Menopause Menopause – the “change of life” – is an unavoidable part of aging that every woman who lives till middle age will experience. It literally means last period, and signals the end of menstruation although the term is commonly used to describe the years leading up to the menopause as well. This transition phase is more correctly called the perimenopause and describes the period of time during which the ovaries release fewer eggs and produce fewer hormones causing a change in menstrual patterns. Menopause is generally considered complete in a woman with an intact uterus if she has not had a period for at least a year. Although high levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH) provide additional evidence that menopause is impending, the diagnosis is not confirmed until a year has passed. Signs of natural perimenopause usually start to occur between the ages of 45 and 55 with an average age of onset of 52. In more than 50% of women, the timing of their menopause is similar to that of the age at which their mother or sister underwent the transition. Early onset or premature menopause is the term used to describe menopause occurring in a woman before the age of 40 and is more likely to occur in women who: • are overweight • come from certain countries with noticeably earlier ages of menopause (eg, Latin America) • have a family history of early menopause • have certain medical conditions or illnesses • have had none or only one child • smoke. Artificial menopause is that caused by surgical removal of both ovaries or the destruction of the ovaries by some cancer treatments. Hormone levels drop suddenly resulting in an abrupt onset of menopausal symptoms which are often more severe than those experienced with natural or premature menopause. Symptoms A change in menstrual patterns is usually the first symptom of perimenopause. Periods become lighter or heavier, longer or shorter, with an increased length of time between cycles. Hot flushes (also called hot flashes in some countries) are experienced by more than 60% of women. A hot flush is a momentary sensation of heat that may be accompanied by a red, flushed face and sweating. Night TREATMENT OPTIONS Category Examples Comments Magnetic devices Vaginal dryness Supplements [GENERAL SALE] eg, Ladycare [GENERAL SALE] eg, Vagisil Intimate Moisturiser, Sylk [SUPPLEMENT] eg, Harmony Menopause*, Amberen Menopause Relief, Clinicians Menopause Balance, Nutralife Meno-life, Promensil, Remifemin eg, EPA, flaxseed, pycnogenol, soy, St John’s wort Ladycare Menopause is a drug-free magnetic device designed to reduce the symptoms of menopause. Attaches discreetly and comfortably to the underwear. Relieves uncomfortable vaginal dryness and can be used during sexual intercourse. Waterbased and safe to use with condoms. Contain various ingredients including angelica polymorpha (Dong Quai), cimicifuga racemosa (black cohosh), peony, shatavari, trifolium pretense (red clover extract), vitex agnus-castus (Chaste tree) to help relieve symptoms of menopause such as night sweats and hot flushes. There is some evidence for the effectiveness of other supplements (ie, EPA, flaxseed, soy, St John’s wort) for relieving menopausal symptoms. Products with an asterisk have a detailed listing in the Menopause section of OTC Products, starting on page 250. Page 104 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION sweats are also common and may interfere with sleep. Other physical and psychological symptoms that may be experienced include: • aching legs/cramps • body hair growth • breast tenderness • fluid retention (eg, swollen ankles, weight gain, bloating) • forgetfulness • increased anxiety and stress • irritability and mood swings • itchy skin • joint and bone pain • low sex drive • migraines/headaches • more noticeable skin ageing (ie, wrinkles) • tinnitus (ringing in the ears) • vaginal dryness (can result in painful intercourse) • vertigo. Urinary tract infections (see Cystitis) and incontinence (see Urinary Incontinence) are also more common due to thinning of the vaginal and bladder walls. Women are at greater risk of medical conditions such as osteoporosis, heart disease (see Heart Health), and breast cancer after menopause. Perimenopausal symptoms may last anywhere from a few months to several years (average three to five years). Initial assessment Not all women have problems during perimenopause and many who seek advice may just require information about possible symptoms and duration of the transition. Some may wish to try complementary therapies. Some evidence of an effect has been found for black cohosh, eicosapentaenoic acid (EPA), flaxseed, pycnogenol, soy and St John’s wort. Many other complementary therapies such as dong quai, evening primrose oil, panax ginseng or wild yam have less convincing evidence although some women may obtain benefit. Lifestyle changes (see Advice for customers) may go some way to alleviating menopausal symptoms and pharmacy staff should advise women to undergo recommended screening tests and Heart Health assessments. Advise all women to talk to their doctor about their symptoms at their next visit as other medical conditions can cause heavier periods or an absence of periods (amenorrhoea). Bleeding that occurs after periods have been absent for a year is not normal and medical investigation is warranted. Treatment Treatment for perimenopausal symptoms is not routinely offered or needed as individual symptoms vary markedly. The decision to treat should be a collaborative one made between doctor and patient after a thorough discussion of the relevant risks and benefits. Prescription medicines, including hormone replacement therapy (HRT) and Refer to PHARMACIST Always refer any woman with particularly severe symptoms to the pharmacist. Also refer: • any woman who is aged less than 40 • women on HRT who are experiencing unusual uterine bleeding • women with irregular periods who do not seem to have any other menopausal symptoms. non-hormonal treatment products (eg, SSRIs, venlafaxine, clonidine, gabapentin) may be considered by a doctor for women who are suitable candidates for these types of therapy. Vaginal dryness is an uncomfortable and a common occurrence in menopausal women and is due to a thinning of the vaginal wall (vaginal atrophy) brought about by lower oestrogen levels. Local (vaginal) oestrogen treatments are very effective at relieving this dryness while having a minimal impact on other tissues of the body. Vaginal moisturising gels and use of lubricants during sexual intercourse are non-hormonal options for managing vaginal discomfort. Advice for customers • Dress in light clothing and in layers to help with the hot flushes. • Eat a balanced, healthy diet. »» Falling oestrogen levels shift fat storage in women from the hips to the waist (truncal obesity) which increases their risk of cardiovascular disease. »» Women going through menopause should begin weight control (see Weight Loss) before it becomes a problem. Eating frequent, smaller meals throughout the day may satisfy appetite better than eating three large meals. »» Women should partake in regular, weight-bearing exercise (ie, walking, dancing, tennis, aerobics, golf) on most days of the week. Exercise is also beneficial for reducing the risk of cardiovascular disease and osteoporosis and in aiding sleep. • Avoid foods which exacerbate menopausal symptoms or decrease sleep (eg, caffeine, fatty or spicy foods and alcohol). • Practise pelvic floor strengthening exercises (Kegel exercises) to help with urinary incontinence. • Use vaginal lubricants or moisturisers to help with vaginal dryness. • Some women find yoga, massage, acupuncture or meditation beneficial. • Stop smoking (see Smoking Cessation). • Women going through early menopause may like to consider joining a local support group (see www.earlymenopause.org.nz). Now you can complete your ENHANCE modules on your phone or tablet www.pharmacytoday.co.nz Page 105
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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