Menopause: Women's Careful Transition and Examination
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Menopause: Women's Careful Transition and Examination

Women transition into menopause over a period of time. A woman who has had 12 consecutive months of amenorrhea is menopausal. Symptoms may begin in the transition period and continue into the postmenopausal period.

Women transition into menopause over a period of time. A woman who has had 12 consecutive months of amenorrhea is menopausal. Symptoms may begin in the transition period and continue into the postmenopausal period. Common problems in women at this stage of life include vasomotor symptoms, atrophic vaginitis, and postmenopausal bleeding.

Vasomotor Symptoms

Vasomotor symptoms include hot flashes and night sweats. Women commonly report a sensation of warmth that spreads throughout the body and is associated with sweating. These symptoms can begin in the transition period and are associated with lower relative estrogen levels. In some women these episodes occur multiple times during the day and night. They may subside in 1 to

2 years but may persist for 5 to 10 years in others. Alcohol, caffeine, or spicy food may trigger hot flashes.

Treatment of moderate to severe vasomotor symptoms is the main indication for postmenopausal estrogen therapy or combined estrogen-progestogen therapy. Hormonal therapy is used at the lowest effective dose for the shortest duration possible (<5 years). Preparations include oral conjugated equine estrogen 0.3 to 0.625 mg daily and oral estradiol 0.5 to 1.0 mg daily. Combined estrogen-progestogen preparations are also available.

Soy products, black cohosh, evening primrose, and dong quai have not been consistently proven in clinical trials. Antidepressants including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have yielded mixed results in clinical trials, as has the _-blocker clonidine.

Atrophic Vaginitis

Vaginal dryness may be a symptom early in the menopause transition. Over time the lining of the vagina is thinned and vaginal secretions decrease. Dyspareunia, burning on urination, vaginal discharge, urinary incontinence, or urinary tract infections may be associated with atrophic vaginitis.

Examination reveals loss of vaginal rugae, a thinned mucosa, scant secretions, friability of the mucosa, and edema of the vaginal mucosa or labia.

Mild symptoms may respond to water-based lubricating jelly or vaginal moisturizers. All hormonal preparations are approved for treatment of severe vaginal atrophy and are effective. Topical preparations are preferred. These include conjugated equine estrogen cream 1 gm vaginally nightly for 2 weeks then 1 or 2 days weekly, estradiol 1 gm vaginally nightly for 2 weeks then 1 or 2 days weekly, or estradiol ring every 90 days.

Post-Menopausal Bleeding

Postmenopausal vaginal bleeding can be caused by many of the same factors as abnormal bleeding earlier in life. The cause is more likely to be structural than hormonal in a postmenopausal woman.

Endometrial carcinoma and vaginal atrophy are common causes. Infection and trauma can cause bleeding. As a woman ages, fibroids are less likely to be the cause of bleeding.

The physical examination should include a complete pelvic examination and Pap smear. The absence of atrophy and trauma are important.

Women with undiagnosed vaginal bleeding should be referred to a gynecologist. Trans-vaginal ultrasound and endometrial biopsy can facilitate the assessment of endometrial atrophy or endometrial carcinoma.

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