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Dx Menopause Treatment:

Observation: This information is outdated.
See Hormone Replacement Therapy by Phillip Sarrel, M.D. incorporating estradiol, progesterone and testosterone replacement.

The Merck Manual Home Edition
"Menopause is the permanent end of menstrual periods and thus of fertility.

*For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular, and symptoms (such as hot flashes) may occur.
*After menopause, bone density decreases.
*Menopause is usually obvious, but blood tests may be done to confirm it.
*Certain measures, including drugs, can lessen symptoms.

During the reproductive years, menstrual periods usually occur in approximately monthly cycles, with an egg released from the ovary (ovulation) about 2 weeks after the first day of a period. For this cycle to occur regularly, the ovaries must produce enough estrogen and progesterone. Menopause occurs because as women age, the ovaries run out of usable eggs and stop producing estrogen and progesterone. During the years before menopause, production of estrogen and progesterone begins to decrease, and menstrual periods and ovulation occur less often. Eventually, menstrual periods and ovulation end permanently, and pregnancy is no longer possible. A woman's last period can be identified only later, after she has had no periods for at least 1 year. (Women who do not wish to become pregnant should use birth control until 1 year has passed since their last menstrual period.)

Perimenopause is a distinctive transitional period that occurs during the years before and the 1 year after the last menstrual period. How many years of perimenopause precede the last menstrual period varies greatly. During perimenopause, estrogen and progesterone levels fluctuate widely. These fluctuations are thought to cause the menopausal symptoms experienced by many women in their 40s.

In the United States, the average age for menopause is about 51. However, menopause may occur normally in women as young as 40. Menopause is considered premature when it occurs before age 40. Premature menopause is also called premature ovarian failure or primary ovarian insufficiency.

Symptoms of menopause can start years before menstrual periods end. The average age for menopause is about 51.


*During perimenopause, symptoms may be nonexistent, mild, moderate, or severe. Symptoms may last from 6 months to about 10 years.
*Irregular menstrual periods may be the first symptom of perimenopause. Typically, periods occur more often, then less often, but any pattern is possible. Periods may be shorter or longer, lighter or heavier. They may not occur for months, then become regular again. In some women, periods occur regularly until menopause.
*Hot flashes affect 75 to 85% women. They usually begin before periods stop.
*Most women have hot flashes for more than 1 year, and more than one half of women have them for more than 4 years. What causes hot flashes in unknown. But it may involve a resetting of the brain's thermostat (the hypothalamus), which controls body temperature. As a result, very small increases in temperature can make women feel hot.
* Hot flashes may be related to fluctuations in hormone levels and may be triggered by cigarette smoking, hot beverages, certain foods, alcohol, and possibly caffeine. During a hot flash, blood vessels near the skin surface widen (dilate). As a result, blood flow increases, causing the skin, especially on the head and neck, to become red and warm (flushed).
*Women feel warm or hot, and perspiration may be profuse. Hot flashes are sometimes called hot flushes because of this warming effect. A hot flash lasts from 30 seconds to 5 minutes and may be followed by chills.
*Night sweats are hot flashes that occur at night.

Other symptoms that may occur around the time of menopause include mood changes, depression, irritability, anxiety, nervousness, sleep disturbances (including insomnia), loss of concentration, headache, and fatigue. Many women experience these symptoms during perimenopause and assume that menopause is the cause. However, evidence supporting a connection between menopause and these symptoms is weak. These symptoms are not directly related to the decreases in estrogen levels that occur with menopause. And many other factors (such as aging itself or a disorder) could explain the symptoms.

Night sweats may disturb sleep, contributing to fatigue, irritability, loss of concentration, and mood changes. In such cases, these symptoms may be indirectly (through night sweats) related to menopause. However, during menopause, sleep disturbances are common even among women who do not have hot flashes. Midlife stresses (such as struggles with adolescents, concerns about aging, caring for aging parents, and changes in marital relationship) may contribute to sleep disturbances. Thus, the relationship between fatigue, irritability, loss of concentration, and mood changes seems less clear.

Many symptoms thought to be related to menopause—mood changes, depression, irritability, anxiety, nervousness, insomnia, loss of concentration, headache, and fatigue—may not be.

After menopause:
Many of the symptoms that occur during perimenopause, although disturbing, become less frequent and less intense after menopause. However, the decrease in estrogen levels causes changes that can continue to negatively affect health (for example, increasing the risk of osteoporosis). These changes may worsen, unless measures to prevent them are taken.

Reproductive tract: The lining of the vagina becomes thinner, drier, and less elastic (a condition called vaginal atrophy). These changes may make sexual intercourse painful and may increase the risk of inflammation (vaginitis). Other genital organs—the labia minora, clitoris, uterus, and ovaries—decrease in size. Sex drive (libido) commonly decreases with age. Most women can still have an orgasm, but some require more time to reach orgasm.

Urinary tract: The lining of the urethra becomes thinner, and the urethra becomes shorter. Because of these changes, microorganisms can enter the body more easily, and some women develop urinary tract infections more easily. A woman with a urinary tract infection may feel a burning sensation when she urinates. Urinary incontinence—the unintended passage of urine—becomes more common and severe with age. However, how much menopause contributes to incontinence is unclear. Many other factors, such as the effects of childbirth and the use of hormone therapy, contribute to incontinence.

Skin: As estrogen decreases, the amount of collagen (a protein that makes skin strong) and elastin (a protein that makes skin elastic) also decrease. Thus, the skin may become thinner, drier, less elastic, and more vulnerable to injury.

Bone: The decrease in estrogen often leads to a decrease in bone density and sometimes to osteoporosis (see see Osteoporosis) because estrogen helps maintain bone. Bone becomes less dense and weaker, making fractures more likely. During the first 2 years after menopause, bone density decreases by about 3 to 5% each year. After that, it decreases by about 1 to 2% each year.

Fat (lipid) levels: After menopause, levels of lipids, particularly low-density lipoprotein (LDL—the bad) cholesterol, increase in women. Levels of high-density lipoprotein (HDL—the good) cholesterol decrease. These changes in lipid levels may partly explain why atherosclerosis and thus coronary artery disease become more common among women after menopause. However, whether these changes result from aging or from the decrease in estrogen levels after menopause is unclear. Until menopause, the high estrogen levels may protect against coronary artery disease.

In about three fourths of women, menopause is obvious. Thus, laboratory tests are usually not needed. If menopause begins several years before age 50 or if symptoms are not clear-cut, tests may be done to check for disorders that can disrupt menstrual periods. Rarely, if menopause or perimenopause needs to be confirmed, blood tests are done to measure levels of estrogen and follicle-stimulating hormone (which stimulates the ovaries to produce estrogen and progesterone).

Before any treatment is started, doctors request information about their medical and family history and do a physical examination, including breast and pelvic examinations and measurement of blood pressure. Mammography is also done. Blood tests may be done, and bone density may be measured, particularly in women with risk factors for osteoporosis (see Osteoporosis). The information obtained helps doctors determine the woman's risk of developing certain disorders after menopause.

Understanding what happens during perimenopause can help women cope with the symptoms. Talking with other women who have gone through menopause or with their doctor may also help.

General measures:
Noting which foods and beverages (such as coffee, tea, and spicy foods) seem to trigger hot flashes and not consuming them may help prevent this symptom. Not smoking and avoiding stress may help prevent hot flashes and improve sleep.

Wearing layers of clothing, which can be taken off when a woman feels hot and put on when she feels cold, can help her cope with hot flashes. Wearing clothing that breathes (such as cotton underwear and sleepwear) or that can wick away moisture (such as certain kinds of underwear and exercise clothes) may enhance comfort. Avoiding hot environments and bright lights can also help.

Exercising regularly (particularly aerobic exercise) may help improve sleep and sometimes helps prevent or relieve hot flashes. Relaxation techniques, meditation, massage, and yoga sometimes help prevent or relieve hot flashes and relieve depression, irritability, and fatigue. A technique called paced respiration, a type of slow, deep breathing exercise, may also help prevent or relieve hot flashes. Weight-bearing exercise (such as walking, jogging, and weight lifting) and taking calcium and vitamin D supplements slow the loss of bone density. Regular exercise, particularly when combined with a diet lower in calories, fat, and cholesterol, also helps with other problems that become more common after menopause. It may help women lose weight, lower cholesterol levels, and reduce the risk of atherosclerosis, including coronary artery disease. Hypnosis may help relieve hot flashes in some women.

If vaginal dryness makes sexual intercourse painful, an over-the-counter vaginal lubricant may help. For some women, regularly applying a vaginal moisturizer helps. Staying sexually active also helps by stimulating blood flow to the vagina and the surrounding tissues and by keeping tissues flexible. Kegel exercises may help with bladder control (see see Exercises). For these exercises, a woman tightens the pelvic muscles as if stopping urine flow.

Hormone therapy:
Hormone therapy can relieve moderate to severe symptoms such as hot flashes, night sweats, and vaginal dryness. However, hormone therapy may increase the risk of developing certain serious disorders. Whether to take hormone therapy is a difficult decision that must be made by a woman and her doctor based on the woman's individual situation. For many women, risks outweigh benefits, so this therapy is not recommended. However, for some women, depending on their medical conditions and risk factors, benefits may outweigh risks.

Hormone therapy can include estrogen, a progestin (such as medroxyprogesterone acetate), or both. Many hormones used in hormone therapy are synthetic hormones, made in laboratories. They may or may not be identical to those made in the body, but the way they act in the body is very similar. Estradiol is the form of estrogen usually used. Progestins resemble progesterone, a female hormone made by the body.

Women who have a uterus are usually given estrogen plus a progestin (combination hormone therapy) because taking estrogen alone increases the risk of cancer of the uterine lining (endometrial cancer). The progestin helps protect against this cancer. Women who no longer have a uterus may take estrogen alone. The benefits and risks depend on whether the hormones are taken alone or together.

Estrogen has several benefits:
*Hot flashes and other symptoms: Estrogen is the most effective treatment for hot flashes.
*Drying and thinning of vaginal and urinary tract tissues: Estrogen can also prevent these tissues from drying and thinning. Thus, it can reduce pain with sexual intercourse. When the only problem a woman has is drying and thinning of these tissues, topical estrogen therapy (such as estrogen tablets or estrogen cream inserted into the vagina) is recommended.
*Osteoporosis: Estrogen, with or without a progestin, helps prevent or slow the progression of osteoporosis. However, taking hormone therapy for the sole purpose of preventing osteoporosis is no longer recommended. Most women can take a bisphosphonate or another drug instead (see Drugs). Bisphosphonates increase bone mass by reducing the amount of bone the body breaks down as it re-forms bones (the amount broken down increases with aging).

Estrogen, taken with or without a progestin, increases the risk of the following:
*Endometrial cancer: If women who have a uterus take estrogen without a progestin, the risk of endometrial cancer is increased. The risk increases with higher doses and longer use of estrogen. Taking a progestin with estrogen almost eliminates the risk of endometrial cancer, reducing the risk below that for women who do not take hormone therapy. A woman whose uterus has been removed has no risk of developing this cancer and thus does not need to take a progestin. Usually, estrogen, with or without a progestin, is not prescribed for women who have had advanced endometrial cancer or who have vaginal bleeding (which can be a symptom of endometrial cancer) unless endometrial cancer has been ruled out. A progestin without estrogen may be prescribed for certain women who have endometrial cancer or breast cancer.
*Breast cancer: The risk of breast cancer begins to increase after taking estrogen plus a progestin for about 3 to 5 years. But if estrogen is taken alone, risk may not begin to increase until after 10 years or even 15 years.
*Blood clots in the legs and lungs
*Urinary incontinence: Taking estrogen increases the risk of developing incontinence and worsens preexisting incontinence.

For certain disorders, determining whether the risk is increased by estrogen alone or by estrogen plus a progestin (combination therapy) is difficult.

Although taking hormone therapy increases the risk of all the above disorders, the risk is still low in healthy women who take hormone therapy for a short time during or shortly after perimenopause. Risk of most of these disorders increases with age, particularly 10 years or more past menopause, whether hormone therapy is taken or not. In older women, taking estrogen plus a progestin may also increase the risk of coronary artery disease.

Most of the risks of hormone therapy are probably lower when low doses of estrogen are used. Forms of estrogen that are inserted into the vagina (such as estrogen creams or tablets or rings that contain estrogen) often have lower doses than tablets taken by mouth.

Combination hormone therapy reduces the risk of the following:
*Colorectal cancer

Progestins have some benefits:
*Endometrial cancer: Taking a progestin with estrogen almost eliminates the risk of endometrial cancer in women who have a uterus.
*Hot flashes: Progestins can sometimes help relieve hot flashes.

Progestins may increase the risk of the following:
*Atherosclerosis and thus coronary artery disease: Progestins may increase this risk because they increase the LDL (the bad) cholesterol level and decrease the HDL (the good) cholesterol level. However, micronized progesterone appears to have fewer side effects than other progestins and may not adversely affect cholesterol levels.
*Blood clots in the legs
*The effect of a progestin alone on the risk of other disorders is not clear.

Estrogen and progestins, especially at high doses, may have side effects, including nausea, breast tenderness, headache, fluid retention, and mood changes.

Estrogen and a progestin can be taken in several ways:
*Tablets taken by mouth (estrogen, a progestin, or both)
*Estrogen skin patches (transdermal estrogen)
*Combination estrogen-progestin patches
*Estrogen lotions, sprays, or gels applied externally to the skin
*Estrogen creams, tablets, or rings inserted into the vagina

As tablets taken by mouth, estrogen and a progestin may be taken as two tablets or as a combination tablet. Commonly, estrogen and a progestin are taken every day. This schedule typically causes irregular vaginal bleeding for the first year or more of therapy. Alternatively, estrogen may be taken daily, with a progestin taken for 12 to 14 days each month. With this schedule, most women have monthly vaginal bleeding.

Estrogen may be used internally, inserted into the vagina. Vaginal forms include a cream that is inserted with a plastic applicator, a tablet, and a ring that contains estrogen (similar to a diaphragm). There are many different products, which come in different doses and which contain different types of estrogen. Creams and rings may contain a high or low dose of estrogen.

Using a vaginal form of estrogen may be more effective than taking estrogen by mouth for preventing or relieving drying or thinning of the vagina. Such treatment helps prevent intercourse from being painful. Some of the estrogen is absorbed through the vagina into the bloodstream. Theoretically, estrogen absorbed through the vagina can increase the risk of endometrial cancer. However, the amount of estrogen absorbed into the bloodstream from the vagina depends on the type and dose of estrogen used. If a high dose is used, much more estrogen is absorbed than when a low dose is used. Therefore, if women have a uterus and use a high-dose estrogen form, they should also take a progestin (to reduce the risk of endometrial cancer). But most women need only a low dose to prevent or relieve dryign or thinning of vaginal tissue. In such cases, they usually do not need to take a progestin.

Estrogen can also be applied to the skin.

Generally, women who have breast cancer, coronary artery disease, or blood clots in the legs, who have had a stroke, or who have risk factors for these disorders should not use estrogen therapy.

Doctors prescribe the lowest hormone dose that controls symptoms.

Selective estrogen receptor modulators (SERMs): SERMs (such as raloxifene nd tamoxifen) function like estrogen in some ways but reverse the effects of estrogen in other ways. SERMs are not usually used to relieve menopausal symptoms. However, one SERM, ospemifene, can be used to relieve vaginal dryness if women cannot take estrogen, if they cannot insert a drug into the vagina (for example, because they have severe arthritis), or if they prefer not to insert something into the vagina. When women take a SERM, hot flashes worsen, usually mildly and temporarily.

Other drugs: Several other types of drugs can help relieve some of the symptoms associated with menopause. Gabapentin, an anticonvulsant, may reduce the frequency of hot flashes. An antidepressant, such as fluoxetine, paroxetine, sertraline, or venlafaxine, may relieve hot flashes but are less effective than hormone therapy. Antidepressants may also help relieve depression, anxiety, and irritability (see see Drug Therapy). A sleep aid is sometimes recommended to relieve insomnia.

Lipid-lowering drugs may be taken to lower cholesterol levels, reducing the risk of atherosclerosis and coronary artery disease. Women with risk factors for osteoporosis can take bisphosphonates or other drugs to reduce that risk (see see Drugs). Bisphosphonates increase bone density and can reduce the risk of some fractures."

Medications Used in Treatment:
1. Estrogens: Premarin®/conjugated equine estrogens (CEE), Prempro® Premphase®/CEE/MPA, Ogen®/estropipate, Cenestin® Enjuvia®/synthetic conjugated estrogen, Menest®/esterified estrogens.
2. Bio-identical estrogens: Estrace®/estradiol, Climara® Minivelle®, Estrogel®, estradiol pellet-compounded, Divigel®, Evammist®, Femring®/esstradiol, Delestrogen®/estradiol valerate, Depo-estradiol, Elestrin®, Alora®
3. Central Alpha Agonists: Catapres®/clonidine
4. Estrogen/Androgen Combination: Estra-Test® Covaryx®/esterified estrogen-methyltestosterone
5. Estrogen/Progestin Combination: Combipatch®/estradiol-norithindrone, Femhrt®/ethinyl estradiol-norethidrone acetate, Activella® Jenantique®/ estradiol-norethindrone, Climara®Pro/Estradiol-levonorgestrel
6. Estrogen Agonist/Antagonists: Osphena®/ospemifene
7. SSRIs: Brisdelle®/paroxetine
8. Anabolic Steroids: Intrinsa®/testosterone patch, testosterone-compounded cream, testosterone-compounded pellet, nandrolone, oxandrolone, stanozolol

[Editor] The Editor disagrees with most of the Merck Manual Home Edition as it is incomplete and inaccurate.
* Measurement of Follicle Stimulating Hormone (FSH) and Luteininzing Hormone (LH), total estradiol, testosterone and Sex Hormone Binding Globulin (SHBG) define menopause.

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