menopausa
Periodo di follia nella donna, che in
certi casi conduce al manicomio il
marito.
• Definizione : cessazione permanente del ciclo
mestruale derivante dall’esaurimento dei
follicoli ovarici
• Diagnosi : retrospettiva. Dopo 12 mesi
consecutivi di amenorrea per la quale non vi
sia una altra causa determinante
• Insorgenza : età media 51 anni.
• Il fumo anticipa la menopausa di 2 anni.
• Menopausa indotta : da cause non fisiologiche
come la asportazione di entrambe le ovaie o
la soppressione della attività ovarica con
radioterapia o chemioterapia.
• Menopausa precoce : ultima mestruazione
prima dei 40 anni
• Perimenopausa : periodo in cui sono presenti
irregolarità del ciclo mestruale. Inizia in media 4 anni
prima dell’ultimo flusso mestruale e si protrae per 1
anno dopo l’ultimo flusso mestruale.
• Perimenopausa e postmenopausa hanno in comune
molti sintomi ma la loro fisiologia e trattamento sono
molto diversi.
• I contraccettivi a basso dosaggio sono determinanti nel
trattamento della perimenopausa, mentre la terapia
ormonale sostitutiva è un metodo per alleviare i
sintomi postmenopausali.
Dosaggio FSH
• What about testing for follicle-stimulating hormone (FSH)?
• As the ovaries’ production of estrogen declines around menopause,
the pituitary gland releases more FSH into the blood to try to
stimulate estrogen production. So, when a woman’s FSH blood
level is consistently elevated, and she is no longer having menstrual
periods, it is generally accepted that she has reached menopause.
• However, a single FSH level can be misleading in perimenopause
because estrogen production doesn’t fall at a steady rate from day
to day. Instead, both estrogen and FSH levels fluctuate from fairly
high to fairly low during perimenopause.
• Also, if a woman is using certain hormone therapies (such as birth
control pills), an FSH test is not valid.
Sintomatologia
• Women in the menopausal transition commonly report a
variety of symptoms,including vasomotor symptoms (hot
flushes and night sweats), vaginal symptoms,urinary
incontinence, trouble sleeping, sexual dysfunction,
depression, anxiety,labile mood, memory loss, fatigue,
headache, joint pains, and weight gain.
• However,in longitudinal studies, after adjusting for age and
other confounders, only vasomotor symptoms, vaginal
symptoms, and trouble sleeping are consistently associated
with the menopausal transition.
• Symptoms such as memory loss and fatigue may be due to
frequent hot flushes or trouble sleeping.
I “calori”
• The most common menopause-related discomfort is the hot flash
(sometimes called a hot flush). Although their exact cause is still a
matter of speculation, hot flashes are thought to be the result of
changes in the hypothalamus, the part of the brain that regulates
the body’s temperature. If the hypothalamus mistakenly senses
that a woman is too warm, it starts a chain of events to cool her
down. Blood vessels near the surface of the skin begin to dilate
(enlarge), increasing blood flow to the surface in an attempt to
dissipate body heat. This produces a red, flushed look to the face
and neck in light-skinned women. It may also make a woman
perspire to cool the body down. An increased pulse rate and a
sensation of rapid heart beating may also occur. Hot flashes are
often followed by a cold chill. A few women experience only the
chill
• The prevalence of hot flushes is maximal in the
late menopausal transition, occurring in about
65% of women.
• In most women, hot flushes are transient. The
condition improves within a few months in about
30 to 50% of women and resolves in 85 to 90% of
women within 4 to 5 years.
• However, for unclear reasons, about 10 to 15% of
women continue to have hot flushes many years
after menopause.
• Vaginal symptoms (including dryness, discomfort,
itching, and dyspareunia) are reported by about
30% of women during the early postmenopausal
period and up to 47% of women during the later
postmenopausal period.
• Urologic symptoms (including urgency,
frequency, dysuria, and incontinence) are not
clearly correlated with the menopausal
transition.
• Unlike hot flushes, vaginal symptoms generally
persist or worsen with aging.
One of the most complex health care decisions facing women is whether to use
postmenopausal HT.
Once prescribed primarily to relieve vasomotor symptoms, HT has been
promoted as a strategy to forestall various disorders that accelerate after
menopause, including osteoporosis and cardiovascular disease.
In 2000, nearly 40% of postmenopausal women age 50–74 in the United States
had used HT. This widespread use occurred despite the paucity of conclusive
data, until recently, on the health consequences of such therapy.
Although observational studies suggest that HT prevents cardiovascular and other
chronic diseases, the apparent benefits may result at least in part from differences
between women who opt to take postmenopausal hormones and women who do
not. Those choosing HT tend to be healthier, have greater access to medical care, are
more compliant with prescribed treatments, and maintain a more health-promoting
lifestyle.
Randomized trials, which eliminate these confounding factors, have not consistently
confirmed the benefits found in observational studies.
Indeed, the largest HT trial to date, the Women's Health Initiative (WHI), which
examined more than 27,000 postmenopausal women age 50–79 (mean age, 63) for
an average of 5–7 years, was stopped early because of an overall unfavorable riskbenefit ratio in the estrogen-progestin arm and an excess risk of stroke in the
estrogen-only arm.
benefici e rischi
Tabella riassuntiva
BENEFICI CERTI
SINTOMI
Compelling evidence, including data from randomized clinical trials, indicates that
estrogen therapy is highly effective for controlling vasomotor and genitourinary
symptoms.
Alternative approaches, the consumption of soy-based products or other
phytoestrogens, may also alleviate vasomotor symptoms, although they are less
effective than HT.
For genitourinary symptoms, the efficacy of vaginal estrogen is similar to that of
oral or transdermal estrogen.
OSTEOPOROSI
By reducing bone turnover and resorption rates, estrogen slows the aging-related
bone loss. Postmenopausal estrogen therapy, with or without a progestogen,
rapidly increases bone mineral density at the spine by 4–6% and at the hip by 2–
3%, and maintains those increases during treatment.
Data from observational studies indicate a 50–80% lower risk of vertebral fracture
and a 25–30% lower risk of hip, wrist, and other peripheral fractures among current
estrogen users.
RISCHI CERTI
CARCINOMA ENDOMETRIALE
A combined analysis of 30 observational studies found a tripling of endometrial
cancer risk among short-term (1–5 years) users of unopposed estrogen and a nearly
tenfold increased risk among users for 10 or more years.
Use of a progestogen, which opposes the effects of estrogen on the endometrium,
eliminates these risks.
TROMBOEMBOLIA VENOSA
A meta-analysis of 12 studies found that current estrogen use was associated with a
doubling of venous thromboembolism risk in postmenopausal women.
Results from the WHI indicate a twofold increase in risk of venous and pulmonary
thromboembolism associated with estrogen-progestin and a one-third increase in
this risk with estrogen-only therapy.
Transdermal estrogen, taken alone or with certain progestogens (micronized
progesterone), appears to be a safer alternative with respect to thrombotic risk.
CARCINOMA MAMMARIO
An increased risk of breast cancer has been found among current or recent
estrogen users in observational studies; this risk is directly related to duration of
use.
In a meta-analysis of 51 case-control and cohort studies, short-term use (<5
years) of postmenopausal HT did not appreciably elevate breast cancer incidence,
whereas long-term use ( > 5 years) was associated with a 35% increase in risk.
In contrast to findings for endometrial cancer, combined estrogen-progestin
regimens appear to increase breast cancer risk more than estrogen alone
RISCHI O BENEFICI ANCORA INCERTI
Until recently, HT had been enthusiastically recommended as a possible cardioprotective agent.
In the past 3 decades, multiple observational studies suggested that estrogen use leads to a 35–
50% reduction in CHD incidence among postmenopausal women.
Randomized trials of estrogen or combined estrogen-progestin in women with preexisting
cardiovascular disease (CVD) have not confirmed the benefits reported in observational studies.
Thus, in clinical trials, HT has not proved effective for the secondary prevention of CVD in
postmenopausal women.
Primary prevention trials also suggest an early increase in cardiovascular risk and absence of
cardioprotection with postmenopausal HT.
However, a closer look at available data suggests that timing of initiation of HT may critically
influence the association between such therapy and CHD. Estrogen may slow early stages of
atherosclerosis but have adverse effects on advanced atherosclerotic lesions.
APPROCCIO ALLA PAZIENTE
The rational use of postmenopausal HT requires balancing the potential benefits and
risks.
The clinician should first determine whether the patient has
moderate to severe menopausal symptoms
the only indication for initiating systemic HT (urogenital symptoms in the absence of
vasomotor symptoms may be treated with vaginal estrogen).
The patient's own preference regarding therapy should be elicited and factored into
the decision.
Contraindications to HT should be assessed routinely and include unexplained vaginal
bleeding, active liver disease, venous thromboembolism, history of endometrial
cancer or breast cancer, and history of CHD, stroke, transient ischemic attack, or
diabetes.
Relative contraindications include hypertriglyceridemia (>400 mg/dl) and active
gallbladder disease; in such cases, transdermal estrogen may be an option.
terapia dei sintomi vasomotori
• Per via sistemica : orale o transdermica
• Ciclica e non continua (a meno che nei giorni di
sospensione non ricompaiano forti sintomi)
• Associata a progesterone naturale nelle donne in cui
l’utero è presente
• Terapia con ormoni bioidentici (cioè con ormoni identici a
quelli ovarici : progesterone, estradiolo)
• La terapia dovrebbe essere eseguita a breve termine, cioè
per meno di 5 anni, inoltre ogni tanto andrebbe sospesa
per valutare se i sintomi menopausali sono ancora presenti.
• E’ molto importante fornire anche raccomandazioni sullo
stile di vita (attività fisica, fumo di tabacco e dieta sana) e
sul mantenimento di adeguati livelli di vitamina D
Farmaci disponibili
• Progesterone : Prometrium , Progeffik
• Estradiolo :
– Gel transdermico :
• Sandrena (0,5 – 1 mg)
• Estrodose (0,75 mg)
• Gelestra, Ginaikos (1,5 mg)
– Cerotto 7 giorni :
• Armonil septem, Dermestril septem (2,5 – 5 mg)
• Femseven (5 mg)
• Zerella (5 – 10 mg)
– Compresse :
• Progynova (2 mg)
Schema di cura
• Semplificando al massimo :
– Estradiolo dal giorno 1 al 24 di ogni mese di
calendario
– Progesterone dal giorno 13 al 24 di ogni mese di
calendario (associato all’estradiolo)
REGOLA AUREA :
al dosaggio minore efficace
per il tempo minimo necessario
terapia dei sintomi genitourinari
Associare o meno il progestinico alla terapia locale vaginale
NO ? (quasi sempre)
SI ?? (qualche volta)
trattamenti alternativi
• Tibolone
• Fitoestrogeni
• Slow breathing
NAMS
(the north american menopause society)
2012 position statement
2012 patient handout