18.17 Perimenopause and Menopause

Perimenopause causes menstrual irregularities attributed to fluctuating hormone levels that can last for months up to several years and ends when menses has ceased for 12 months. Menopause refers to 12 months of amenorrhea that typically occurs between ages 40 and 59, with the average age being 51 years old. In addition to the natural transition that occurs with advancing age, medical menopause can also occur due to surgical removal of the ovaries, chemotherapy, radiation therapy to the reproductive organs, or from certain medications that affect ovarian or hormonal function. Women who undergo medically induced menopause have the same signs and symptoms as natural menopause, although the symptoms are often more severe with the sudden reduction of estrogen levels.^[1]

Changing estrogen and progesterone levels during perimenopause can cause menstrual cycles to become longer or shorter, menstrual flow to be heavier or lighter, or bleeding or spotting to occur between periods. It is not unusual for women experiencing perimenopause to skip periods for several months and then resume a regular pattern of menstruation.^[2]

Vasomotor symptoms, commonly known as hot flashes and night sweats, are common symptoms of perimenopause and menopause. These episodes of sudden and intense heat are accompanied by skin flushing, perspiration, palpitations, and an acute feeling of discomfort that can last for several minutes. Vasomotor symptoms often disturb clients’ sleep patterns and impact daily activities, making symptom management crucial for quality of life. The pathophysiology of vasomotor symptoms is not well understood, but it is believed that reduced thermoregulation is caused by a reduction in several hypothalamic hormones. Although vasomotor symptoms have long been thought of as uncomfortable without a physiologic effect, growing research is showing that they may be associated with negative cardiovascular risk factors, including insulin resistance, diabetes, and hypertension.^[3]

Declining estrogen levels during perimenopause and menopause can also cause vulvovaginal atrophy, causing the tissue to become thinner and less elastic with a reduction in lubrication and increased vaginal pH. These changes can result in discomfort, dyspareunia (pain during intercourse), dysuria, and increased vulnerability to infections. Nurses can teach menopausal clients to use lubrication during intercourse to reduce pain and injury to the vagina.^[4]

Metabolic shifts occur during perimenopause and menopause, as estrogen levels decline and androgen levels increase, making it more likely for women to gain weight, particularly around the abdomen, and also experience muscle loss. Menopausal women often experience increased blood pressure, blood glucose, lipid levels, and inflammatory markers, increasing their risk for metabolic syndrome and cardiovascular disease. Nurses teach clients about healthy diet choices and regular exercise to help reduce the risk of cardiovascular disease.^[5]

Decreased estrogen levels also affect the musculoskeletal system, causing bone density loss, joint inflammation, and decreased muscle mass. Untreated bone density loss can lead to osteoporosis and possible bone fractures. Increased joint inflammation causes increased pain and stiffness. Starting around age 50, muscle loss speeds up, and women lose 5% to 10% of their muscle mass each decade. Nurses teach clients the importance of weight-bearing exercise and strength training to maintain bone mass and muscle strength.^[6]

Emotional well-being can be significantly impacted during perimenopause and menopause due to hormonal fluctuations, resulting in mood swings, irritability, and possible episodes of depression. Many women report emotional symptoms similar to premenstrual syndrome (PMS) but they occur for long periods of time without a discernible pattern. These emotional changes can affect a woman’s quality of life and interpersonal relationships, highlighting the importance of emotional support and holistic care from the nurse and the health care team.^[7]

Diagnostic testing involves assessing hormone levels, especially follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. During perimenopause and menopause, the ovaries are less responsive to these hormones, requiring increased levels to activate follicular growth. Elevated FSH levels and decreased estradiol levels are indicative of perimenopause and menopause. However, nurses should be aware that these hormones vary throughout the cycle, so a single elevated FSH level does not definitively diagnose perimenopause. An additional diagnostic test is the anti-Müllerian hormone (AMH) level. The anti-Müllerian hormone is produced by the ovarian follicles, so when there is high ovarian function, the AMH level is high, but when ovarian function starts to decline, the AMH level drops. The health care provider may also order additional testing to determine if the perimenopausal symptoms can be from another medical condition that causes similar symptoms, such as thyroid dysfunction.^[8]

The primary medical treatment for vasomotor symptoms, vulvovaginal atrophy, sleep disturbances, depression/anxiety, and joint pain associated with perimenopause and menopause is hormone replacement therapy (HRT). HRT is the administration of estrogen, progesterone, or a combination of both hormones.^[9] HRT was formerly considered standard therapy, but research findings from the Women’s Health Initiative (WHI) in 2002 significantly decreased the use of HRT. These research findings showed that HRT caused an increased risk of breast cancer, stroke, heart disease, and emboli in older postmenopausal women (i.e., those over age 62 or who were menopausal for more than ten years) who were prescribed HRT to prevent chronic conditions such as cardiovascular disease and osteoporosis. It is important to note that this research did not address the risks of HRT for preventing or treating menopausal symptoms. Ongoing research has shown that HRT is a safe option for treating menopausal symptoms for up to five years in most healthy, young postmenopausal wοmen (i.e., those aged 50 to 59 or are menopausal for less than ten years). Health care providers use an individualized approach based upon calculating a ԝomаn’s baseline cardiovascular and breast ϲаnсеr risks prior to prescribing HRT.^[10]

Clients with an intact uterus must take HRT that contains both estrogen and progesterone because estrogen alone can cause endometrial hyperplasia that increases the risk for uterine cancer. Progesterone opposes estrogen and reduces that risk by preventing uncontrolled proliferation of the endometrial lining. Additionally, progesterone may relieve other symptoms not affected by estrogen, such as insomnia and mood swings. Estrogen and progesterone can be administered via patches, creams, pills, vaginal inserts, or subdermal pellets, depending on the client preferences. Side effects of estrogen include nausea, fluid retention, headache, and breast enlargement. Side effects of progesterone include increased appetite, weight gain, irritability, depression, spotting, and breast tenderness. Clients are taught the risks of HRT, including deep vein thrombosis, pulmonary embolism, and cerebrovascular accidents, and when to contact the health care provider or seek emergency care for concerning symptoms.^[11]

Clients who are not candidates for HRT may be prescribed other medications for reducing vasomotor symptoms, including serotonin receptor reuptake inhibitors (SSRIs), such as paroxetine, citalopram, and escitalopram (Lexapro), or serotonin-norepinephrine reuptake inhibitors (SNRI), such as venlafaxine. The most common side effects reported for both SSRIs and SNRIs are nausea and constipation, with most resolving within the first week of treatment. SNRIs are associated with increased blood pressure and should be used with caution in women with hypertension. Women with a history of breast cancer who are taking tamoxifen should also avoid SSRIs, which have been shown to interfere with tamoxifen metabolism.^[12]

Nurses support clients experiencing symptoms of perimenopause and menopause by providing health teaching about physical and emotional changes, available treatment options, and self-care strategies. It is also important for perimenopausal clients to understand that although their periods may be irregular, it is still possible to become pregnant. Nurses also teach clients about nonpharmacological interventions that can be used alone or to complement medical treatments. Lifestyle modifications that may contribute to overall well-being and wellness include the following^[13]:

• Eating a low fat, healthy diet rich in calcium and vitamin D to maintain bone health
• Engaging in regular physical activity that includes cardiovascular exercise, weight-bearing exercise, and strength training
• Practicing stress reduction techniques
• Quitting smoking
• Reducing alcohol consumption
• Reducing obesity and managing weight
• Engaging in cognitive behavioral therapy and mindfulness practices to manage mood swings and emotional changes