Care of the Menopausal Woman: Beyond Symptom Relief

Lynne T. Shuster, MD, Women’s Health Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Sharonne N. Hayes, MD, Women’s Heart Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Mary L. Marnach, MD, Women’s Health Clinic, Department of Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA.
Virginia M. Miller, PhD, Departments of Surgery and Physiology and Biomedical Enginering and Office of Women’s Health, Mayo Clinic College of Medicine, Rochester, MN, USA.

Women in the Western world may expect to spend a significant portion of their lives in postmenopause. After menopause, women are at increasing risk for several conditions associated with aging that may or may not be related to declining hormone levels. Caring for women seeking advice and treatment for menopausal concerns presents a golden opportunity to not only identify individuals at risk for early intervention but also to address prevention and screening strategies important to sustaining health.
Key words: cancer, cardiovascular disease, menopause, osteoporosis, screening.

Introduction
Risk and prevalence of chronic diseases such as cardiovascular disease, osteoporosis, and cancer increase with age. These diseases negatively impact quality of life and represent a significant financial burden for an aging population. Women presenting for advice about menopausal concerns represent a golden opportunity to identify and treat the risks for these conditions. This review will highlight optimal screening and prevention strategies for care of the postmenopausal woman, regardless of whether or not she is taking hormone therapy to relieve symptoms.

Health concerns associated with menopause are illustrated in Figure 1.

 

Cardiovascular Disease
Cardiovascular disease (CVD) is the single most common cause of death among women in the developed world. While cardiovascular mortality for men has decreased over the past three decades, no such decrease is observed for women.¹ In part, this is because women’s risk for CVD has been historically under-recognized, underdiagnosed, and undertreated. This need for more widespread implementation of screening, assessment, and individual management of CVD risk in women led to the publication in 2004 of the American Heart Association’s (AHA) Evidence-Based Guidelines for CVD Prevention in Women,² which offers health care providers a clear road map for CVD prevention.

A global CVD risk assessment defined by the Framingham 10-year Coronary Heart Disease (CHD) risk score³ is a useful tool to plan interventions and individualize treatment. Available as both a web-based (hin.nhlbi.nih.gov/atpiii/calculator.asp) and a pen and paper calculator, points are accumulated for risk factors that include age, gender, total and HDL-cholesterol (HDL-C), blood pressure, and smoking status. High risk is defined as a greater than 20% 10-year CHD risk and is represented by women with established CVD as well as those with CHD equivalents such as diabetes and chronic renal disease. Intermediate-risk women have a 10-20% 10-year CHD risk and lower risk individuals less than a 10% 10-year CHD risk. “Optimal” is defined as optimal levels of all risk factors (nonsmoker, LDL cholesterol <2.6 mmol/L, and blood pressure <120/80 mmHg) and adherence to a heart-healthy lifestyle (Table 1).

 

With menopause, the decline in endogenous estrogen has a number of adverse effects on cardiac risk factors, including increased LDL cholesterol (LDL-C), lipoprotein a (Lp[a]), homocysteine, and decreased levels of HDL-C.⁴ Therefore, measurements of blood pressure and lipids are important at menopause to assess the need for interventions or pharmacologic therapy. Although hormone treatment for symptoms of menopause favourably alters the plasma lipid profile,^5,6 the issue of whether or not estrogen treatment provides primary prevention for cardiovascular disease remains controversial.^7,8 Results of a new trial (Kronos Early Estrogen Prevention