Menopause is an eventuality for most women. With a mean age of 46.8 years, the 95% of U.S. nurses who are women face this physiological and sometimes life-altering phenomenon as a short-term certainty.¹

As the average life expectancy for women increases, the number of women reaching and living in menopause has escalated. Nurses care for women approaching and experiencing menopause on a daily basis. With both a personal and professional vested interest, nurses should be aware of the chronology and physiology of menopause. They need to know the risks and benefits of the various pharmacological and nontraditional therapies and lifestyle modifications currently available to competently assess and counsel this burgeoning segment of the population. Nurses need to know about these issues to better care for their patients and themselves.

Chronology

Strictly speaking, menopause refers to the time of life when the ovaries stop making the female hormones estrogen and progesterone. For most women, menopause occurs gradually over a two- to five-year period.

Perimenopause encompasses the one to five years before the final cessation of menses. During this time, the amount of circulating estrogen and progesterone fluctuates, causing a variety of menstrual and other physiological changes. Women are in menopause when they have had a full year without menstrual bleeding. Women over 40 are considered to be perimenopausal.²

Most women experience menopause between the ages of 45 and 55. The average age is 51, a figure that has remained constant in the U.S. throughout the past century. Although rare, menopause can occur at much younger ages due to premature ovarian failure, surgical removal of the ovaries, chemotherapy, or pelvic radiation therapy.

Postmenopause extends throughout the remainder of a woman’s life, starting two years after the last menstrual period. However, as the longevity of women has increased, the number and severity of potential health risks associated with postmenopause have escalated. Because the aging population is increasing rapidly, more women will be living a greater portion of their lives after menopause. Nurses must understand the physiological changes of menopause and be aware of the important role they can play in promoting the health of midlife and older women.

Effects of diminished estrogen and progesterone levels

Women experience the effects of reduced hormone levels in many ways. Generally, these changes affect four areas of the body — the urogenital tract, circulatory system, brain, and skeletal system.³

The urogenital tract includes the bladder, uterus, and vagina. In menopause, these organs atrophy and lose elasticity, turgor, and thickness, which may lead to dysuria, urinary incontinence, urinary frequency, an increased incidence of cystitis, dryness and itching of the vagina, and painful intercourse. A drop in hormonal levels changes the environment for normal flora, which may increase the incidence of urinary tract infections.⁴ Midlife women may seek healthcare to resolve these problems.

The withdrawal of estrogen and progesterone also affects the circulatory system. Blood vessels become unstable, leading to the classic signs of hot flashes and temperature fluctuations experienced by many perimenopausal women. No one completely understands the physiology of hot flashes, but they seem to originate in the hypothalamus. Women frequently have these uncomfortable symptoms while sleeping, battling night sweats and insomnia and having to change nightclothes and bed sheets on a regular basis. Vasomotor instability can trigger chills or periods of extreme warmth during the daytime hours, as well. Estrogen loss leads to changes in lipid profiles: increased low-density lipoproteins, decreased high-density lipoproteins, and a rise in total cholesterol and triglyceride levels.⁵ Before menopause, most women are protected from heart disease by high levels of circulating estrogen. Menopause signals the withdrawal of estrogen, and when coupled with advanced age, this may escalate the risk of heart attack and death due to cardiovascular disease.

For many years, mental health problems during menopause, such as depression and anxiety, were believed to be inevitable, and were associated with a decline in hormone production. In reality, no controlled clinical trials support the belief that natural menopause is responsible for clinical depression, anxiety, severe memory loss, or erratic behavior. Available research does indicate that waning levels of estrogen may lead to Alzheimer’s disease in postmenopausal women, although some research indicates that estrogen therapy may contribute to the development of Alzheimer’s disease.⁶

Midlife women may suffer from anxiety, irritability, fatigue, and emotional distress. However, these problems can affect anyone at any age and may simply be due to a lack of REM (rapid eye movement) sleep or problems coping with aging and other stressors. Midlife women who have had a previous episode of clinical depression may be more at risk for depression in menopause. A careful history to elicit past personal or family experience with mental health problems may help delineate other etiologies early on. Counseling and pharmacotherapy may help ease these problems.

During menopause, women lose a significant amount of bone mass, which makes them susceptible to osteopenia (low bone mass) while increasing their risk of osteoporotic fractures of the spine, hip, and distal radius.⁷ Calcium loss from bones that occurs as a result of estrogen withdrawal during the menopausal years is a primary cause of osteoporosis in aging women. Sufficient amounts of circulating estrogen are necessary for the maintenance of calcium balance and adequate bone mass. Healthcare practitioners may diagnose osteoporosis in women after a bone density test indicates that their bone mass has dropped below a critical point. A screening test, such as a heel ultrasound or a urinary marker assay, can determine the risk for this disease.

Historically, scientists have attributed a variety of additional signs and symptoms to the hormonal fluctuations of menopause.⁸ Sleep disturbances characterized by unusual dreams and early morning awakenings, new onset of allergies, fluctuations in sexual desire and response, appearance of facial hair, weight gain in unusual places, dizziness, headaches, and loss of self-confidence have been associated with the hormonal changes experienced by women in midlife. While some of these changes may in fact be due to the withdrawal of hormones during menopause, many other genetic, physiological, situational, or environmental factors may be the cause of these signs and symptoms.

Menopause signals the end of an era for many women. It concludes their ability to reproduce and often coincides with events such as children leaving home or changes in employment or caregiver roles. Many women welcome these changes and thrive in new life challenges. On the other hand, some women may find advancing age, altered roles, and physiological changes experienced during menopause to be overwhelming events that may spark depression and anxiety.

Benefits of Hormone Withdrawal

Women derive some benefits from the cessation of menses. Freedom from the risk of pregnancy and the need for birth control enables some to experience a greater sexual desire and more enjoyment with their sexual partner. For women who have experienced heavy menstrual flow and debilitating monthly periods, menopause can signal the end of a difficult monthly routine.

Women with naturally occurring menopause who do not have uncomfortable menopause symptoms may not seek advice or treatment in the healthcare system. While medical treatment of menopause is not essential, it may be beneficial in avoiding or delaying postmenopausal problems, such as osteoporosis, sexual dysfunction, and coronary artery disease. The treatment of menopause with standard or complementary therapies should be a personal and educated decision for each woman.

Treatment Options

Lifestyle Modifications: Menopause is a naturally occurring phase of every woman’s life. While not a disease state, menopause does put women at greater risk for the development of many of the diseases of aging. Proactive disease prevention is one way to help perimenopausal and menopausal women learn about their individual risk for postmenopausal diseases, as well as strategies to prevent them.

While the timing of primary prevention screening varies among experts, screening tests can help provide early diagnosis and treatment of serious illness. Menopausal women should be screened regularly for osteoporosis, cardiovascular, and other chronic disease risks.⁹ Guidelines recommend the assessment of blood pressure and blood cholesterol, as well as mammograms; pap, pelvic examinations, and digital rectal examinations; and bone density testing as a baseline at menopause and then on a regular basis, depending on results and risk factors.

In addition to screening tests, nurses should encourage menopausal women to become involved in their own health maintenance. To avoid osteoporosis, counsel them to obtain adequate calcium through a combination of diet and supplements. Menopausal women need a total of 1,200 mg to 1,500 mg of calcium per day.¹⁰ Women taking calcium supplements should not take more than 500 mg to 600 mg at one time because that is the maximum amount the body can absorb. Additionally, a nutritional diet, regular weight-bearing exercise, smoking cessation, and prudent alcohol and caffeine intake can help prevent osteoporosis. To prevent cardiovascular disease, advise women to reduce their dietary intake of fat, cholesterol, and sodium. Regular exercise, stress reduction, smoking cessation, and weight control can also help prevent or reduce cardiovascular disease. Although cancer has not been directly linked to menopause, midlife women are at greater risk because of advancing age. To prevent cancers, teach women to eat a low-fat, high-fiber diet, avoid sun exposure, stop smoking, reduce or control weight, engage in routine aerobic exercise, limit alcohol intake, perform breast self-examinations, and have mammograms regularly.

Lifestyle modifications are cost-effective, participatory
ways to avoid the onset of postmenopausal diseases. Nurses
can counsel peri- and postmenopausal women about their personal risks and help them prevent disease with specific health-maintenance education.

Pharmacological Options

Hormone therapy (HT) has been the mainstay of menopause pharmacotherapy for many years. HT can help treat or prevent a number of menopausal problems. However, recent results of the Women’s Health Initiative (WHI) trial have made the use of HT much more controversial. It is effective in the treatment of vasomotor instability, urogenital atrophy, and mood or sleep disorders. Also clinical evidence shows that HT prevents osteoporosis by enhancing bone mass, reduces the incidence of colorectal cancer, and improves lipid profiles.¹¹ However, despite the positive effects on lipid chemistry, evidence suggests that HT doesn’t protect against coronary heart disease.

For women who have had a hysterectomy, estrogen is safe to take alone. Women with an intact uterus must use combined hormone replacements (estrogen and progesterone) to reduce the risks of endometrial cancer. Synthetic or plant-derived agents can be taken orally or transdermally in patches or creams; both individual and combination therapies are available. Unfortunately, no magic formula can determine a precise prescription, and women need to work closely with their primary care providers to find the best combination of delivery systems, hormonal type, and amount. Several different trials of HT may be necessary to determine the best therapy with the least amount of adverse effects. Often, several months of trial and error are needed to arrive at an optimal treatment plan.

HT is not an option for every woman. Many women simply cannot tolerate the adverse effects of HT, such as vaginal bleeding and moods swings, and leave them to seek alternative menopausal therapy. HT is contraindicated for women with a personal history of breast cancer, uterine cancer, liver disease, gall bladder disease, blood clots, or unexplained vaginal bleeding. Additionally, the recent report from the WHI, the first randomized controlled study of HT, indicates that risks outweigh benefits for healthy postmenopausal women ages 50 to 79 who have an intact uterus and are taking the combination estrogen/progesterone HT. (See Sidebar, WHI Results). Specifically, this group experienced an increase in the incidence of invasive breast cancer, coronary heart disease (CHD), stroke, and venous thromboembolism (VTE) disease including deep vein thrombosis (DVT) and pulmonary embolism (PE), when compared with the placebo group. The results of this study have and will continue to generate questions and concerns from women about HT. Nurses should advise women to discuss HT with their health care provider who knows the woman’s medical history, information that is relevant to the risks and benefits of HT.

Recently, a new classification of drugs — selective estrogen receptor modulators (SERMs) — has been approved to meet the needs of women who cannot tolerate HT. SERMs are synthetic menopausal agents designed to prevent heart disease and osteoporosis, while avoiding the risks of breast and uterine cancers associated with HT.¹² Tamoxifen (Nolvadex), which was originally designed as adjuvant therapy in breast cancer, was the first drug in this category to be recognized for its potential use in menopause. In 1998, the Food and Drug Administration (FDA) approved raloxifene (Evista) as the first SERM to be used specifically for osteoporosis prevention in postmenopausal women. Raloxifene mimics estrogen in some parts of the body and blocks estrogen’s cancer-promoting effects in others.¹³ In 1999, raloxifene received additional approval by the FDA as an osteoporosis treatment choice. Research data indicates that this agent may not only prevent osteoporosis, but may also be useful in the prevention of heart disease and breast cancer in postmenopausal women. Unfortunately, raloxifene has no effect on some menopausal symptoms that may occur at this time of life. In fact, some women who take raloxifene have reported a higher incidence of hot flashes than before they started taking this medication.¹⁴

Nontraditional Remedies

Many women believe menopause is a naturally occurring state that should not be managed pharmacologically. In an effort to avoid synthetic, manufactured drugs, women have turned to options from health food stores or mail order catalogs to relieve perimenopausal symptoms. Although scientific evidence for many of these remedies may be lacking, their use has skyrocketed. Nurses should be aware of alternatives and be able to provide information about their safety, efficacy, and potential harmful effects. A government website provides reliable information about complementary therapies <http://nccam.nih.gov>. Common herbal remedies used by menopausal women include Dong Quai, melatonin, and ginseng. Research data regarding the safety and efficacy of these substances is minimal and sometimes conflicting. While some benefits may be gained from their use, longitudinal, randomized, placebo-controlled clinical trials that demonstrate their efficacy have yet to be conducted.

Other substances have gained popularity in recent years for the prevention and treatment of menopausal problems. Health food stores and catalogs market wild yam creams as a treatment for menopausal symptoms. Because yam creams contain diosgenin and sarsasapogenin — precursors of progesterone¹⁵ — they are often confused with progesterone creams, which may indeed provide some relief from menopausal hot flashes. Unfortunately, humans lack the enzymes necessary to produce progesterone from these substances. Therefore, costly yam creams ultimately have no effect on the reduction of menopausal symptoms beyond softening skin because of the emollients used as a base for the yam derivatives. On the other hand, true progesterone creams compounded by a reputable pharmacist can reduce menopausal symptoms and the risk of postmenopausal osteoporosis. Researchers in several small clinical trials have found an improvement in vasomotor symptoms, psychological symptoms, and bone density with daily transdermal applications of progesterone cream,¹⁶ although more recent studies have failed to demonstrate the success of progesterone cream in alleviating postmenopausal symptoms.¹⁷

Soy products have also entered the scene as alternative therapy for menopause. Soy products are formulated as pure soy, phytoestrogens, or isoflavones. Phytoestrogens are non-steroidal, plant-derived compounds that mimic estrogenic effects at several sites in the body. The isoflavones are one class of phytoestrogens that are derived largely from soy-based products. These products are consumed as pills, powders, liquids, or food additives. Clinical trial data do not support the use of isoflavones to prevent or treat osteoporosis in postmenopausal women.¹⁸ The estrogen-like effects of isoflavones may increase the risk of breast cancer in some postmenopausal women at high risk for breast cancer.¹⁹

Some substances, such as black cohosh and St. John’s wort, have been found to be superior to placebo in alleviating the symptoms of menopause.²⁰ Nurses should be aware of the purported action of alternative therapies, as well as any potential adverse effects or drug interactions that patients may experience.

Women beyond the childbearing years interact with nurses in the healthcare system for many reasons — annual checkups, elective or emergent surgical procedures, monitoring of chronic illnesses, and sometimes specifically for counseling and advice about menopausal issues. Nurses can help them evaluate therapeutic options and direct them to consumer-oriented books that deal with the physiological and emotional changes of menopause. A growing volume of information is also available through the Internet. Two reliable electronic sources are the North American Menopause Society <www.menopause.org> and the Association of Women’s Health, Obstetric, and Neonatal Nurses <www.awhonn.org>.

All women will experience some type of menopause sometime during their lives. Despite this, women rarely seek specific advice and counsel from healthcare providers to manage its signs, symptoms, and disease risks. Nurses caring for peri- and postmenopausal women should take every opportunity to educate, counsel, and teach them about menopausal health and the multitude of options available for prevention and treatment. Nurses in every healthcare setting can play a major role in promoting the health of women before, during, and after this inevitable event.