Menopause Aging Zie Gen Be in 103007
Transcript of Menopause Aging Zie Gen Be in 103007
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
1/38
Menopause and Aging
Sylvia Ziegenbein, MD
M3 Student Lecture2007
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
2/38
Objectives
Define menopauseDescribe associated changes and symptomsTreatment options for bothersome
symptomsReview physiologic changes of aging,
specific age related problems andscreening in elderly
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
3/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
4/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
5/38
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.
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
6/38
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.
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
7/38
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.
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
8/38
Case #6
53 yo WF began continuous HRT 4wks ago. She is now having somevaginal spotting after beingamenorrheic for 14 months. She is
concerned.
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
9/38
Menopause
DefinitionAverage AgeRelated Sxs
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
10/38
Classification System
STRAW SystemHelp communication
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
11/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
12/38
Vasomotor symptoms:Why dont we treat every
women with hormones?
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
13/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
14/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
15/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
16/38
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)
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
17/38
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)
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
18/38
Menopausal Complaints:Treatments
Hormones vs non-hormones vsherbalsEfficacy
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
19/38
Hormones Contraindicated
Breast CA
Endometrial CAUndiagnosed vaginal bleedingCHDVenous thrombosis
StrokePregnancyWhat is not here, that is a CI on OCPs?
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
20/38
Normal Physiologic Changes
of Aging
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
21/38
Demographics
34 million elderly now69 million in 2030
GerontologyHealth in the agedAbsence of dsMaintain function and comfortPresence of satisfactory support systems
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
22/38
Body Composition andHomeostasis
Decrease muscle massIncrease body fatChanges volume of distribution
Impaired baroreceptorOrthostatic hypotension
Impaired thermoregulation
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
23/38
Cardiovascular
Decrease LV complianceIncreased reliance on atria
More LVHStiffer arteries
Decreased beta-adrenergicresponsivenessDecreased max. HR with exercise
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
24/38
Pulmonary
Decreased elastic recoil, airways collapse
earlierDecreased forced vital capacity, functional
residual capacity, residual volume, FEV1Decreased ventilatory response and
chemoreceptor functionIncreased hypoxia and hypercapnia
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
25/38
RenalDecreased mass, # of glomeruliIncreased glomerulosclerosis
GFR slowly decreasesCrCl maintains
Decreased Na+ rentention, decreased
responsiveness to AVP; less concentrationof urineDecreased thirst and drink responseIncreased dehydration
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
26/38
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
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
27/38
Immunologic
Decreased T-cell activityDecreased Ab response to foreign
antigenIncreased autoantibodies
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
28/38
Specific Geriatric Issues
Other assessments tobe made.
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
29/38
Cognitive Function
Normal declineDementiaAlzheimersVascularOthers
DepressionMedicationsEtOH
MMSE
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
30/38
Sensory
VisualAuditoryBalance
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
31/38
Incontinence
TypesRisk factorsAssessTests
Treatment
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
32/38
Types of Incontinence
UrgeStressFunctionalOverflow
Mixed
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
33/38
Fall Risks
IntrinsicPerson oriented issuesMobilityGet up and go test
ExtrinsicEnvironment
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
34/38
Polypharmacy
Medication ListDrug-drug interactionsAltered pharmacokinetics,
pharmacodynamicsHerbals
OTC
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
35/38
Osteoporosis
ScreeningRisk FactorsTreatments
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
36/38
Others
AbuseSexualityVaccinationsFinancial
Support SystemDriving
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
37/38
Screening
ThyroidCancerSxsPap
MammogramColonoscopyLipids
-
8/11/2019 Menopause Aging Zie Gen Be in 103007
38/38
Questions???
Thank you very muchfor your participation!!Good luck on your shelf!