Hendry Barka Pangidoan 406118064

A 51-year old woman

has frequent and

distressing hot flushes that interfere with her

work and sleep, and vaginal dryness that

makes sexual intercourse with her husband

uncomfortable. She is otherwise healthy. How

should her case be managed

Menopausal Transition

Vasomotor symptoms

Vaginal symptoms

Premenopausal

Reproductive

Menopausal

 Hot

Flush is a sudden feeling of warmth that is generally most intense over the face, neck, and chest.

Asian White

Others: Cigarette Smoking Surgical Menopause Physical activity Body-mass index Alcohol Consumption Socioeconomic status

Black and Latina

Improve within few month 30%to 50%

Resolves within 4 to 5 years 85% to 90%

Resolves Many years after menopause 10% to 15%

Hot Flushes resemble heat-dissipation response and may represent abnormal thermoregulation by the anterior hypothalamus The precise role of estrogen in the pathogenesis of this symptom is not clear Endogenous estrogen do not differ substantially between postmenopausal women who have hot flushes and those who do not have them Hot flushes do not occur in women with gonadal dysgenesis unless estrogen therapy is used and discontinues.

Dryness

Discomfort

Vaginal Symptoms Itching Dyspareunia

Late Postmenopausal Period

Up to 47%
Early Postmenopausal Period

About 30%

Vaginal Symptoms

Urologic Symptoms

 Postmenopausal women

with vaginal symptoms as compared with premenopausal women have:

Decreased vaginal blood flow and secreations Hyalinization of collagen Fragmentation of elastin Proliferation of vaginal connective tissue Vaginal fluid less acidic

Vasomotor Symptoms
FSH and LH may be within the normal premenopausal range during the meopausal transtition Its not routinly recommended

Vaginal Symptoms
Elevated pH level in vaginal fluid and cytogenic analysis of exfoliated cells from vaginal wall containing more than 20% parabasal cells are corelated with menopause. But their use in the diagnosis of symptomatic vaginal atrophy has not been established

 Estrogens
Nonestrogenic

Hormonal

Therapies Other Presciption Drugs

Vaginal estrogens Vaginal moisturizer Oral phytoestrogens

Tablets
Estradiol releasing ring

Creams

Vaginal Estrogens

The causes of hot flushes and vaginal atrophy remain uncertain Although many treatments have been evaluated None have been proved to be both highly effective and safe

FDA and American College of Obstetricians and Gynecologists

Use postmenopausal therapy at the lowest dose and for the shortest possible time for the treatment of menopausal symptoms

The North American Menopause Society

For Mild Hot Flushes Symptoms lifestyle changes either alone or combined with nonprescription remedy For Mild to Severe Hot Flushes Symptoms hormon therapy as therapeutic standard

FDA, The North American Society, and The Society of Obstetricans and Gynaecologist of Canada
Use of vaginal estrogens preparation when menopausal symptoms are limited to the vagina

vasomotor symptoms generally improve or resolve within a few years but that vaginal symptoms may not improve spontaneously The lowest dose of estrogen that adequately controls symptoms should be used Given the natural history of vasomotor symptoms, it is reasonable to try discontinuing hormone therapy every 6 to 12 months. If symptoms recur, restarting and then gradually tapering the dose or the number of days per week that hormones are used may be helpful For vaginal symptoms alone, systemic estrogen therapy is not indicated. A vaginal moisturizer may provide adequate relief; if not, topical estrogen therapy should be used.

From the Women's Health Clinical Research Center, University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center both in San Francisco.
Address reprint requests to Dr. Grady at the Women's Health Clinical Research Center, 1635 Divisadero St., Suite 600, San Francisco, CA 94115