menopause aging zie gen be in 103007

8/11/2019 Menopause Aging Zie Gen Be in 103007

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Menopause and Aging

Sylvia Ziegenbein, MD

M3 Student Lecture2007


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Objectives

Define menopauseDescribe associated changes and symptomsTreatment options for bothersome

symptomsReview physiologic changes of aging,

specific age related problems andscreening in elderly


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Case #1

35 yo G1 P0101 female presents with c/o

hot flashes and amenorrhea for 12 months.She doesnt know why this is happening, hersxs are worsening. She wants your help.

DDxTests


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Case #245 yo G2 P2002 female presents with c/o

hot flashes and irregular menses (q 3-5mos) for the past 9 months. She doesntknow why this is happening, she wants yourhelp. By the way, she wants your help tostop smoking also.

DDxTests


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Case #365 yo WF presents to start HRT. She

heard it would help protect her heart,

make her feel younger and help hermemory. She went through menopause 10years ago and has not had any problemsexcept an occasional hot flash. She is 54,

108 lbs. By the way, she had a wrist fx 2yrs ago takes her Viactiv faithfully.


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Case #4

49 yo WF presence b/c she cant stand her

hot flashes anymore. She cant sleep verywell b/c she wakes up 3 times a nightdrenched with sweat. She is an executiveat First National Bank. She has a history of

breast cancer 2 years ago. Please Dr.Ziegenbein, I need some hormones orsomething.


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Case #5

55 yo BF returns to discuss stoppingher HRT. She has been taking it for 5

years now with good relief of hervasomotor sxs.


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Case #6

53 yo WF began continuous HRT 4wks ago. She is now having somevaginal spotting after beingamenorrheic for 14 months. She is

concerned.


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Menopause

DefinitionAverage AgeRelated Sxs


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Classification System

STRAW SystemHelp communication


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Menopause Terminology:

STRAW* Staging System

*STRAW = Stages of Reproductive Aging Workshop.Stages most likely to be characterized by vasomotor symptoms.

Soules MR, et al. Menopause. 2001;8:402-7.

Stages: -2 -1 +1 +2

Terminology:

Durationof Stage:

MenstrualCycles:

Menopausal Transition Postmenopause

Early Early

Late

LatePerimenopause

Variable

Variablecycle length(>7 daysdifferent

from normal)

2 skippedcycles and aninterval of

amenorrhea(60 days)

4 yrsUntil

demise

None

0Final Menstrual Period

1 yr

Amen.

12

mos.

a b


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Vasomotor symptoms:Why dont we treat every

women with hormones?


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WHI: HRT vs Placebo

Large prospective RCT, 2002, JAMA16,608 postmenopausal women (50-79 y.o.)Ave age at enrollment = 63 yrsTwo arms:

Estrogen + Progestin (Prempro 0.625/2.5), n=8506Placebo, n=8102

Outcomes measured:

Primary : Coronary heart disease (CHD) and invasive breastcancerSecondary : stroke, pulmonary embolism, DVT, endometrial

CA, colorectal CA, hip and vertebral fractures and death fromother causes


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HRT Arm: Stopped Early @ 5.2 yrsInvasive Breast Cancer = 38 vs 30/10,000

person yrs (HR 1.26)CHD = 37 vs 30/10,000 (HR 1.29)Stroke = 29 vs 21/10,000 (HR 1.41)Venous Thromboembolic disease = 34 vs

16/10,000 (HR 2.11)

Colorectal cancer = 10 vs 16/10,000 (HR 0.63)Hip fracture = 10 vs 15/10,000 (HR 0.66)Vertebral fracture = 9 vs 15/10,000 (HR 0.66)No change in endometrial and lung cancer


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WHI: Estrogen Only vs Placebo

WHI 2004: JAMA10,739 postmenopausal womens/p hysterectomy (50-79 y.o.)Ave. age @ enrollment = 63.6 y.o.

Two arms:Estrogen (Premarin 0.625 mg), n=5310Placebo, n=5429

Outcomes:Primary: CHD and invasive breast cancerSecondary: stroke, pulmonary embolism, DVT, colorectal

cancer, hip/vertebral fractures and death from othercauses


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OutcomesAve. follow up 6.8 years (Hazard Ratio)Invasive breast Cancer = 26 vs 33/10,000

person yrs (0.77)

CHD = 49 vs 54/10,000 (0.91)Venous Thromboembolic disease = 28 vs21/10,000 (1.33)Stroke = 44 vs 32/10,000 (1.39)Fatal = 4 vs 4/10,000 (1.13)Nonfatal = 32 vs 23/10,000 (1.39)

Colorectal cancer = 17 vs 16/10,000 (1.08)Hip fracture = 11 vs 17/10,000 (0.61)Vertebral fracture = 11 vs 17/10,000 (0.62)


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Clinical EventHazard Ratio, 95% confidence interval

HERS E+P WHI E+P WHI E alone

CHD Events 0.99 (0.80-1.22) 1.29 (1.02-1.63) 0.91 (0.75-1.12)

Stroke 1.23 (0.89-1.70) 1.41 (1.07-1.85) 1.39 (1.10-1.77)

Pulm. Embolism 2.79 (0.89-8.75) 2.13 (1.39-3.25) 1.34 (0.87-2.06)

Breast Cancer 1.30 (0.77-2.19) 1.26 (1.00-1.59) 0.77 (0.59-1.01)

Colon Cancer 0.69 (0.32-1.49) 0.63 (0.43-0.92) 1.08 (0.75-1.55)

Hip Fracture 1.10 (0.49-2.50) 0.66 (0.45-0.98) 0.61 (0.41-0.91)

Death 1.08 (0.84-1.38) 0.98 (0.82-1.18) 1.04 (0.88-1.22)

Global Index - 1.15 (1.03-1.28) 1.01 (0.89-1.70)


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Menopausal Complaints:Treatments

Hormones vs non-hormones vsherbalsEfficacy


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Hormones Contraindicated

Breast CA

Endometrial CAUndiagnosed vaginal bleedingCHDVenous thrombosis

StrokePregnancyWhat is not here, that is a CI on OCPs?


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Normal Physiologic Changes

of Aging


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Demographics

34 million elderly now69 million in 2030

GerontologyHealth in the agedAbsence of dsMaintain function and comfortPresence of satisfactory support systems


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Body Composition andHomeostasis

Decrease muscle massIncrease body fatChanges volume of distribution

Impaired baroreceptorOrthostatic hypotension

Impaired thermoregulation


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Cardiovascular

Decrease LV complianceIncreased reliance on atria

More LVHStiffer arteries

Decreased beta-adrenergicresponsivenessDecreased max. HR with exercise


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Pulmonary

Decreased elastic recoil, airways collapse

earlierDecreased forced vital capacity, functional

residual capacity, residual volume, FEV1Decreased ventilatory response and

chemoreceptor functionIncreased hypoxia and hypercapnia


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RenalDecreased mass, # of glomeruliIncreased glomerulosclerosis

GFR slowly decreasesCrCl maintains

Decreased Na+ rentention, decreased

responsiveness to AVP; less concentrationof urineDecreased thirst and drink responseIncreased dehydration


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Endocrine

Decreased glucose toleranceIndependent of obesity and inactivityFG decreases 1 mg/dL/decade

Increased insulin resistance

Decreased GH, IGF-1Give elderly men GH, increases lean

body mass


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Immunologic

Decreased T-cell activityDecreased Ab response to foreign

antigenIncreased autoantibodies


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Specific Geriatric Issues

Other assessments tobe made.


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Cognitive Function

Normal declineDementiaAlzheimersVascularOthers

DepressionMedicationsEtOH

MMSE


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Sensory

VisualAuditoryBalance


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Incontinence

TypesRisk factorsAssessTests

Treatment


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Types of Incontinence

UrgeStressFunctionalOverflow

Mixed


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Fall Risks

IntrinsicPerson oriented issuesMobilityGet up and go test

ExtrinsicEnvironment


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Polypharmacy

Medication ListDrug-drug interactionsAltered pharmacokinetics,

pharmacodynamicsHerbals

OTC


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Osteoporosis

ScreeningRisk FactorsTreatments


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Others

AbuseSexualityVaccinationsFinancial

Support SystemDriving


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Screening

ThyroidCancerSxsPap

MammogramColonoscopyLipids


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Questions???

Thank you very muchfor your participation!!Good luck on your shelf!

menopause aging zie gen be in 103007

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