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Published on : Jan 08, 2015
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Slide 1 - Menopause and Aging Sylvia Ziegenbein, MD M3 Student Lecture 2007
Slide 2 - Objectives Define menopause Describe associated changes and symptoms Treatment options for bothersome symptoms Review physiologic changes of aging, specific age related problems and screening in elderly
Slide 3 - Case #1 35 yo G1 P0101 female presents with c/o hot flashes and amenorrhea for 12 months. She doesn’t know why this is happening, her sxs are worsening. She wants your help. DDx Tests
Slide 4 - Case #2 45 yo G2 P2002 female presents with c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. She doesn’t know why this is happening, she wants your help. By the way, she wants your help to stop smoking also. DDx Tests
Slide 5 - Case #3 65 yo WF presents to start HRT. She heard it would help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an occasional hot flash. She is 5’4”, 108 lbs. By the way, she had a wrist fx 2 yrs ago takes her Viactiv faithfully.
Slide 6 - Case #4 49 yo WF presence b/c she can’t stand her hot flashes anymore. She can’t sleep very well b/c she wakes up 3 times a night drenched with sweat. She is an executive at First National Bank. She has a history of breast cancer 2 years ago. “Please Dr. Ziegenbein, I need some hormones or something.”
Slide 7 - Case #5 55 yo BF returns to discuss stopping her HRT. She has been taking it for 5 years now with good relief of her vasomotor sxs.
Slide 8 - Case #6 53 yo WF began continuous HRT 4 wks ago. She is now having some vaginal spotting after being amenorrheic for 14 months. She is concerned.
Slide 9 - Menopause Definition Average Age Related Sxs
Slide 10 - Classification System STRAW System Help communication
Slide 11 - 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: Duration of Stage: Menstrual Cycles: Menopausal Transition Postmenopause Early Early† Late† Late Perimenopause Variable Variable cycle length (>7 days different from normal) 2 skipped cycles and an interval of amenorrhea (60 days) 4 yrs Until demise None 0 Final Menstrual Period 1 yr Amen. × 12 mos. a b
Slide 12 - Vasomotor symptoms: Why don’t we treat every women with hormones?
Slide 13 - WHI: HRT vs Placebo Large prospective RCT, 2002, JAMA 16,608 postmenopausal women (50-79 y.o.) Ave age at enrollment = 63 yrs Two arms: Estrogen + Progestin (Prempro 0.625/2.5), n=8506 Placebo, n=8102 Outcomes measured: Primary : Coronary heart disease (CHD) and invasive breast cancer Secondary : stroke, pulmonary embolism, DVT, endometrial CA, colorectal CA, hip and vertebral fractures and death from other causes
Slide 14 - HRT Arm: Stopped Early @ 5.2 yrs Invasive 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
Slide 15 - WHI: Estrogen Only vs Placebo WHI 2004: JAMA 10,739 postmenopausal women s/p hysterectomy (50-79 y.o.) Ave. age @ enrollment = 63.6 y.o. Two arms: Estrogen (Premarin 0.625 mg), n=5310 Placebo, n=5429 Outcomes: Primary: CHD and invasive breast cancer Secondary: stroke, pulmonary embolism, DVT, colorectal cancer, hip/vertebral fractures and death from other causes
Slide 16 - Outcomes Ave. 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 vs 21/10,000 (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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Slide 18 - Menopausal Complaints: Treatments Hormones vs non-hormones vs herbals Efficacy
Slide 19 - Hormones Contraindicated Breast CA Endometrial CA Undiagnosed vaginal bleeding CHD Venous thrombosis Stroke Pregnancy What is not here, that is a CI on OCP’s?
Slide 20 - Normal Physiologic Changes of Aging
Slide 21 - Demographics 34 million elderly now 69 million in 2030 Gerontology Health in the aged Absence of ds Maintain function and comfort Presence of satisfactory support systems
Slide 22 - Body Composition and Homeostasis Decrease muscle mass Increase body fat Changes volume of distribution Impaired baroreceptor Orthostatic hypotension Impaired thermoregulation
Slide 23 - Cardiovascular Decrease LV compliance Increased reliance on atria More LVH Stiffer arteries Decreased beta-adrenergic responsiveness Decreased max. HR with exercise
Slide 24 - Pulmonary Decreased elastic recoil, airways collapse earlier Decreased forced vital capacity, functional residual capacity, residual volume, FEV1 Decreased ventilatory response and chemoreceptor function Increased hypoxia and hypercapnia
Slide 25 - Renal Decreased mass, # of glomeruli Increased glomerulosclerosis GFR slowly decreases CrCl maintains Decreased Na+ rentention, decreased responsiveness to AVP; less concentration of urine Decreased thirst and drink response Increased dehydration
Slide 26 - Endocrine Decreased glucose tolerance Independent of obesity and inactivity FG decreases 1 mg/dL/decade Increased insulin resistance Decreased GH, IGF-1 Give elderly men GH, increases lean body mass
Slide 27 - Immunologic Decreased T-cell activity Decreased Ab response to foreign antigen Increased autoantibodies
Slide 28 - Specific Geriatric Issues Other assessments to be made.
Slide 29 - Cognitive Function Normal decline Dementia Alzheimer’s Vascular Others Depression Medications EtOH MMSE
Slide 30 - Sensory Visual Auditory Balance
Slide 31 - Incontinence Types Risk factors Assess Tests Treatment
Slide 32 - Types of Incontinence Urge Stress Functional Overflow Mixed
Slide 33 - Fall Risks Intrinsic Person oriented issues… Mobility “Get up and go” test Extrinsic Environment
Slide 34 - Polypharmacy Medication List Drug-drug interactions Altered pharmacokinetics, pharmacodynamics Herbals OTC
Slide 35 - Osteoporosis Screening Risk Factors Treatments
Slide 36 - Others Abuse Sexuality Vaccinations Financial Support System Driving
Slide 37 - Screening Thyroid Cancer Sxs Pap Mammogram Colonoscopy Lipids
Slide 38 - Questions??? Thank you very much for your participation!! Good luck on your shelf!