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Upon completion of the chapter, the reader will be able to:
Explain the physiologic changes associated with menopause.
Identify the signs and symptoms associated with menopause.
Determine the desired therapeutic outcomes for a patient taking hormone therapy (HT).
Explain how to evaluate a patient for the appropriate use of HT.
Recommend nonpharmacologic therapy for menopausal symptoms.
Explain the risks, benefits, and contraindications associated with HT.
Describe the circumstances by which nonhormonal therapies should be recommended.
Describe the monitoring parameters for a patient taking HT.
Menopause is the permanent cessation of menses following the loss of ovarian follicular activity. The clinical diagnosis of menopause is made after a woman experiences amenorrhea for 12 consecutive months. The loss of ovarian follicular activity leads to an increase in follicle-stimulating hormone (FSH), which on laboratory examination may confirm the diagnosis.
The role of hormone therapy (HT) has changed dramatically. HT has long been prescribed for relief of menopausal symptoms and, until recently, has been purported to protect women from coronary heart disease (CHD). Recommending HT in postmenopausal women revolved around a simple theory: hormones lost during menopause could be replaced through drug therapy and protect women from both menopausal symptoms and sequelae of menopause. Recent studies have disproved this theory.
In 1996, the United States Preventive Services Task Force published its recommendations that not all postmenopausal women should be prescribed HT, but that therapy should be individualized based on risk factors. This recommendation was supported with publication of the Heart and Estrogen/Progestin Replacement Study (HERS) in 1998, which demonstrated that women with established CHD were at an increased risk of experiencing a myocardial infarction within the first year of HT use compared with similar women without CHD risk factors. As a result, the authors concluded that HT should not be recommended for secondary prevention of CHD.1 In 2002, the Women’s Health Initiative (WHI) study was published. This trial demonstrated that HT was not protective against CHD but rather could increase the risk in women with underlying CHD risk factors. The risk of breast cancer was also increased after a woman was on combination estrogen and progestogen for approximately 3 years. Notably, this was not the case with estrogen alone. As a result of this study, the US Food and Drug Administration (FDA) issued a statement that HT, in general, should not be initiated or continued for primary prevention of CHD.2,3
This trial led to changes in how HT is prescribed and greater understanding of the associated risks. Systemic HT should be used primarily to reduce the frequency and severity of moderate to severe vasomotor symptoms (VMS) associated with menopause in women without risk factors for CHD or breast cancer.
EPIDEMIOLOGY AND ETIOLOGY