Management of the perimenopause

MANAGEMENT OF THE PERIMENOPAUSE This page intentionally left blank MANAGEMENT OF THE PERIMENOPAUSE PRACTICAL PATHWAYS IN OBSTETRICS AND GYNECOLOGY James H Liu, MD Arthur H Bill Professor Chair, Department of Reproductive Biology Case School of Medicine Chair, Department of Obstetrics and Gynecology University MacDonald Women’s Hospital Cleveland, Ohio Margery L S Gass, MD Professor, Clinical Obstetrics and Gynecology Department of Obstetrics and Gynecology University of Cincinnati College of Medicine Cincinnati, Ohio McGRAW-HILL Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid New Delhi San Juan Seoul Singapore Sydney Toronto Mexico City Milan Copyright © 2006 by The McGraw-Hill Companies, Inc All rights reserved Manufactured in the United States of America Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher 0-07-149193-7 The material in this eBook also appears in the print version of this title: 0-07-142281-1 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs For more information, please contact George Hoare, Special Sales, at george_hoare@mcgraw-hill.com or (212) 904-4069 TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc (“McGraw-Hill”) and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise DOI: 10.1036/0071422811 Professional Want to learn more? 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If you’d like more information about this book, its author, or related books and websites, please click here For more information about this title, click here Contents Contributors Foreword Preface Acknowledgments ix xiii xv xvii SECTION PHYSIOLOGY OF THE PERIMENOPAUSE Chapter Perimenopause Perspective Margery L S Gass Chapter Endocrine Changes and Stages of the Menopausal Transition 17 Robert W Rebar SECTION AGING AND NEUROCOGNITIVE CHANGES Chapter Management of Hot Flashes 39 Robert R Freedman Chapter Cognitive Changes in Perimenopause 57 Robert Krikorian Chapter Sleep Disorders in Perimenopausal and Menopausal Women, Diagnosis and Clinical Management 77 E.O Bixler A.N Vgontzas Chapter Perimenopause and Sexuality 91 Sheryl A Kingsberg Chapter Migraine Headaches 119 Ken N Muse Chapter Impact of Perimenopause on Physical Appearance and Reproductive Tissues James H Liu 131 v vi Contents SECTION PATHOPHYSIOLOGY Chapter Abnormal Uterine Bleeding: Evaluation, Diagnosis, and Treatment 147 James H Liu Chapter 10 Clinical Management of Uterine Myomas 159 Karen L Ashby Chapter 11 Evaluation and Management of Pelvic Pain 177 Thomas Janicki Chapter 12 Management of Cystic Ovarian Tumors in the Perimenopausal Woman 197 Fred R Ueland Paul D DePriest John R van Nagell, Jr Chapter 13 Breast Pain, Mass, or Discharge 219 Elizabeth A Shaughnessy Chapter 14 Hypercholesterolemia and Lipoprotein Disorders 241 Cynthia A Stuenkel Chapter 15 Depression, Moodiness, and Premenstrual Syndrome 277 Lesley M Arnold Chapter 16 Thyroid Dysfunction 307 Sona Kashyap Shahla Nader Chapter 17 Vulvodynia 323 Michael S Baggish SECTION HORMONE THERAPIES Chapter 18 Sexual Dysfunction and Androgen Replacement Therapy 355 Elizabeth A Wise Carol J Mack James A Simon Chapter 19 Postmenopausal Hormone Therapy: Observational Studies to Clinical Trials 377 Shari S Bassuk JoAnn E Manson Chapter 20 Hormone Therapy: When and How? Margery L S Gass 411 Contents vii SECTION PREVENTIVE HEALTH STRATEGIES Chapter 21 Contraception 431 Paul A Robb Daniel B Williams Chapter 22 Cancer Screening and Prevention 441 Elizabeth V Brandewie Chapter 23 Bone Health in the Perimenopause 467 Rebecca D Jackson W Jerry Mysiw Shubhangi Shidham Chapter 24 Alternative Medicine Use 489 Maida Taylor Index 515 This page intentionally left blank Index Cache County Study, 395 Calcitonin, 481 Calcium, recommended intake, 479 Calcium channel blockers, for migraine headaches, 128t Cancer Prevention Study II (CPS II) cardiovascular disease and hormone therapy, 387 colorectal cancer and hormone therapy, 393 Cancer screening American Cancer Society guidelines, 442f in at-risk patients, 454f breast See Breast cancer, screening cervical See Cervical cancer, screening colorectal See Colorectal cancer, screening endometrial See Endometrial cancer, screening ovarian See Ovarian cancer, screening principles, 441, 443 Cardiovascular disease See also Stroke case discussion, 266–267 female deaths from, 9f hormone therapy and, 379t, 381–389, 382–383t, 415f, 416t, 417t, 418f incidence, 241 prevention guidelines, 241–242, 244t risk factors assessment, 243–245, 244t, 245t, 246t, 247–248t guiding questions, 266 lipid disorders See Dyslipidemia metabolic syndrome See Metabolic syndrome new and emerging, 265 517 Catecholamines, role in hot flashes, 42–43 Cervical cancer, screening in at-risk patients, 454f new technologies, 455 Pap smear, 452–453 Cervicitis, chronic, 182 Chronic pelvic pain syndrome, 185–186, 193–194 See also Pelvic pain Circadian rhythms, hot flashes and, 43–44, 44f Citalopram, 283t Clinical trials considerations in application of results to clinical practice, 377–378, 380, 400–401 of postmenopausal hormone therapy, 401–402 disease outcomes, 379t, 382–383t methodologic considerations, 385–387 Clitoris, changes with aging, 101 Clonazepam, for pelvic pain, 189 Clonidine, for hot flashes, 48 Cluster headaches, 123–124 Cognitive-behavioral therapy, 293 Cognitive decline See also Dementia assessment, 65–66 case discussions, 63, 66 characteristics, 59–60 complementary and alternative therapies for, 504–505 estrogen’s role, 60–63 evidence, 69–70 factors affecting, 57–59 guiding questions, 69 hormone therapy and, 395–396 treatment algorithm, 56f Colonoscopy, 452 Colorectal cancer hormone therapy and, 379t, 393–394, 415f, 418f 518 Index Colorectal cancer (Cont.): screening American Cancer Society guidelines, 442f in at-risk patients, 450t, 454f colonoscopy, 452 dual-contrast barium enema, 451–452 fecal DNA testing, 452 fecal occult blood testing, 450–451 flexible sigmoidoscopy, 451 virtual colonoscopy, 452 Complementary and alternative medicine appeal, 490–491 botanical medicines research and regulatory issues, 493 toxicity, contamination, and adulterations, 493–495 case discussions, 509–511 for cognition and memory, 504–505 counseling, 492f, 508–509 definition, 489–490 for depression and mood disorders, 505–506 evidence, 508 extent of usage, 490 for menopausal symptoms black cohosh, 500–501 dong quai, 501–502 evening primrose oil, 502 ginseng, 503 soy foods and isoflavones, 496–499, 510–511 topical progesterone, 503–504 wild yam cream, 504 Complex visceral pain syndrome, 185–186 See also Pelvic pain Computed tomography, quantitative, 477 Contraception algorithm, 430f barrier methods, 432 case discussion, 437 evidence, 436–437 hormonal combined, 434–436 See also Oral contraceptives discontinuation, 436 progestin only, 433–434 intrauterine devices, 433 natural methods, 433 sterilization, 432 Coronary artery calcium, 265 Coronary heart disease See Cardiovascular disease Corticotrophin-releasing hormone, aging and effects of, 80 Cortisol, aging and effects of, 80 COX inhibitors, for chronic pelvic pain, 188 Cystic ovarian tumors See Ovarian tumors Cysts, breast See Breast mass D Danazol for breast pain, 223–224 for chronic pelvic pain, 187 for endometriosis, 180 for premenstrual dysphoric disorder, 292 Dang gui, 501–502 Deep breathing, for hot flashes, 46–47, 48t, 49 Dehydroepiandrosterone (DHEA), 136–137 See also Androgens Dementia See also Cognitive decline clinical manifestations, 60 complementary and alternative therapies for, 504–505 hormone therapy and, 379t, 395–396, 415f, 418, 418f prevalence, 59 Index Depot medroxyprogesterone acetate (DMPA), 433–434 Depression, perimenopausal case discussion, 288–289 clinical manifestations, 278 complementary and alternative therapies kava, 505–506 St John’s wort, 506–507 epidemiology, 277 etiology, 278–279 evaluation, 285–288, 286f guiding questions, 288 insomnia and, 78, 80, 81 management algorithm, 286f androgens, 281 antidepressants, 281–283, 283t antidepressants with estrogen combination therapy, 283–284 estrogen and progestogen combination therapy, 280–281 estrogen monotherapy, 279–280 psychosocial interventions, 284–285 risk factors, 279 Dietary Supplement Health and Education Act (DSHEA), 493 Dioscorea villosa, 504 DMPA (depot medroxyprogesterone acetate), 433–434 Dong quai, 501–502 Dual energy x-ray absorptiometry (DXA), 476–477 Ductal lavage, 228, 447–448 Ductoscopy, 228 Dyslipidemia case discussion, 266–267 guiding questions, 266 519 hormone therapy and, 248–250, 381 management decreased HDL-C, 264 decreased HDL-C and elevated triglycerides, 261, 262f elevated LDL-C algorithm, 252f bile acid sequestrants, 260 case discussion, 266–267 ezetimibe, 253t, 258–259 fibrates, 259 hormone therapy, 260 nicotinic acid, 259 selective estrogen receptor modulators, 260 statin therapy, 251, 254t, 256–258 therapeutic agents, 253t elevated triglycerides with normal HDL-C and LDL-C, 263–264 future directions, 265–266 guidelines, 242, 249t lifestyle changes, 250 prevalence, 242 secondary causes, 245 selective estrogen receptor modulators and, 250 Dyspareunia, 99–100 See also Sexual dysfunction E Echinacea, 495 Endometrial biopsy indications, 13 in postmenopausal vaginal bleeding, 152 Endometrial cancer hormone therapy and, 379t, 391 screening, 454f, 457–458 Endometriosis, 180–181 Endometritis, 182 Ephedra, 494, 495 520 Index Erectile dysfunction, 94, 106 Ergots, 127t Escitalopram, 283t Estradiol, changes in menopausal transition, 19–23, 20f, 21–24f Estrogen in the Prevention of Reinfarction Trial (ESPIRIT), 382t, 384 Estrogen Replacement and Atherosclerosis (ERA) trial, 382t, 384 Estrogens Alzheimer’s disease risk and, 62–63 bone loss and, 469–470 cardiovascular disease and, 381 migraine headaches and, 121–122, 124–125, 129 replacement therapy See Hormone therapy role in cognitive function, 58–59, 60–63, 71 role in hot flashes, 41–42 topical effects on skin, 133 for vaginal atrophy, 134, 140 Evening primrose oil for breast pain, 223, 233 for menopausal symptoms, 502 Exercise bone loss and, 474 for premenstrual syndrome, 293 for prevention of osteoporosis, 480 Ezetimibe, 253t, 258–259 F Fecal DNA testing, 452 Fecal occult blood testing, 450–451 Female androgen insufficiency, 102, 103f Female orgasmic disorder, 98–99 See also Sexual dysfunction Female sexual arousal disorder, 97–98 See also Sexual dysfunction Fibrates for decreased HDL-C and high triglycerides, 261 dosage, 253t for elevated LDL-C, 253t, 259 Fibroids abnormal uterine bleeding and, 151, 153, 155 case discussions, 172–173 clinical presentation, 161–162 diagnosis, 162–163, 162f, 163–164f incidence, 159 pathophysiology, 159–161 treatment algorithm, 165f costs, 165t focused ultrasound surgery, 171–172 future developments, 172 GnRH agonists, 168–170 mifepristone, 170 options, 165t oral contraceptives, 168 surgical, 165–168 uterine artery embolization, 170–171 Fine needle aspiration biopsy (FNAB) of breast mass, 232 of thyroid nodules, 316 Flexible sigmoidoscopy, 451 Fluoxetine, 283t Fluvoxamine, 283t FNAB See Fine needle aspiration biopsy Focused ultrasound surgery, for fibroids, 171–172 Follicle-stimulating hormone (FSH), in menopausal transition, 18–19, 19t, 21–23f, 22, 26f Index Food and Drug Administration (FDA), hormone therapy guidelines, 399–400 Fractures hormone therapy and risk of, 379t, 397–398, 415t, 418t risk factors, 475–476 Framingham point score, 247–248t G Gabapentin for chronic pelvic pain, 189 for hot flashes, 48 Galactography, 227–228, 237 Galactorrhea See Breast discharge Gallbladder disease, hormone therapy and, 379t, 394–395 Genitourinary tract changes with aging, 133–134 hormone therapy effects, 134, 140 Ghrelin, 137 Giant cell arteritis, 123 Ginkgo, 504–505 Ginseng, 503 Gonadotropin-releasing hormone (GnRH) agonists for chronic pelvic pain, 187 for endometriosis, 180 for fibroid treatment, 166t, 168–170 Gonadotropin-releasing hormone (GnRH) antagonists, for fibroid treatment, 170 Gonadotropins, in hot flashes, 42 Graves’ disease, 313–314, 319 Group Health Cooperative Study cardiovascular disease and hormone therapy, 386 stroke and hormone therapy, 389–390 Growth factors, for fibroid treatment, 172 521 Growth hormone (GH), body composition changes and, 137 H Hashimoto’s disease, 312t Headaches, 123–124 See also Migraine headaches Heart and Estrogen/Progestin Replacement Study (HERS), disease outcomes breast cancer, 393 cardiovascular disease, 382t, 384 cognitive decline, 395 fractures, 398 gallbladder disease, 394–395 overview, 379t stroke, 390 Heart disease See Cardiovascular disease Hernias, chronic pelvic pain in, 183 HERS See Heart and Estrogen/Progestin Replacement Study High-density lipoprotein cholesterol (HDL-C), 242, 245t See also Dyslipidemia High-sensitivity C-reactive protein, 265 Hip fracture, hormone therapy and, 379t, 415f, 418f Hormone therapy for abnormal uterine bleeding, 152–153, 155 body composition changes and, 137, 140 case discussions, 423–424 clinical practice guidelines algorithm, 410f FDA, 399–400 U.S Preventive Services Task force, 399 522 Index Hormone therapy (Cont.): contraindications, 415 disease outcomes and breast cancer, 391–393, 415f, 416t, 417t, 418f cardiovascular disease, 379t, 381–389, 382–383t, 415f, 416t, 417t, 418f clinical trial interpretation, 385–387, 400–401, 425 cognitive decline and dementia, 62–63, 71, 395–396, 415f, 418, 418f colorectal cancer, 379t, 393–394, 415f, 418f endometrial cancer, 391 gallbladder disease, 394–395 hip fracture, 379t, 415f, 418f osteoporosis, 397–398, 480–481 stroke, 382–383t, 389–391, 415f, 416t, 417t, 418f urinary incontinence, 134–135 urinary tract infections, 135 venous thromboembolism, 379t, 391, 415f, 416t, 417t, 418f effect on skin, 133, 139–140 estrogen alone vs combination, 417, 417t, 419–420 guiding questions, 425 historical perspective, 411, 412f for hot flashes, 32–33, 46 insomnia and, 79–80, 81 lipoprotein levels and, 248–250, 260 menopause perspective changes and, 7–8 migraine headaches and, 124–125, 129 in natural vs surgical menopause, oral vs transdermal, 419 for perimenopausal depression, 279–281 quality of life and, 397 racial differences in use, risks and benefits, 415–418, 415f, 416t, 417t, 418f sleep apnea and, 82 triglyceride levels and, 263–264 unexpected vaginal bleeding in, 152 for vaginal atrophy, 134, 140 Hot flashes body temperature during, 41 case discussions, 49 characteristics, 39–40 circadian rhythms and, 43–44, 44f cultural differences in reporting, 39 endocrinology, 41–43 evidence, 49–50, 50t measurement, 40–41, 40f physiology, 39–41, 40f prevalence, 39 risk factors, 39 thermoregulation and, 44–45, 45f treatment algorithm, 38f behavioral techniques, 46–47, 48t clonidine, 48 complementary and alternative therapies acupuncture, 47 black cohosh, 500–501 dong quai, 501–502 evening primrose oil, 502 ginseng, 503 soy foods and isoflavones, 496–499 topical progesterone, 503–504 wild yam cream, 504 environmental manipulations, 46, 421 gabapentin, 48 guiding questions, 49 Index hormone therapy for, 32–33, 46 selective serotonin reuptake inhibitors, 47–48, 50t Hypercholesterolemia See Dyslipidemia Hypericum perforatum, 506–507 Hyperprolactinemia anovulatory bleeding in, 151–152 breast discharge in, 227 Hyperthyroidism case discussion, 319 clinical manifestations, 315 etiology, 313–315 vs menopausal transition, 33 treatment, 315–316 Hypoactive sexual desire disorder, 104–105 See also Sexual dysfunction Hypothyroidism case discussion, 318–319 clinical manifestations, 312–313 differential diagnosis, 313, 314f etiology, 311–312, 312t treatment, 313 Hysterectomy, for fibroid treatment, 165–166, 166t Hysteroscopy, 163 I I131, 316 Inhibins, 24–25, 26f Insomnia case discussion, 86–87 definition, 77, 78 gender differences, 78–79 hormone therapy and, 79–80 management algorithm, 76f complementary and alternative therapies, 507–508, 509–510 pharmacotherapy, 84 screening, 83–84, 84t 523 sleep hygiene measures, 84–85, 85t menopause and, 79–80, 81 objective measurement, 80–81 prevalence, 78–79 psychopathology and, 78, 80, 81 Interstitial cystitis, 180t, 184 Intrauterine devices, 433 Irritable bowel syndrome, 183–184 Isoflavones, 496–499 K Kava, 505–506 L Leiomyomas See Fibroids Leptin, 137 Leuprolide acetate depot, 292 Levonorgestrel IUD, 433 See also Contraception Lipids See also Dyslipidemia interpretation of levels in menopausal transition, 245–250 optimal levels in women, 245t Low-density lipoprotein cholesterol (LDL-C), 242, 245t See also Dyslipidemia Luteinizing hormone (LH), role in hot flashes, 42 M Ma Huang (ephedra), 494, 495 Magnesium, 511 Magnetic resonance imaging (MRI), breast, 446–447 Mammography, screening, 443–444 Mastalgia See Breast pain Mastitis, periductal, 228 Mastodynia See Breast pain Medullary thyroid cancer, 317 Memory complaints See Cognitive decline; Dementia 524 Index Memory function, in young and middle-aged women, 67–69, 67t, 68f Menopausal transition abnormal uterine bleeding in See Abnormal uterine bleeding approach to the patient, 9–12, 11f case discussions, 32–33 cognitive changes See Cognitive decline; Dementia cultural differences in symptom manifestation, 64 definition, 28 evidence, 32 heavy menses during, 12–13 hormonal changes androgens, 25–27, 101–102 gonadotropins, estradiol, and progesterone, 18–23, 19t, 20f, 21–23f inhibins, 24–25, 26f hormone therapy in See Hormone therapy vs hyperthyroidism, 33 identification, 30–31, 31f longitudinal cohort studies, 4–5, 4t memory complaints in See Cognitive decline menstrual cycle changes during, 19t migraine headaches in See Migraine headaches ovarian changes, 18 vs perimenopause, 28, 28f sexuality in See Sexual dysfunction; Sexual health and function sleep disturbances in See Insomnia; Sleep apnea stages, 28–30, 28f symptoms associated with, 4–5, 27, 64–66 Menopause changes in perspectives, 5–7 definition, 27–28 natural vs surgical, hormone therapy use in, Menorrhagia See also Abnormal uterine bleeding case discussion, 12–13 causes, 149, 151 documentation, 150f fibroids as cause of, 161–162 progesterone for, 13 treatment options, 13 Menstrual cycle changes during menopausal transition, 18–23, 19t, 20f, 21–23f irregular, 32–33 ovulatory vs anovulatory, 149–152 See also Abnormal uterine bleeding Menstrual migraines, 121, 122, 129 See also Migraine headaches Metabolic syndrome cardiovascular disease risk and, 261 characteristics in women, 135–136, 135t, 242–243, 243t management, 261, 268 prevalence in women, 243 Metformin, for weight loss, 139t Methimazole, 315 Mifepristone, for fibroid treatment, 166t, 170 Migraine headaches assessment, 122–123 case discussions, 129 clinical manifestations, 120–121 differential diagnosis, 123–124 estrogen and, 121–122 guiding questions, 128 pathophysiology, 119–120 referral indications, 125–126 Index treatment acute, 126, 127t estrogen manipulation for, 124–125 lifestyle modifications, 124 preventive, 126, 128t rescue, 126, 127t triggers, 121 Mild cognitive impairment (MCI), 59–60 See also Cognitive decline Million Women Study, 392 Mondor’s disease, 222 Myomas See Fibroids Myomectomy, 166–168, 166t, 167f N Neurocognitive changes See Cognitive decline; Dementia Neuromodulating techniques, 190 Neuropathy, in chronic pelvic pain, 184–185, 192–193 Nicotinic acid dosage, 253t for elevated LDL-C, 253t, 259 for elevated triglycerides, 263 for low HDL-C, 264 Nipple discharge See Breast discharge Nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic pelvic pain, 188 for endometriosis, 180 Norepinephrine, role in hot flashes, 42–43 Nurses’ Health Study (NHS), hormone therapy and disease outcomes breast cancer, 392 cardiovascular disease, 381, 386, 389 colorectal cancer, 393–394 gallbladder disease, 394 stroke, 389 venous thromboembolism, 391 525 O Obesity See also Body mass index in metabolic syndrome, 135–136, 135t sleep apnea and, 82 treatment, 138–139, 139t, 140 Observational studies considerations in application of results to clinical practice, 377–378, 380 of postmenopausal hormone therapy, 379t Oenothera biennis See Evening primrose oil Oocytes, loss during reproductive lifespan, 18 Opiate receptors, role in hot flashes, 42 Opioids for migraine headaches, 127t for pelvic pain, 189 Oral contraceptives See also Contraception for abnormal uterine bleeding, 153, 155, 156 for chronic pelvic pain, 187 fibroid growth and, 160 for fibroid treatment, 166t, 168 for menorrhagia, 13 migraine headaches and, 122 perimenopausal bone loss and, 480 for premenstrual dysphoric disorder, 292–293 stroke risk and, 125 use in menopausal transition, 434–435 Orgasm, female, 99, 101 Orlistat, for weight loss, 139t Osteoporosis See also Bone mass case discussion, 483–484 definition, 468 diagnosis algorithm, 466f laboratory evaluation, 478–479 radiologic tests, 476–478 526 Index Osteoporosis (Cont.): epidemiology, 468 guiding questions, 482–483 hormone therapy and, 397–398 prevention algorithm, 466f pharmacologic, 480–482 primary, 479–480 risk factors, 473–475, 473t, 482–483 Ovarian cancer, screening algorithm, 213f American Cancer Society guidelines, 442f approaches, 211–212, 456–457 in BRCA mutation carriers, 454f, 457 case discussion, 216, 459 rationale, 210, 213–214, 216, 456 statistical definitions, 211t Ovarian remnant syndrome, 181 Ovarian torsion, 192 Ovarian tumors assessment algorithm, 203–205, 204f morphologic index, 198–201, 199f, 199t, 200f, 201f ovarian blood flow, 201–202, 214 proteomics, 203 serum markers, 202–203 ultrasound, 198 benign vs malignant, ovarian blood flow in, 201–202, 214 case discussions, 215–216 evidence, 214 incidence, 197 treatment, 205, 206f, 207–210f P Panax ginseng, 503 Pap smear, 452–453 Papworth Hormone-Replacement Therapy Atherosclerosis Study, 382t, 384 Paroxetine for depression, 283t for hot flashes, 48, 49 Paxil See Paroxetine PCOS See Polycystic ovary syndrome Pelvic adhesions, 181 Pelvic pain acute, causes, 178t case discussions, 192–194 chronic in adenomyosis, 181 causes, 179t in chronic cervicitis and endometritis, 182 in chronic pelvic pain syndrome, 185–186 definition, 178 in degenerative changes of vertebrae and pelvic joints, 183 in endometriosis, 180–181 in fibroids, 182 See also Fibroids in hernias, 183 incidence, 178 in interstitial cystitis, 184 in malignancy, 182 neuropathic, 184–185, 192–193 nongynecologic, treatment, 180t in ovarian remnant syndrome, 181 in pain processing disorders, 185 in painful bowel conditions, 183–184 in pelvic adhesions, 181 in pelvic relaxation, 182 in uterine malposition, 182 management algorithm, 191f anti-inflammatory drugs, 188 anticonvulsants, 189–190 Index antidepressants, 188–189 complementary therapy, 186 hormonal manipulation, 186–187 modalities, 186t neuromodulating techniques, 190 physical therapy, 190 psychotherapy, 190 Pelvic relaxation, chronic pain in, 182 Perimenopause See also Menopausal transition definition, 3, 28 vs menopausal transition, 28, 28f Phentermine, for weight loss, 139t Phosphodiesterase inhibitors for erectile dysfunction, impact on female partner, 106 for female sexual arousal disorder, 98 Physical activity See Exercise Physical therapy, for chronic pelvic pain, 190 PI (pulsatility index), 202 Piper methysticum, 505–506 Plummer’s disease, 314 Polycystic ovary syndrome (PCOS), cardiovascular disease risk and, 243 Postmenopause definition, 28–29, 28f hormone therapy in See Hormone therapy Pregnancy, in menopausal transition, 431 See also Contraception Premenstrual dysphoric disorder (PMD) case discussion, 296–297 clinical manifestations, 290–291 epidemiology, 289 527 etiology, 291 evaluation, 295, 295f guiding questions, 296 risk factors, 291 treatment algorithm, 295f cognitive-behavioral therapy, 293 diet and exercise, 293 guidelines, 294, 296 pharmacological, 291–293 vitamins and minerals, 293 Premenstrual syndrome (PMS) clinical manifestations, 289–290 epidemiology, 289 treatment, 293, 295f Progesterone changes in menopausal transition, 19–23, 20f, 21–24f topical, 503–504 Progestogens for chronic pelvic pain, 187 for hot flashes, 33 for menorrhagia, 13 Propylthiouracil, 315 Proteomics, for ovarian cancer diagnosis, 203 Psychotherapy, for chronic pelvic pain, 190 Pudendal neuralgia clinical manifestations, 325 epidemiology, 327 etiology, 325–326 examination, 331 history, 330 treatment, 334–335 vs vulvar vestibulitis syndrome, 327–328 Pulsatility index (PI), 202 Q Quantitative computed tomography, 477 Quantitative ultrasound, 477 528 Index R Radioactive iodine, 316, 317 Raloxifene lipoprotein levels and, 250, 260 vaginal atrophy and, 134 Red clover, 497–499 Relaxation techniques, for hot flashes, 46–47, 48t Resistive index (RI), 202 RI (resistive index), 202 S Saline-infused sonography, 163, 164f Screening tests cancer American Cancer Society guidelines, 442f in at-risk patients, 454f breast See Breast cancer, screening cervical, 452–455 colorectal See Colorectal cancer, screening endometrial See Endometrial cancer, screening ovarian See Ovarian cancer, screening principles, 441, 443 Selective estrogen receptor modulators (SERMs) lipoprotein levels and, 250, 260 vaginal atrophy and, 134 Selective serotonin reuptake inhibitors (SSRIs) for chronic pelvic pain, 189 for depression, 282–283, 283t for hot flashes, 47–48, 50t for premenstrual dysphoric disorder, 291–292 SERMS See Selective estrogen receptor modulators Sertraline, 283t Serum markers, in ovarian cancer detection, 202–203, 211–212 Sexual aversion disorder, 96–97 See also Sexual dysfunction Sexual dysfunction androgen insufficiency in clinical manifestations, 360t definition, 102 diagnosis and treatment algorithm, 103f case discussions, 111–114, 371–373 evaluation algorithm, 109f, 359f guiding questions, 108, 110 patient history, 356–357 physical examination, 357–358 sexual history, 107, 108f, 110t testosterone measurement, 358 evidence, 111 impact of partner dysfunction, 105–106 physiologic factors, 100–101 prevalence, 94, 111 risk factors, 360–362 symptoms, 362–363 types dyspareunia, 99–100 orgasmic disorder, 98–99 sexual arousal disorder, 97–98 sexual aversion disorder, 96–97 sexual desire disorder, 104–105 vaginismus, 100 Sexual health and function androgen levels in women and, 101–102 attitudes of aging adults, 93–94 changes in aging adults, 94–96 definition, 92–93 frequency of sexual activity, 93–94, 111 menopause and, 95 Index Sibutramine, for weight loss, 139t Sildenafil, for female sexual arousal disorder, 98 Skin changes with aging, 131–133 hormone therapy effects, 133, 140 Sleep apnea hormone therapy and, 82 management, 76f, 85–86 menopause and, 82, 83 prevalence, 82 risk factors, 82–83 Sleep disturbances See Insomnia; Sleep apnea Smoking bone loss and, 474 oral contraceptive use and, 434 periductal mastitis and, 228 Soy supplements for menopausal symptoms, 496–499, 510–511 for vaginal atrophy, 134 St John’s wort, 506–507 Stages of Reproductive Aging Workshop (STRAW), 28–29, 28f Statins clinical trials, 253, 254t, 256–257, 268 dosage, 253t for elevated LDL-C, 251, 253t, 254t, 256–258 evidence, 268 side effects, 257–258 Sterilization, 432 Stroke See also Cardiovascular disease hormone therapy and, 379t, 389–391, 415t, 416t, 417t, 418t oral contraceptives and, 125 Study of Osteoporotic Fractures, hormone therapy and disease outcomes cognitive decline, 395 529 nonvertebral fracture, 397 vertebral fracture, 397–398 Study of Women’s Health Across the Nation (SWAN) hot flashes incidence, 39 perimenopausal symptoms incidence, T T score, 476–477 Tamoxifen for breast pain, 224 lipoprotein levels and, 250 vaginal atrophy and, 134 Tang kuei, 501–502 Temporal arteritis, 123 Tension headaches, 123 Testosterone See also Androgens diagnostic tests, 363 replacement therapy in women, 363–370, 369t role in female sexual response, 101–102, 104 Thermoregulation, hot flashes and, 44–45, 45f ThinPrep, 455 Thyroid anatomy, 307 cancer, 316–317 disorders See Hyperthyroidism; Hypothyroidism nodules, 316 testing scintiscan, 311 serum free T4 and free T3, 310 serum T4 and T3, 310 serum TSH concentration, 311 ultrasound, 311 Thyroid hormones actions, 308–309 circulating, 308, 308t low levels in nonthyroid illness, 317–318 metabolism, 309 530 Index Thyroid hormones (Cont.): regulation, 309–310 synthesis and secretion, 307–308 Thyroiditis, 312t, 314–315 Thyrotoxicosis, 313, 314f Thyroxine, 313 Tibolone, for fibroid treatment, 169–170 Toxic adenomas, 314 Toxic multinodular goiter, 314 Transabdominal ultrasound, in ovarian tumor evaluation, 198 Transvaginal ultrasound for ovarian cancer screening, 212–213, 456–457 in ovarian tumor detection and evaluation, 198, 200f, 201f in postmenopausal vaginal bleeding, 152 of uterine masses, 163–164f Triglycerides, elevated with decreased HDL-C, 261, 262f with normal HDL-C and LDL-C, 263–264 Triptans, 127t U Ultrasound breast, 446 quantitative, 477 thyroid, 311, 316 transabdominal, 198 transvaginal See Transvaginal ultrasound Urinary incontinence, hormone therapy and, 134–135, 140 Urinary tract infections, hormone therapy and, 135, 140 U.S Preventive Services Task force breast cancer screening guidelines, 443, 444, 445 cervical cancer screening guidelines, 453 colorectal cancer screening guidelines, 450–451 hormone therapy guidelines, 399 Uterine artery embolization, for fibroid treatment, 166t, 170–171 Uterine cancer hormone therapy and, 379t, 391 screening, 454f, 457–458 Uterine fibroids See Fibroids Uterine malposition, 182 V Vaginal atrophy, 134, 140, 420, 422 Vaginismus, 100 See also Sexual dysfunction Valerian, 507–508 Venlafaxine for depression, 283t for hot flashes, 48 Venous thromboembolism, hormone therapy and, 379t, 391, 415t, 416t, 417t, 418t Vestibulectomy See Vulvar vestibulitis syndrome, treatment Vestibulitis, vulvar See Vulvar vestibulitis syndrome Virtual colonoscopy, 452 Vitamin B6, for premenstrual syndrome, 293 Vitamin D, recommended intake, 476 Vulvar pain syndromes anatomy, 326–327 differential diagnosis, 332–333 historical considerations, 323–324 pudendal neuralgia See Pudendal neuralgia self-help skin care, 349t vulvar vestibulitis syndrome See Vulvar vestibulitis syndrome Index 531 Vulvar vestibulitis syndrome clinical manifestations, 324 differential diagnosis, 332–333 epidemiology, 327 etiology, 325–326 examination, 330–331 history, 328–329 vs pudendal neuralgia, 327–328 treatment cognitive-behavioral therapy, 348 medical, 334–335 nonefficacious, 324t surgical, 335–344, 335t, 337–346f, 347t, 348 Vulvitis, vs vulvar vestibulitis syndrome, 332 Vulvodynia, 323–324 See also Pudendal neuralgia; Vulvar pain syndromes; Vulvar vestibulitis syndrome Wild yam cream, 504 Women’s Angiographic Vitamin and Estrogen (WAVE) Trial, 382t Women’s Estrogen for Stroke Trial (WEST), 390–391 Women’s Health Initiative (WHI) hormone therapy and disease outcomes breast cancer, 392–393 cardiovascular disease, 378, 383t, 384–385 cognitive decline, 396, 418 colorectal cancer, 394 fractures, 398 overview, 379t, 415t, 416t, 417t, 418t stroke, 390 venous thromboembolism, 391 impact on clinical practice, 412–414 overview, 412–413 W WHI See Women’s Health Initiative Z Z score, 476 ... the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether... (2) that many of the symptoms often complained of by women in the fifth decade of life are wrongly attributed to the menopause.”9 This last phrase has been verified by the results of the symptom... appropriate until the average age of menopause as a means of simulating the normal duration of the female reproductive stage of life Furthermore, there is a widely held belief, confirmed by the SWAN study,