menopausa

Periodo di follia nella donna, che in

certi casi conduce al manicomio il

marito.

• Definizione : cessazione permanente del ciclo

mestruale derivante dall’esaurimento dei

follicoli ovarici

• Diagnosi : retrospettiva. Dopo 12 mesi

consecutivi di amenorrea per la quale non vi

sia una altra causa determinante

• Insorgenza : età media 51 anni.

• Il fumo anticipa la menopausa di 2 anni.

• Menopausa indotta : da cause non fisiologiche

come la asportazione di entrambe le ovaie o

la soppressione della attività ovarica con

radioterapia o chemioterapia.

• Menopausa precoce : ultima mestruazione

prima dei 40 anni

• Perimenopausa : periodo in cui sono presenti irregolarità del ciclo mestruale. Inizia in media 4 anni prima dell’ultimo flusso mestruale e si protrae per 1 anno dopo l’ultimo flusso mestruale.

• Perimenopausa e postmenopausa hanno in comune molti sintomi ma la loro fisiologia e trattamento sono molto diversi.

• I contraccettivi a basso dosaggio sono determinanti nel trattamento della perimenopausa, mentre la terapia ormonale sostitutiva è un metodo per alleviare i sintomi postmenopausali.

Dosaggio FSH

• What about testing for follicle-stimulating hormone (FSH)?

• As the ovaries’ production of estrogen declines around menopause, the pituitary gland releases more FSH into the blood to try to stimulate estrogen production. So, when a woman’s FSH blood level is consistently elevated, and she is no longer having menstrual periods, it is generally accepted that she has reached menopause.

• However, a single FSH level can be misleading in perimenopause because estrogen production doesn’t fall at a steady rate from day to day. Instead, both estrogen and FSH levels fluctuate from fairly high to fairly low during perimenopause.

• Also, if a woman is using certain hormone therapies (such as birth control pills), an FSH test is not valid.

Sintomatologia

• Women in the menopausal transition commonly report a variety of symptoms,including vasomotor symptoms (hot flushes and night sweats), vaginal symptoms,urinary incontinence, trouble sleeping, sexual dysfunction, depression, anxiety,labile mood, memory loss, fatigue, headache, joint pains, and weight gain.

• However,in longitudinal studies, after adjusting for age and other confounders, only vasomotor symptoms, vaginal symptoms, and trouble sleeping are consistently associated with the menopausal transition.

• Symptoms such as memory loss and fatigue may be due to frequent hot flushes or trouble sleeping.

I “calori”

• The most common menopause-related discomfort is the hot flash (sometimes called a hot flush). Although their exact cause is still a matter of speculation, hot flashes are thought to be the result of changes in the hypothalamus, the part of the brain that regulates the body’s temperature. If the hypothalamus mistakenly senses that a woman is too warm, it starts a chain of events to cool her down. Blood vessels near the surface of the skin begin to dilate(enlarge), increasing blood flow to the surface in an attempt todissipate body heat. This produces a red, flushed look to the face and neck in light-skinned women. It may also make a woman perspire to cool the body down. An increased pulse rate and a sensation of rapid heart beating may also occur. Hot flashes areoften followed by a cold chill. A few women experience only the chill

• The prevalence of hot flushes is maximal in the late menopausal transition, occurring in about 65% of women.

• In most women, hot flushes are transient. The condition improves within a few months in about 30 to 50% of women and resolves in 85 to 90% of women within 4 to 5 years.

• However, for unclear reasons, about 10 to 15% of women continue to have hot flushes many years after menopause.

• Vaginal symptoms (including dryness, discomfort, itching, and dyspareunia) are reported by about 30% of women during the early postmenopausal period and up to 47% of women during the later postmenopausal period.

• Urologic symptoms (including urgency, frequency, dysuria, and incontinence) are not clearly correlated with the menopausal transition.

• Unlike hot flushes, vaginal symptoms generally persist or worsen with aging.

One of the most complex health care decisions facing women is whether to use

postmenopausal HT.

Once prescribed primarily to relieve vasomotor symptoms, HT has been

promoted as a strategy to forestall various disorders that accelerate after

menopause, including osteoporosis and cardiovascular disease.

In 2000, nearly 40% of postmenopausal women age 50–74 in the United States

had used HT. This widespread use occurred despite the paucity of conclusive

data, until recently, on the health consequences of such therapy.

Although observational studies suggest that HT prevents cardiovascular and other

chronic diseases, the apparent benefits may result at least in part from differences

between women who opt to take postmenopausal hormones and women who do

not. Those choosing HT tend to be healthier, have greater access to medical care, are

more compliant with prescribed treatments, and maintain a more health-promoting

lifestyle.

Randomized trials, which eliminate these confounding factors, have not consistently

confirmed the benefits found in observational studies.

Indeed, the largest HT trial to date, the Women's Health Initiative (WHI), which

examined more than 27,000 postmenopausal women age 50–79 (mean age, 63) for

an average of 5–7 years, was stopped early because of an overall unfavorable risk-

benefit ratio in the estrogen-progestin arm and an excess risk of stroke in the

estrogen-only arm.

benefici e rischi

Tabella riassuntiva

SINTOMICompelling evidence, including data from randomized clinical trials, indicates that

estrogen therapy is highly effective for controlling vasomotor and genitourinary

symptoms.

Alternative approaches, the consumption of soy-based products or other

phytoestrogens, may also alleviate vasomotor symptoms, although they are less

effective than HT.

For genitourinary symptoms, the efficacy of vaginal estrogen is similar to that of

oral or transdermal estrogen.

OSTEOPOROSIBy reducing bone turnover and resorption rates, estrogen slows the aging-related

bone loss. Postmenopausal estrogen therapy, with or without a progestogen,

rapidly increases bone mineral density at the spine by 4–6% and at the hip by 2–

3%, and maintains those increases during treatment.

Data from observational studies indicate a 50–80% lower risk of vertebral fracture

and a 25–30% lower risk of hip, wrist, and other peripheral fractures among current

estrogen users.

BENEFICI CERTI

CARCINOMA ENDOMETRIALE

A combined analysis of 30 observational studies found a tripling of endometrial

cancer risk among short-term (1–5 years) users of unopposed estrogen and a nearly

tenfold increased risk among users for 10 or more years.

Use of a progestogen, which opposes the effects of estrogen on the endometrium,

eliminates these risks.

TROMBOEMBOLIA VENOSA

A meta-analysis of 12 studies found that current estrogen use was associated with a

doubling of venous thromboembolism risk in postmenopausal women.

Results from the WHI indicate a twofold increase in risk of venous and pulmonary

thromboembolism associated with estrogen-progestin and a one-third increase in

this risk with estrogen-only therapy.

Transdermal estrogen, taken alone or with certain progestogens (micronized

progesterone), appears to be a safer alternative with respect to thrombotic risk.

RISCHI CERTI

CARCINOMA MAMMARIO

An increased risk of breast cancer has been found among current or recent estrogen users in observational studies; this risk is directly related to duration of use.In a meta-analysis of 51 case-control and cohort studies, short-term use (<5 years) of postmenopausal HT did not appreciably elevate breast cancer incidence, whereas long-term use ( > 5 years) was associated with a 35% increase in risk.In contrast to findings for endometrial cancer, combined estrogen-progestin regimens appear to increase breast cancer risk more than estrogen alone

RISCHI O BENEFICI ANCORA INCERTI

Until recently, HT had been enthusiastically recommended as a possible cardioprotective agent.

In the past 3 decades, multiple observational studies suggested that estrogen use leads to a 35–

50% reduction in CHD incidence among postmenopausal women.

Randomized trials of estrogen or combined estrogen-progestin in women with preexisting

cardiovascular disease (CVD) have not confirmed the benefits reported in observational studies.

Thus, in clinical trials, HT has not proved effective for the secondary prevention of CVD in

postmenopausal women.

Primary prevention trials also suggest an early increase in cardiovascular risk and absence of

cardioprotection with postmenopausal HT.

However, a closer look at available data suggests that timing of initiation of HT may critically

influence the association between such therapy and CHD. Estrogen may slow early stages of

atherosclerosis but have adverse effects on advanced atherosclerotic lesions.

APPROCCIO ALLA PAZIENTE

The rational use of postmenopausal HT requires balancing the potential benefits and

risks.

The clinician should first determine whether the patient has

moderate to severe menopausal symptoms

the only indication for initiating systemic HT (urogenital symptoms in the absence of

vasomotor symptoms may be treated with vaginal estrogen).

The patient's own preference regarding therapy should be elicited and factored into

the decision.

Contraindications to HT should be assessed routinely and include unexplained vaginal

bleeding, active liver disease, venous thromboembolism, history of endometrial

cancer or breast cancer, and history of CHD, stroke, transient ischemic attack, or

diabetes.

Relative contraindications include hypertriglyceridemia (>400 mg/dl) and active

gallbladder disease; in such cases, transdermal estrogen may be an option.

terapia dei sintomi vasomotori

• Per via sistemica : orale o transdermica

• Ciclica e non continua (a meno che nei giorni di sospensione non ricompaiano forti sintomi)

• Associata a progesterone naturale nelle donne in cui l’utero è presente

• Terapia con ormoni bioidentici (cioè con ormoni identici a quelli ovarici : progesterone, estradiolo)

• La terapia dovrebbe essere eseguita a breve termine, cioèper meno di 5 anni, inoltre ogni tanto andrebbe sospesa per valutare se i sintomi menopausali sono ancora presenti.

• E’ molto importante fornire anche raccomandazioni sullo stile di vita (attività fisica, fumo di tabacco e dieta sana) e sul mantenimento di adeguati livelli di vitamina D

Farmaci disponibili

• Progesterone : Prometrium , Progeffik

• Estradiolo : – Gel transdermico :

• Sandrena (0,5 – 1 mg)

• Estrodose (0,75 mg)

• Gelestra, Ginaikos (1,5 mg)

– Cerotto 7 giorni :• Armonil septem, Dermestril septem (2,5 – 5 mg)

• Femseven (5 mg)

• Zerella (5 – 10 mg)

– Compresse :• Progynova (2 mg)

Schema di cura

• Semplificando al massimo :

– Estradiolo dal giorno 1 al 24 di ogni mese di calendario

– Progesterone dal giorno 13 al 24 di ogni mese di calendario (associato all’estradiolo)

REGOLA AUREA :

al dosaggio minore efficace

per il tempo minimo necessario

terapia dei sintomi genitourinari

Associare o meno il progestinico alla terapia locale vaginale

NO ? (quasi sempre)

SI ?? (qualche volta)

trattamenti alternativi

• Tibolone

• Fitoestrogeni

• Slow breathing

NAMS

(the north american menopause society)

2012 position statement

2012 patient handout