¬man’s life can be challenging. What’s more, certain health issues (such as breast cancer risk and breast cancer treatments) may complicate the menopause experience. Women may be confused about menopause and seek guidance about the changes they’re experiencing.

You can help improve their quality of life by providing education and counseling on menopause symptom management, bleeding, and other problems that may arise during this period. By increasing your menopause knowledge base, you can better address patients’ concerns and questions.

Menopause signs and symptoms

A wide range of signs and symptoms can occur during the meno¬pause transition and early postmenopausal years. (See Defining menopause-related terms by clicking the PDF icon above.)

Vasomotor symptoms

The most common menopause symptoms are vasomotor and include hot flashes and sweats. A hot flash is a sudden sensation of intense heat starting in the chest or neck area that lasts several minutes. Some women may report a hot sensation that persists throughout the day and varies in intensity. An associated redness of the face and neck is called a hot flush.

Hot flashes result from a decrease in the body’s estrogen level, which signals the hypothalamus in the brain to dilate blood vessels in the skin to cause the heat to disperse. (Before menopause, estrogen regulates body temperature and prevents hot flashes and temperature fluctuations.) Body temperature deregulation also causes sweats, which tend to be more severe at night, possibly from the natural temperature drop we experience at night. This small temperature decrease triggers a hot flash followed by sweating to cool the body down.

Sleep disturbances

Sleep disturbances are common during the menopause transition and into the early postmenopausal years. They may range from difficulty falling asleep to frequent awakening throughout the night. Although hot flashes and night sweats may contribute to sleep disturbances, reports of insomnia increase as women reach midlife. Sometimes sleep disturbances don’t result from vasomotor symptoms but from age-related midlife changes or such chronic conditions as arthritis, fibromyalgia, respiratory disease, coronary artery disease, or GI problems.

Hair, skin, and eye changes

During midlife, many women experience changes in their hair, skin, and eyes. Thinning of scalp hair
and growth of unwanted facial hair probably stem from an increased ratio of andro¬gen to estrogen
during this time. Changes in hair growth and hair loss may significantly affect a woman’s body image and self-esteem.

Midlife skin changes may include collagen and elastin loss, dry skin, and acne. Decreased collagen and skin thickness probably result from reduced estrogen levels. Some women experience a 30% to 40% reduction in skin collagen within 5 years after menopause. Xerosis (dry skin), the most common condition related to aging skin, results from decreased oil production in the skin. Some women also develop acne, probably from the increased androgen-estrogen ratio.

Midlife eye changes may include dry eyes, blurred vision, increased lacrimation, tired eyes, and swollen and reddened eyes. Presbyopia may arise before menopause and necessitate use of reading glasses by the postmenopausal period. Ocular changes, specifically those linked to dry eyes, also may result from decreased androgen levels. (Adequate androgen helps maintain an anti-inflammatory environment in the eye.)

Memory problems and mood changes

Sometimes called “brain fog,” memory problems may cause difficulty finding the right words or an overall haziness, similar to what some postpartum women report. Changes in estrogen levels are thought to contribute to memory problems, which usually are transient.

Mood changes associated with the menopause transition and postmenopause most likely result from hormone fluctuations that influence serotonin, dopamine, and norepinephrine—brain neurotransmitters that regulate mood, sense of well-being, appetite, and libido. The risk for depression rises during the menopause transition, especially in women with a history of depression.

Weight changes

Many menopausal women report weight changes or inability to lose weight. Although no documented link exists between weight gain and menopause, one study found women gain 5 lbs on average during the menopause transition. Menopause also is associated with increased abdominal fat and decreased lean body mass. Decreased muscle mass is linked to declining hormone levels. Muscle burns more calories than fat, so decreased muscle mass may contribute to difficulty losing weight during menopause.

Vaginal changes

Vaginal changes are among the most profound symptoms of the menopause transition and postmenopause and may persist into the postmenopausal years. Such changes include decreased lubrication and vaginal dryness.

Sometimes vaginal changes are more severe and progress to atrophic vaginitis. Resulting from vaginal estrogen loss, atrophic vaginitis is marked by significant vaginal mucosa changes, including a more alkaline pH. Also, the vaginal flora—previously rich in lactobacilli—is replaced by a more diverse flora that includes pathogenic organisms associated with urinary tract infections. As a result, the vaginal walls become thin, pale, dry, and inflamed. These changes can cause pain during intercourse and speculum exams, as well as increased urinary symptoms, such as urine leakage and frequent bladder infections.

Managing menopause symptoms

Management should be patient-centered, tailored to the patient’s specific symptoms and risk profile. It may include hormonal and nonhormonal pharmacologic therapies and various nonpharmacologic approaches. Nurses can play a valuable role in teaching patients about management options, as well as in screening women for menopause symptoms and encouraging them to ask about treatment options. (See Menopause resources for patients and healthcare professionals by clicking the PDF icon above.)

Managing vasomotor symptoms

Hormonal or nonhormonal pharmacologic therapies may be used to ease vasomotor symptoms. The only medications approved by the Food and Drug Administration (FDA) to treat hot flashes and night sweats are hormonal therapies (HT), such as estrogen and progesterone therapy (EPT) for patients with a uterus, or estrogen therapy (ET) alone for those without a uterus. For women with a uterus, estrogen and progesterone must be used together, because unopposed estrogen may cause abnormal cell growth in the endometrial lining of the uterus.

In 2012, the North American Menopause Society (NAMS) published an updated position statement on HT for postmenopausal women, stating that it remains the most effective treatment for hot flashes and night sweats. But women considering HT should discuss their health history with their healthcare providers. For some women, HT may increase the risk of blood clots, heart disease, stroke, and breast cancer. (See Managing menopause symptoms in women with breast cancer by clicking the PDF icon above.)

How long can a woman safely use HT? This depends on whether she takes EPT or ET. EPT use longer than 3 to 5 years is linked to an increased breast cancer risk. In contrast, ET use up to 7 years doesn’t increase breast cancer risk, as shown by the Women’s Health Initiative (WHI) study. The risk of stroke and blood clots may rise with the use of HT over time, but the risk is low for healthy women younger than age 60 (fewer than one in every 1,000 women per year on HT).

The much-anticipated Kronos Early Estrogen Prevention Study found that EPT initiated soon after menopause relieves menopausal symptoms, appears to be safe, and improves mood, bone density, and several markers of cardiovascular health. The cognitive portion of the study found that women on EPT had improved memory recall.

Women and healthcare professionals alike may be confused by bioidentical hormones, which are molecularly similar or identical to what our bodies naturally produce. In FDA-approved formulations, bioidentical HT is available as estradiol and progesterone. Compounding pharmacies also may produce bioidentical HT, in which case they’re called custom-compounded HT. But these custom-compounded preparations aren’t FDA approved and may not have been tested for effectiveness, safety, dose accuracy, or purity. Also, they have the same risk profile as FDA-approved HT preparations. They’re sometimes prescribed when certain medications are available only as compounded formulations.

For women with a medical history that increases the risks of using HT—including a history of hormone-dependent cancers, such as breast or endometrial cancer, blood clots, or stroke—nonhormonal pharmacologic options may be an option for treating vasomotor symptoms. Although used off-label, these therapies have been addressed in the literature. For instance, serotonin and norepinephrine reuptake inhibitors (SNRIs) are safe and effective in treating menopause symptoms. The SNRI venlafaxine may help decrease hot flashes, night sweats, and depression. A newer SNRI, desvenlafaxine, has been studied extensively and may help reduce hot flashes, night sweats, and depression. Other drugs used off-label to relieve vasomotor symptoms include clonidine and gabapentin. (See Help for hot flashes and night sweats by clicking the PDF icon above.)

Managing vaginal symptoms

Management of vaginal symptoms may include pharmacologic and nonpharmacologic therapies. The 2007 NAMS position statement recommended topical estrogen as the most effective FDA-approved medication for treating atrophic vaginitis. Available in intravaginal tablets, vaginal rings, and intravaginal creams, it may reverse vaginal epithelial changes and significantly improve atrophic vaginitis.

Topical dehydroepiandosterone (DHEA) intravaginal ovules also may be an option for atrophic vaginitis. Although not FDA approved and available only from specialized compounding pharmacies, intravaginal DHEA used alone has been found to be highly effective in treating vaginal atrophy without increasing serum estradiol or testosterone levels.

Nonpharmacologic therapies include vaginal moisturizers and lubricants. As appropriate, encourage patients to use vaginal moisturizers, such as Replens® or Luvena®, regularly to improve vaginal pH balance. Lubricants help decrease pain with intercourse.

Vaginal dilators may help gradually improve a woman’s experience with intercourse and penetration, especially when used in conjunction with topical moisturizers, lubricants, and medications. Vaginal stimulators may increase circulation to the vaginal area and improve overall sexual functioning.

Managing bleeding irregularities

Some women experience bleeding irregularities throughout the meno¬pause transition. Because menstrual cycles may change with respect to flow, length, and frequency, wom¬en may have trouble determining if bleeding is abnormal during this time. Bleeding variations may result from the menopause transition, uterine fibroids, endometriosis, adenomyosis, endometrial hyperplasia, or uterine cancer.

Inform patients that any bleeding after the final menstrual period (FMP) is considered abnormal and should be evaluated. Counsel them to discuss menstrual irregularities with their healthcare providers. Irregular bleeding may be evaluated with an intravaginal pelvic ultrasound exam and in some cases, endometrial sampling (dilation and curettage or endometrial biopsy). Management depends on the cause of bleeding and pathology findings.

Helping women maintain bone health

Healthcare providers should discuss bone health with women during the menopause transition. Meno¬pause is linked directly to bone thinning and osteoporosis. Approximately 5 to 7 years after her FMP, a woman may lose 20% to 30% of her bone mass. Risk factors that contribute to osteoporosis include a thin or small frame, a family history of osteoporosis, a personal history of a fracture after age 40, cigarette smoking, excessive alcohol use, inactivity, and advanced age.

Experts vary on recommendations for bone mineral density (BMD) testing. Some recommend a BMD test within 2 years of the FMP. Others believe women with no known risk factors should begin BMD testing at age 65. Testing may be offered sooner for women who have known risk factors or experience nontraumatic fractures. Counsel women about risks associated with osteoporosis and encourage them to discuss their risks with their healthcare providers.

In 2013, the U.S. Preventive Services Task Force concluded that not enough evidence exists to assess the balance of the benefits and harms of daily supplementation with more than 400 international units (IU) of vitamin D3 and more than 1,000 mg of calcium for primary prevention of fractures in noninstitutionalized postmeno¬paus¬al women. Also, it recommends against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for primary prevention of fractures in these women.

On the other hand, the Institute of Medicine recommends a daily dietary allowance of 1,200 mg of calcium daily for women older than age 50, achieved by eating calcium-rich foods. Most dairy products and calcium-rich foods contain approximately 300 mg of calcium per serving. Calcium may be supplemented in women who don’t get enough daily calcium. Advise patients to space out dietary and supplemental calcium doses during the day because the body can’t absorb more than 500 mg over a 2-hour period.

Addressing sexuality concerns

Women who are postmenopausal or in the menopause transition commonly report decreased libido, reduced sexual functioning, or both. Advise them that pharmacologic and nonpharmacologic therapies can be used to treat atrophic vaginitis and relieve pain on intercourse. However, no FDA-approved medications currently are available to treat decreased libido in women; studies haven’t confirmed a beneficial effect of estrogen on libido.

Be aware that changes in sexual functioning aren’t considered a problem unless the woman thinks they are. As some women age, they’re content with less sexual activity, whereas others are distressed by their lack of sexual desire.

Offer appropriate counseling for women experiencing sexuality concerns, along with their partners. Counseling should include educating couples about normal age-related sexual responses in women, including decreased lubrication, increased time needed for stimulation and arousal, reduced orgasmic contractions, and decreased clitoral sensitivity. You might suggest that couples take a warm bath before sexual activity, extend foreplay longer to promote arousal, and engage in sex in the morning when energy levels are higher. Inform patients that using alternative sexual positions may increase comfort and stimulation. If appropriate, suggest that patients and their partners consider experimenting with erotic clothing and materials, massage, oral stimulation, and masturbation.

Other nursing considerations

When teaching patients about menopause, emphasize it’s a normal event with varying symptoms, which can be managed effectively through various pharmacologic and nonpharmacologic therapies. As appropriate, follow up with them by telephone to assess the effectiveness of management, help validate their concerns, and provide additional support. Finally, stay up-to-date on the current literature on menopause and women’s health so you can be sure you’re using an evidence-based approach when counseling and educating women.

Selected references

Bioidentical hormone therapy. North American Menopause Society. 2013. www.menopause.org/publications/clinical-practice-materials/bioidentical-hormone-therapy. Accessed November 4, 2013.

Chism L. Breast cancer and menopause: art, science, and quality of life. Adv NPs PAs. 2012;3(10):21-4.

Franklin RM, Ploutz-Snyder L, Kanaley JA. Longitudinal changes in abdominal fat distribution with menopause. Metabolism. 2009;58(3):311-5.

Hormone therapy has many favorable effects in newly menopausal women: Initial findings of the Kronos Early Estrogen Prevention Study (KEEPS) [press release]. Kronos Lon¬gevity Research Institute. October 3, 2012. http://www.menopause.org/docs/agm/general-release.pdf?sfvrsn=0. Accessed November 9, 2013.

Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011.

KEEPS results give new insight into hormone therapy. North American Menopause Society. 2012. www.menopause.org/annual-meetings/2012-meeting/keeps-report. Accessed November 9, 2013.

Manson JE, Bassuk SS. NAMS Practice Pearl: Calcium supplements: do they help or harm? September 6, 2012. www.menopause.org/docs/professional/pp_calcium.pdf. Accessed November 12, 2013.

North American Menopause Society. Meno¬pause Practice: A Clinician’s Guide. 4th ed. May¬field, OH: North American Menopause Society; 2010.

North American Menopause Society, 2013 Symptomatic Vulvovaginal Atrophy Advisory Panel. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902.

North American Menopause Society, 2012 Hormone Therapy Position Statement Advisory Panel. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause. 2012;19(3):257-71.

Pinkerton JV, Archer DF, Guico-Pabia CJ, Hwang E, Cheng RF. Maintenance of the efficacy of desvenlafaxine in menopausal vasomotor symptoms: a 1-year randomized controlled trial. Menopause. 2013;20(1):38-46.

Thacker HL. Assessing risks and benefits of nonhormonal treatments for vasomotor symptoms in perimenopausal and postmenopausal women. J Womens Health (Larchmt). 2011;20(7):1007-16.

Trinkaus M, Chin S, Wolfman W, Simmons C, Clemons M. Should urogenital atrophy in breast cancer survivors be treated with topical estrogens? Oncologist. 2008;13(3):222-31.

Vitamin D and calcium supplementation to prevent cancer and osteoporotic fractures in adults: U.S. Preventive Services Task Force recommendation statement draft. U.S. Preventive Services Task Force. February 2013. www.uspreventiveservicestaskforce.org/uspstf12/vitamind/finalrecvitd.htm#summary. Accessed November 4, 2013.

Yamaguchi N, Okajima Y, Fujii T, Natori A, Kobayashi D. The efficacy of nonestrogenic therapy to hot flashes in cancer patients under hormone manipulation therapy: a systematic review and meta-analysis. J Cancer Res Clin Oncol. 2013;139(10):1701-7.

Lisa Astalos Chism is a nurse practitioner/certified menopause practitioner, doctor of nursing practice, and clinical director of the Women’s Wellness Clinic at the Karmanos Cancer Institute in Detroit and in Farmington Hills, Michigan.

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2 thoughts on “Guiding your patients through menopause”

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