Update on Hormone Replacement: Sorting Out the Options for Preventing Coronary Artery Disease and Osteoporosis

, Ohio State University

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Medical Evaluation of Menopausal Women

History. The medical evaluation of menopausal women should include a complete history and physical, with a focus on the 5 target areas affected by menopause: the cardiovascular system, the skeleton, the genitourinary system, the neuroendocrine system, and the integument.[1] The patient should be asked whether she is experiencing hot flashes, sleep disturbance, mood and memory changes, skin and hair changes, urinary frequency or urgency, exacerbation of stress, urinary incontinence, dyspareunia, and sexual dysfunction. The medical, gynecologic, substance use, and sexual history, as well as exercise habits, provide the basis for health assessment of the menopausal woman. A dietary history should also be ascertained, with particular attention paid to fat and calcium intake.

Physical examination. The physical exam should include a baseline measurement of height, weight, and blood pressure. Skin, thyroid, breast, cardiovascular, abdominal, pelvic, and rectal exams should be performed.

Laboratory evaluation. Papanicolaou smears of the exocervix and endocervix should be obtained for cervical cancer screening. Laboratory tests include a baseline total cholesterol level and HDL-cholesterol. If a screening total cholesterol level is elevated or the HDL-cholesterol is low, a 12-hour fasting lipid profile including triglycerides is needed.[2] Marked hypertriglyceridemia is an independent risk factor for coronary artery disease (CAD) in women.[3]

Follicle stimulating hormone (FSH) and estradiol (E2) levels are usually not needed to diagnose menopause but can be helpful. An assay-specific, second-generation FSH greater than 20 IU/L and particularly greater than 100 IU/L with an estradiol level less than 20-40pg/mL usually confirms primary gonadal failure. Because perimenopausal women may have similar values, the diagnosis of menopause is always retrospective.

When deciding whether to institute estrogen replacement in a woman who has had a hysterectomy (without oophorectomy), measuring FSH and/or E2 may be helpful. These hormone levels may also be helpful in diagnosing healthy, nonsmoking women who have continued taking oral contraceptives through the time of menopause because it can be difficult to determine when menopause has occurred in these women. The FSH is usually measured on day 5 of the pill-free week.[4]

For any perimenopausal woman with nonspecific symptoms and/or a menstrual disorder, thyroid stimulating hormone (TSH) levels should also be measured to evaluate thyroid function. Symptoms of the perimenopause may mimic symptoms of hypothyroidism, a disorder that increases in incidence with advancing age. TSH levels can be helpful in detecting possible over-replacement in women taking thyroxine replacement. The hyperthyroid state has been associated with accelerated bone loss, which raises the risk for osteoporosis fractures.

A screening mammogram should be obtained yearly for women who are more than 50 years old. Mammograms for women between the ages of 40 and 50 are obtained at the discretion of the clinician, as there is no general agreement about the value of screening in women in this age group; however, it may be prudent for women taking HRT to get periodic mammograms regardless of their chronologic age.

Bone densitometry with dual energy x-ray absorptiometry (DXA) of the hip and spine in healthy menopausal women should generally be obtained in women for whom the results of bone densitometry would affect the decision to institute HRT. Although new drugs for treatment are available, estrogen replacement is still the only FDA-approved therapy for the prevention of osteoporosis.[5] An individualized health assessment can be made based on a history and physical and selected use of diagnostic tests.

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