Table of Contents

• Overview and Objectives
• Introduction
• Aging of Women
• Menopause as a Transition
• Reframing Menopause
• Clinical Implications of the Menopausal Transition
• The Normal Menstrual Cycle
• The Endocrinology of Menopause
• The Physiology of Estrogen
• Outdated Model of Estrogen Action
• Estrogen Acts Through At Least Two Receptors
• HRT Counseling for Every Woman
• Vasomotor Hot Flushes
• Genitourinary Atrophy
• Psychological Function
• Long-term HRT Benefits
• Nursing Management of HRT
• Cyclic therapy
• Continuous cyclic regimen
• Continuous combined HRT
• Case Studies
• Menopausal and Midlife Nursing Assessment
• Patient Handout

Overview

• providing an overview of menopausal health
• explaining the normal menstrual cycle
• discussing the implications of the estrogen loss that occurs with menopause
• outlining the increase in disease risk for postmenopausal women
• explaining short-term menopausal symptoms (vasomotor and genitourinary)
• describing the therapeutic options and regimens available

Objectives

• define the health issues that commonly affect the perimenopausal woman
• describe the recently discovered complexities of estrogen and estrogen receptors
• describe the physiology of the normal menstrual cycle and how it is changed by menopause
• list the short-term symptoms associated with menopause
• develop a plan for appropriate counseling for the perimenopausal woman
• identify the therapeutic options and treatment regimens available for menopausal women

Introduction

One of the most significant challenges for contemporary nursing is helping women preserve health after menopause. The modern approach to menopause has changed dramatically to reflect both the complexity of the changes that occur during this transition and the potential for improved quality of life in the years beyond. Not only are the standards of normal aging being revised, but there are also new therapeutic options that can help women prevent a number of disabling conditions.

For nurses, managing menopausal health is more than an issue of understanding aging or hormone loss. It requires an ongoing effort to keep up to date with the options and benefits available to menopausal women. Moreover, perimenopause represents an important opportunity for establishing preventive health goals and helping women understand how they can be responsible for their own well-being.

The changing approach to menopause must include knowledge from a number of areas. By interweaving physiology, pharmacology, and lifestyle modifications in a nursing management plan, it is possible to enhance life expectancy and function. This monograph covers current concepts in menopausal health and focuses on new information from basic science research.

Such a discussion is particularly important given the new discoveries about how estrogen acts in the body. This new concept of estrogen action is emerging from basic science research. The recent identification of a second estrogen receptor suggests an expanded role for estrogen in a number of body systems. Not only is hormone loss related to a broad range of menopausal changes, but hormone replacement may have more beneficial effects than previously recognized. Hormone replacement therapy (HRT) in the form of estrogen (ERT) alone or in combination with progesterone (HRT) is a comprehensive therapy that offers both short-term and long-term benefits to the majority of menopausal women.

Monograph 1 is part of a program that is designed to help nurses and their patients weigh the risks and benefits of HRT, explore therapeutic alternatives, and make appropriate choices for a healthy life. Menopause can be a time of positive change provided that women and their nurses understand and individualize their healthcare.

Aging of Women

In addition to simple population growth, life expectancy is slowly and progressively increasing. The result is that the older population is itself aging. By the year 2020, more than 1 in 5 Americans will be even older; the number of women older than 65 years will have grown from 18 million in 1990 to more than 25 million in 2020.(1)

The traditional healthcare approach viewed menopause simply as an event in the aging process. For women living at the beginning of the 20th century this view may have made sense. But the fact that life span has increased dramatically since that time, makes a reexamination of menopause critical. A woman born in 1900 had a life span of only 48.3 years. Today, the average life span for women is around 80 years. And a woman born in 2050 can expect a life span of 83.6 years.(2) The obvious implication is that the percentage of the typical life spent in older age is increasing.

Despite the change in life span, the age of menopause has remained relatively stable. In 1900 the average age of menopause was 47, a time that was near the end of life. Today, the average age of menopause is 51.4. This means that women spend more than one third of their life beyond menopause (Figure 1).(3,4)

The ideal scenario of health after menopause is that of maximum vigor until death. This is in contrast to the traditional concept of aging that views gradually diminishing function, including fading eyesight and hearing, impaired cognitive function and memory, and decreased strength and stamina as the norm. Although some decline is unavoidable, much of what is considered normal aging can be modified with lifestyle and pharmacologic interventions.

Figure 1

More than ever before, the perimenopausal woman can set a course for healthier aging. It is important for nurses to help women begin to think about menopause as a time to evaluate their health and lifestyle practices. With appropriate nurse counseling, patient information, and an understanding of the role of HRT, menopause can become a time of beginning, rather than an end.

Menopause as Transition

Although the medical definition of menopause centers around a single event, it is impossible to identify this event until a woman has experienced 12 months of amenorrhea. Some women experience regular cycles until menopause, others may have irregular periods with heavy or scant bleeding. But regardless of the pattern, menopause itself is not a sudden event. Instead, it is a result of progressive hormonal changes that begin to take place several years before the actual cessation of menses.

It is important to recognize that education, counseling, and therapeutic intervention should not be limited to women who have experienced menopause. Postmenopausal women benefit greatly from such healthcare efforts. But it is critical to introduce these concepts and interventions early in a woman's menopausal transition. There is no reason to allow patients to suffer with immediate menopausal symptoms (ie, hot flushes and urogenital changes) for several months before beginning therapy.

In fact, early discussion of hormones as a therapeutic option in life might easily begin with women who use oral contraception. Women who realize that hormones, both estrogen and progesterone, have benefit for diverse reasons at different times during life may have a more useful frame of reference for considering HRT later in life.

Table 1

Reframing Menopause

One of the most harmful myths that has an impact on menopausal health is that cardiovascular disease is a man's disease. Statistics show overwhelmingly that cardiovascular disease – and not cancer – is the major cause of mortality for postmenopausal women. One in 2 women will eventually die of heart disease or stroke, but only 1 in 25 women will die because of breast cancer (Figure 2).(5,6)

Figure 2

After menopause, women's risk for heart disease begins to approach that of men. HRT may help forestall some of the most common health risks faced by postmenopausal women, including cardiovascular disease, osteoporosis, and Alzheimer's disease. But women who do not perceive their health risks accurately, or who do not receive information about the risks and benefits of HRT, miss an important opportunity.

Table 2

Also, nurses need to be aware that the emerging image of menopausal women is not one of old age.(7) Healthcare providers may stereotype the years after menopause as old age, and perceive the accompanying health problems as an inevitable, untreatable part of aging. In fact, many menopausal women will be running households, preparing children for independence, and managing careers. They may simultaneously have children in school and elderly parents who require increasing amounts of attention. Women at this stage of life are often overwhelmed with tasks that involve managing others.

Table 3

Nurses can help them focus attention on their own health and their options beyond menopause. Such counseling can begin the process of reframing the perception of menopause. It is the beginning of the last third of life and a time to reassess life goals, focus on health, and plan new practices.

Clinical Implications of the Menopausal Transition

The decrease in estrogen associated with menopause is accompanied by many physical changes, both short-term and long-term (Table 2). Many of the early changes relate to vasomotor instability, and are manifested by hot flushes and night sweats. Some 75% of women experience hot flushes at the time of menopause, and they are the most common reason women seek medical attention.(8-10)

Figure 3

These symptoms can result in psychological effects such as sleep disturbances, irritability, and mood disturbances, including depression. However, many women do not report these symptoms to their provider unless specifically asked, underscoring the importance of provider sensitivity to this transition.

Estrogen loss produces direct effects in a number of body systems (Table 3). As estrogen diminishes, collagen (the major constituent of connective tissue) is lost. Skin collagen and skin thickness decrease significantly and proportionately after menopause (Figure 3).(11,12) Also, the urogenital system begins to atrophy as a result of estrogen deficiency. As collagen decreases, the vulvovaginal area becomes thinner, less elastic, and less able to produce secretions. Vaginitis, painful intercourse, urinary frequency, and incontinence can result.

These symptoms and physical changes can have a major impact on the quality of a woman's life. It is the long-term consequences of estrogen loss, however, that represent the most significant concern in terms of disease. After menopause, a woman's risk increases dramatically for several chronic diseases, including cardiovascular disease, osteoporosis, Alzheimer's disease, and cancer. HRT can play a therapeutic role in managing both the short-term symptoms and the long-term disease risks that accompany menopause.

The Normal Menstrual Cycle

Figure 4

The ovary produces 95% of the circulating estrogen in the form of estradiol.(13,14) The second major estrogen is estrone, which is derived from the metabolism of estradiol and the conversion of androstenedione from body fat. A review of the endocrinology of the normal menstrual cycle, as outlined in Rousseau,(15) is warranted.

The normal menstrual cycle is mediated by a complex interplay of hormones modulated by the hypothalamic-pituitary-ovarian axis. Under the influence of gonadotropin-releasing hormone (GnRH) from the hypothalamus, the pituitary gland produces follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which in turn stimulate the production of estrogen and progesterone by the ovary.

These hormones are not secreted at constant rates throughout the monthly cycle. Instead, they interact in a feedback mechanism primarily involving FSH, LH, estrogen, and progesterone. Hormone levels vary drastically during different times of the cycle. Physiologically, the delicate sequential balance of hormone production allows maturation of the ovarian follicle and release of an ovum, as well as preparation of the endometrium for implantation of a fertilized ovum.

The normal menstrual cycle represents an intricate process that involves 3 successive phases: follicular (or proliferative), periovulatory, and luteal (or secretory). Menses coincides with the beginning of the follicular phase (Figure 4). At the onset of menses, estrogen and progesterone levels in the blood are low. This signals the hypothalamic-pituitary connection to release large amounts of FSH and LH. The FSH initiates the process of follicular maturation, and the follicle increases the production of estrogen to stimulate new endometrial growth. At the end of the follicular phase, the endometrium has thickened threefold, and a primordial follicle has matured in preparation for the release of an ovum.

During preovulation, increased estrogen from the mature follicle triggers a sharp increase in LH, causing release of the ovum. After this release, LH continues to stimulate the residual ovarian follicle, transforming it into the corpus luteum.

Figure 6

The secretory or luteal phase involves increased progesterone secretion from the corpus luteum to support and enrich the thickened endothelium. If fertilization of the ovum does not occur, estrogen and progesterone levels drop and menses takes place (Figure 5).

Figure 5

The Endocrinology of Menopause

The ovary contains the maximum number of ovarian follicles during fetal life. By the time menopause approaches, the number of ovarian follicles has decreased substantially, and those present respond poorly to FSH and LH. As a result, cycle irregularity develops because of erratic ovulation.(16,17) As follicular development declines, the cyclical fluctuations in estrogen and progesterone are lost, and circulating levels of these hormones decrease.

In the normal ovarian cycle, circulating serum estradiol levels fluctuate from 40 pg/mL in the early follicular phase to 200-400 pg/mL at midcycle and 100 pg/mL during the luteal phase.(18) Postmenopausal women, however, have very low serum estradiol levels (Figure 6). At the same time, FSH increases dramatically (Figure 7). FSH levels >30 mIU/mL are a strong indication that a woman is menopausal.

The Physiology of Estrogen

Estrogen research has become the most exciting and rewarding of the issues surrounding women's health. Estrogen replacement, either alone (ERT) or in combination with progesterone (HRT), has an impact on many tissues in the body (Figure 8). Many of the symptoms or diseases associated with menopause and aging can be forestalled or improved with HRT/ERT. But until basic science research began to define the mechanism of estrogen action, estrogen was thought to have effects limited to the uterine and breast tissues. Now, however, there is growing scientific evidence that estrogen exerts beneficial actions in a number of tissues and systems including: bone and teeth, brain, eyes, vasomotor, heart, colon, and urogenital.(19-24)

Figure 7

In the early 1970s, estrogen was believed to be primarily a reproductive hormone with effects limited to the uterus and mammary glands. As the clinical utility of estrogen has become more commonplace, however, it is increasingly clear that it is a key hormone in the maintenance of skeletal integrity.

Figure 8

Other emerging benefits of estrogen include improved cardiovascular tone, cognition, cancer prevention, and protection against tooth loss and macular degeneration.

Historically, the concept that estrogen could have effects in so many organs was never taken seriously. Estrogen was thought to act primarily through a lock-and-key mechanism that involved a single estrogen receptor. But the following discoveries about estrogen action are changing this idea:

• There are at least 2 estrogen receptors (ERa and ERb).
• Different estrogens appear to exhibit different activities in different cells.
• The potency and efficacy of a specific estrogen can vary from cell to cell and tissue to tissue.
• Estrogen receptors are more highly concentrated in some areas of the body.

Outdated Model of Estrogen Action

This now outdated model of estrogen action produced a number of ideas that are incorrect. For example, there are a number of estrogen compounds, and each compound's biological activity was thought to be directly proportional to its binding affinity. This would mean that all estrogens are functionally the same. In fact, further research has proved these tenets to be wrong.(26,27)

It has been discovered that the old model of estrogen action does not take into account the variation in action that can result from newly discovered postreceptor binding events.

For example, a closer look at conjugated equine estrogen (CEE) in Table 4 shows that binding affinity is not the primary predictor of biological activity.(6) CEE, which is a common agent used for HRT, is a complex blend of several active estrogenic compounds. Ten of its commonly characterized components are listed in Table 4, and comparing their affinity and biological activity produced some surprising results. Æ8, 9-dehydroestrone, which has only 1% the binding affinity of estradiol, exhibited very high biological activity in this assay.

Table 4

What also complicates the picture of how estrogen works is that researchers have learned that estrogens can function as either antagonists (blockers) or agonists (stimulators) at the estrogen receptor. Furthermore, they do not act uniformly in all tissues.

There is some clinical evidence of this variable activity as well. Tamoxifen, which is an antiestrogen or pure antagonist in breast tissue and is used to treat breast cancer, acts as an estrogen agonist in the bone.(28,29) Thus, tamoxifen has been termed the first selective estrogen receptor modulator (SERM). It shows tissue selectivity. Another SERM, raloxifene, functions similarly to tamoxifen in the bone, breast, and cardiovascular system, but exhibits minimal agonist activity in the uterus.(30,31) The implication is that the classification of estrogen agonists or antagonists is complex and tissue-dependent.

Estrogen Acts Through at Least Two Receptors

Many mysteries that have surrounded estrogen action may be unraveled now that a second estrogen receptor has been identified. Ongoing research is attempting to determine which tissues are most responsive to which receptors, and there may be other receptors discovered in the process. As research uncovers specific information about receptor distribution in other tissues, the role of estrogen, or antiestrogens, can be better defined.

Another reason that estrogens can exhibit diverse activities in different cells pertains to the interaction between an estrogen or an estrogen-like compound and the receptor itself. When a compound binds with an estrogen receptor, it forms a new unique shape (Figure 9) that influences its interaction with the DNA in the cell. Given the existence of a number of estrogen-like compounds and at least 2 known receptors along with variable receptor distribution, the possible combinations are numerous.

Figure 9

Different compounds produce different biological activities (Figure 10). For example, a pure agonist like estrogen binds to a receptor creating one type of active configuration. The fact that SERMs bind with receptors to create a shape slightly different from that of estrogen means they will have different biological consequences in different tissues.(25,34,35) Thus, the potential for clinical efficacy varies among compounds.

In summary, the field of estrogen receptor activity is in its infancy, and discoveries are continuously changing old concepts. Research has found that estrogens can exhibit different activities in different tissues. Such new findings about the science of estrogen action support the concept that different estrogens acting through the same receptor can induce different biological activity. And, the implications for clinical efficacy are greatly expanded.

Figure 10

HRT Counseling for Every Woman

Every woman who approaches menopause ought to be counseled about HRT (Figure 11) and the benefits it offers. Despite the fact that women seek healthcare more frequently than men, perimenopausal healthcare remains fragmented. In part, this is because menopause is a normal transition, and symptom control and disease prevention can be approached in a number of ways. But it is also because the majority of women do not seek help for this transition. Moreover, only a fraction of those women who would benefit from HRT take advantage of such therapy.

Efforts to increase awareness about postmenopausal disease prevention are influenced by cultural differences. There is very little literature on whether ethnicity alters the physical and biological experience of menopause. One survey found that reporting of hot flushes and night sweats was significantly lower among Japanese women.(36) It also is well established that Japan has a lower incidence of heart disease, osteoporosis, and breast cancer. Other studies suggest that not only are attitudes towards menopause influenced by ethnicity, but they are also altered by social factors. This was apparent in 2 studies, one among recent Korean immigrants and another involving Filipina Americans.(37,38) The studies suggest that role conflicts (such as transition from housewife to working status), recent immigration, and social status can influence whether women see this time as a natural healthy transition.

Such differences are also hard to quantify among the largest minority group in the United States. One study found significant racial differences in estrogen use among menopausal black women (Table 5),(39) while another did not.(40) Given the fact that African American women are at higher risk for developing coronary artery disease than white women, nurses must begin to address the counseling gap. What is apparent is that cultural differences abound,(41,42) and that they deter women from seeing menopause as a time to plan preventive health measures. The time of the perimenopause offers a unique opportunity for nurses who are aware of cultural influences to provide, direct, and encourage a program of preventive healthcare.

Table 5

Whether or not HRT is chosen as an option by every menopausal woman, it offers benefits that every woman should know about. Such a counseling discussion sets the stage for a review of each woman's health profile. Even though women with menopausal symptoms or increased risk of chronic disease may have the most obvious need for counseling, women without apparent symptoms or health risks can also benefit (Figure 11). However, counseling women about HRT cannot occur in a vacuum. It must be combined with discussions about the importance of the complementary lifestyles changes listed in (Figure 11.)

Figure 11

An emphasis on lifestyle changes is a critical part of a health assessment for menopausal woman. The ill effects of long-standing, unhealthy habits may begin to surface around the time of menopause, and such effects will surely progress with age. Although smoking cessation may be the single most important factor that can enhance life expectancy, moderation in other areas (diet and alcohol) and regular participation in exercise can significantly alter quality of life.

At the time of menopause, a woman's risk for developing several conditions can serve as a focal point for a review of her health. Routine HRT counseling should go beyond simple symptom control and include both short-term and long-term benefits (Figure 12), known contraindications, and common patient concerns and misconceptions. Figures on compliance suggest that such counseling is needed. A recent study found high noncompliance (54%) among women 1 year after HRT was initiated.(43)

Figure 12

This monograph addresses the short-term benefits of HRT in detail. However, in-depth discussions of the long-term benefits, as well as cutting-edge research data, will be included in monographs 2 and 3.

Short-term HRT Benefits

Vasomotor Hot Flushes

The hot flush is a sudden, transient sensation that ranges from warmth to intense heat, spreading over the face, scalp, and anterior thorax. It usually is accompanied by erythema and perspiration and is often followed by a chill. In some women, palpitations and anxiety accompany the flush. Each episode usually lasts from 30 seconds to several minutes, and the frequency and severity of flushes are quite variable.

Data have suggested that hot flushes occur in up to 75% of women.(44) Women who have undergone surgical menopause are more likely to have hot flushes than those with a natural menopause. Prevalence is highest in the first 2 postmenopausal years, and the episodes usually lessen with time. However, hot flushes may precede menopause by several years and may continue for 10, 20, or even more than 40 years after menopause.(10)

Severe hot flushes, which occur in roughly 15% of women, can disrupt a woman's life. Such episodes usually occur spontaneously, but are often increased in frequency or severity with hot, humid weather; confining spaces; or the ingestion of caffeine, alcohol, or spicy foods. Often, the flushes are increased by stress and tension, but they may be less frequent or less severe in obese women.

The precise etiology of the hot flush remains controversial, but it is associated with a drop in estrogen concentration.(10) The effects of estrogen go beyond the reproductive tissues to include thermoregulatory, neural, and vascular function. The firing rate of thermosensitive neurons in the preoptic area of the hypothalamus in response to thermal stimulation can be modified by estrogen.(10,45) Estrogen also influences internal body temperature.(10,46) The responsiveness of vascular smooth muscle to vasoreactive substances such as epinephrine and norepinephrine has been shown to be greater in women who have hot flushes than in those who do not.47 Thus, estrogen probably has peripheral as well as central effects important in the physiology of the hot flush.

A primary problem caused by hot flushes is the disruption of sleep. Often, a woman is not only awakened from sleep, but also finds herself soaked with perspiration.(48) Although many women adapt by modifying diet and behavior, reducing room temperatures, and wearing light, layered clothing, 25% of women experience so much discomfort that they seek medical relief. Although available treatment does not "cure" them, it does provide symptomatic relief. The positive effects of estrogen therapy in this area have been documented for quite some time.(10) (Table 6) lists several nonpharmacologic actions that may help women establish more restful sleep patterns.(49)

Table 6

Genitourinary Atrophy

Genitourinary atrophy is another consequence of estrogen loss. The tissues of the vagina, vulva, urethra, and trigone of the bladder all have large numbers of estrogen receptors, and all 3 undergo atrophy during menopause. Estrogen loss accounts for most of the postmenopausal anatomic, cytologic, bacteriologic, and physiologic urogenital changes (Table 7). Such changes may even occur during the perimenopause, well before menses ceases. Although this is the least discussed consequence of estrogen loss, virtually every woman will experience such atrophy. The resulting potential for urinary and sexual dysfunction creates significant changes in a woman's quality of life.

Table 7

The atrophic vulva loses much of its collagen, adipose tissue, and water-retaining ability. Vaginal shortening and narrowing occur as the vaginal walls become thin, lose elasticity, and grow pale in color. The vagina produces fewer secretions and loses much of its ability to lubricate in response to sexual stimulation. The urethra is easily irritated, often resulting in dysuria, urgency, and frequency. All of these changes enhance the likelihood of trauma, infection, and pain. All tend to decrease comfort during and interest in coitus. Estrogen replacement is the only treatment that significantly improves all of these problems. In addition, important data have documented that the frequency of urinary tract infections in postmenopausal women may be decreased by estrogen use, and as many as 50% of women with genuine urinary stress incontinence show improvement with estrogen.(50)

Sexuality in menopausal women is a topic that is all too infrequently discussed in the healthcare office. It is surrounded by myths, taboos, and personal beliefs. It is a fallacy that women lose interest in sexual activity after menopause. A whole host of factors can contribute to sexual dysfunction (Table 8), some physical and some psychological. But what is apparent is that women are concerned about their ability and desire to engage in sexual activity. Half of menopausal women list sexual dysfunction as 1 of their top 3 complaints.(51) Other studies have shown that among older women the most common reason for not being sexually active is the lack of an available partner.(51,52) In addition, a woman's premenopausal sexual activity is predictive of her postmenopausal sexuality.(53)

Table 8

In fact, in a survey of 1001 women conducted by Yankelovich Partners, Inc., 4 out of 5 women said their sex lives had either improved or remained the same since menopause.(54) The women in the survey were aged 50 to 65, and about 900 respondents had already passed through menopause. About half the women were taking HRT. When asked to compare their sex lives before and after menopause, 82% of women taking HRT said their sex lives had remained the same or improved, compared to 69% of those not taking HRT.

Nurses can play an important role in helping menopausal women voice their concerns about sexuality. Sensitive interviewing that establishes sexuality as a normal healthy part of life can elicit more information.(55) It can lead to an opportunity to discuss measures that can improve sexual dysfunction. For example, estrogen, in the form of either an oral supplement or a vaginal cream, can attenuate much of the physical discomfort that women experience. Any method of delivery is effective, but direct, vaginal application is the most rapid in onset of action.

Psychological Function

Long-Term HRT Benefits

Because short-term and long-term therapy have different rationales, counseling for each may occur separately, although ideally they should be discussed together. In any event, it is important to begin a discussion of long-term benefits by the time a woman is taking HRT for symptom relief. That is also an appropriate time to start assessing a woman's risk for CVD and osteoporosis. Monographs 2 and 3 will cover these topics in depth.

Nursing Management of HRT

There are numerous estrogen and progesterone formulations available for HRT (Table 9). Despite the lack of studies and consensus on HRT regimens, there are several basics to keep in mind. For example, estrogen can be administered cyclically, for up to 25 days each month with a pill-free interval at the end of the month, or continuously, for 365 days a year.

Table 9

If a woman has a uterus, progesterone must be added for protection against estrogen-induced endometrial cancer. Progesterone can be added to estrogen therapy either cyclically for a certain number of days each month, or continuously, for 365 days a year. Figure 13 shows the most common regimens in use today including cyclic, continuous cyclic, and continuous combined.

Figure 13

Cyclic Therapy

Each regimen has advantages and disadvantages (Table 10). Cyclic therapy is the most widely used regimen in the United States. It closely mimics the normal premenopausal ovulatory cycle both in timing of hormone secretion and resulting bleeding patterns. As in a normal menstrual cycle, the addition of progesterone initiates a secretory phase. The subsequent withdrawal of progestin causes sloughing of the endometrium, and thus menses. Bleeding usually begins 1 to 2 days after the last progestin dose and continues for 2 to 3 days during the pill-free interval. Regardless of whether bleeding has stopped, a woman should take her next estrogen tablet on the first day of the following cycle.

Table 10

Major drawbacks of the cyclic regimen include the possible recurrence of vasomotor symptoms during the estrogen-free interval and the return of regular monthly bleeding. Both of these drawbacks can affect patient compliance. Many women object to the return of monthly periods and discontinue HRT. With this regimen, however, bleeding is predictable and can be planned for specific times.

Continuous Cyclic Regimen

Continuous Combined HRT

In an effort to eliminate withdrawal bleeding and aid compliance, the continuous combined regimen was introduced and has gained in popularity. In theory, a small dose of progestin daily counteracts the endometrial proliferation caused by estrogen. Within several months, the endometrium can become atrophic and amenorrhea results. But with this regimen, it is important for women to understand that they may experience some breakthrough bleeding, especially during the first 4 to 6 months. Studies on the use of continuous combined HRT show that the incidence of unscheduled bleeding decreases with the length of treatment (Figure 14).(58) Women who are informed and prepared for this event are more likely to adhere to therapy. In addition, because smaller doses of progestin are used, there may be fewer progestin-related side effects.

Figure 14

When irregular bleeding persists with the continuous combined regimen, an endometrial biopsy may be warranted to rule out endometrial cancer. According to the American College of Physicians (ACP), women on continuous combined HRT should undergo an endometrial biopsy if bleeding is heavy (heavier than normal menstrual period), prolonged (longer than 10 days at a time), or frequent (more often than monthly), or if bleeding persists longer than 10 months after initiating therapy.(59) For women using a cyclic HRT regimen, the ACP guidelines indicate that an endometrial biopsy should be performed only if bleeding occurs at other than the expected time of withdrawal bleeding or if bleeding persists for more than 10 days.

Once a patient has been identified as an appropriate, and interested, candidate for HRT, there are several components of nursing management. Assessment involves gathering the information listed in Figure 15. The nursing checklist on page 27 (Menopausal and Midlife Nursing Assessment) goes beyond a simple history and physical examination to include patient attitudes and concerns. Understanding a patient's expectations of HRT, her lifestyle habits, and any other medications or herbal remedies that she is using will help the nurse tailor patient counseling. This is also an important time to discuss some of the inconveniences that can occur with HRT. Estrogen may initially cause some breast tenderness. It is important for women to know that such discomfort is unrelated to breast cancer and that this tenderness is similar to the premenopausal state. Also, progestin may cause some fluid retention and mood swings, similar to premenstrual tension. Some women tolerate continuous progestin at a low dose better than cyclic dosing.

A checklist of patient concerns might include the following:

• Skin changes/appearance – estrogen can relieve dryness
• Sexuality – difficult or painful sex can be improved
• Breast changes – breast pain is seldom a signal of cancer
• Fertility – the monthly bleeding produced by HRT does not mean the return of fertility
• Cost of medication
• Variation of regimen/dosages – not all estrogens are the same
• Sleep issues – controlling hot flushes will provide better sleep
• Mood alteration – sleep disturbance may be the cause of this
• Weight gain – estrogen is not associated with weight gain

right dosage and regimen for them may take some time, can greatly enhance compliance. In addition, starting with a very low dose of estrogen or gradually increasing doses as tolerated may enhance acceptance. Many women who are given a prescription for HRT never get it filled, and the rate for those who will drop out within the first year of therapy is very high. It is important for women to realize that for the maximum benefits of HRT, therapy may last as long as 20 to 30 years. New single-pill products may aid in compliance by eliminating the need to take 2 pills. In addition, such formulations erase the confusion surrounding which cycle day it is and when to start the progestin.

The final component of nursing management is follow-up. If the patient develops troublesome side effects with HRT, they are likely to occur within the first 3 months of therapy. Thus, a repeat visit at 1 month is critical to assess patient reaction and to reinforce the importance of compliance. Follow-up visits after 2 or 3 months of HRT are needed for women who have difficulty adjusting to their regimen. As always, women should be encouraged to call with questions and problems. Finding the right HRT regimen for each patient takes time and patience. Follow-up, however, should not be limited to the woman who opts for HRT. Rather, this should become a consistent thread in future patient visits. Women who refuse HRT at 50 may change their minds later, and it is never too late to start HRT and gain some of its health benefits. Because there are many facets to HRT, nursing counseling plays a critical part in helping women preserve health beyond menopause.

CASE STUDY 1

Perimenopausal Woman

• Are these symptoms normal for my age?
  
• Is this the beginning of menopause?
  
• Will HRT help me?
  
• Am I going crazy or do I have a disease?
  
• Can I get pregnant now?

Nursing Management

CASE STUDY 2

POSTMENOPAUSAL WOMAN

Assessment

Nursing Management

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19. Colditz GA, Hankinson SE, Hunter DJ, et al. The use of estrogens and progestins and the risk of breast cancer in postmenopausal women. Engl J Med. 1995;332:1589-1593.
20. Birge SJ, Mortel KF. Estrogen and the treatment of Alzheimer's Disease. Am J Med. 1997;103(3A):36S-45S.
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22. Grodstein F, Colditz GA, Stampfer MJ. Post-menopausal hormone use and tooth loss: a prospective study. J Am Dent Assoc. 1996;127:370-377.
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24. Notelovitz M. Urogenital aging: solutions in clinical practice. Int J Gynaecol Obstet. 1997;59(suppl 1):S35-S39.
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Menopausal and Midlife Nursing Assessment

YES NO PATIENT HAS QUESTIONS Change in appetite Weight gain Change in hair pattern Hot flushes Mood swings Periods of sadness Difficulty concentrating Memory loss Problems sleeping Pelvic pain Back pain Nocturnal incontinence Increased frequency of urination Burning with urination Vaginal dryness Painful intercourse

Patient Handout

What is menopause?

• The menopause represents a change in life. It is marked by the end of menstrual periods, and the end of your reproductive years. At menopause, the ovaries stop producing eggs and stop making the hormone estrogen.
  • If you have had no menstrual cycles for 12 months, you have gone through the menopause. At this point, you can no longer become pregnant.
  • Most women experience menopause between the ages of 45 and 55.

Menopause is a transition

• Generally, the ovaries do not stop producing estrogen suddenly. Instead, estrogen production becomes erratic, and over months, or years, your body's estrogen levels begin to decrease.
• The loss of estrogen causes the first signs of approaching menopause.

What are the signs of menopause?

• Irregular periods
  • If you are approaching menopause, your periods will eventually stop. However, even if you are the right age for the menopause, you need to see your healthcare provider if you have:
    • Periods that are closer together than every 21 days
    • Periods that last longer than 7 days
    • Periods that are very heavy
    • Bleeding between periods
• The hot flush
  • This is a sensation of warmth or intense heat that spreads over the face, scalp, and chest. You may sweat profusely.
  • Hot flushes usually last several minutes. They may happen occasionally or many times a day.
  • Roughly 75% of women will have hot flushes.
  • Because they are common during the night, they may prevent you from having a good night's sleep.
• Vaginal dryness
  • As your estrogen level drops, the lining of the vagina becomes thin, and is less able to make secretions.
    This dryness can cause pain during sex. It might also cause vaginal infections.
  • The urethra (the tube that carries urine from the bladder out of the body) also becomes thin as the menopause approaches. This may produce a burning sensation during urination.

Can these symptoms be treated?

• Hormone replacement therapy (either estrogen and progestin or estrogen alone) can help reduce these menopausal symptoms.
• If you have a uterus, it is important to take both estrogen and progestin. Estrogen alone can increase your risk of developing uterine cancer; adding progestin protects you against this.
• If you have had a hysterectomy, you can take estrogen alone.
• In addition to hormone replacement therapy you might try the following:
• For hot flushes: wear light, layered clothing; drink ice water during a flush
• Vaginal dryness: use a vaginal lubricant such as KY Jelly or estrogen cream

Are there other reasons to take estrogen?

• At the time of menopause your health risks change dramatically. Estrogen provides protection against some diseases and can help preserve your health beyond menopause.
• After menopause, you have a higher risk for developing osteoporosis, heart disease, Alzheimer's disease, and colon cancer.
• Research shows that estrogen reduces your risk for these conditions.
• You can take hormone replacement therapy for many years after menopause. It is not just a temporary measure to relieve your symptoms.

Are there side effects?

• Although the majority of women can safely take estrogen, there are some women who cannot. Please talk with your healthcare provider to find out what makes sense for you. What about breast cancer?
• Some studies suggest that estrogen increases your risk of developing breast cancer. Other studies show no such risk. This question has not been answered definitively. But if there is any risk of HRT adversely affecting your risk of breast cancer, it is minimal. Explore this topic with your healthcare provider.
• After menopause, heart disease kills far more women than breast cancer. Menopause is a time to take stock of your current lifestyle and chart a healthy course for the future. Please talk with us about your concerns and questions.