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The use of adaptable styles makes formatting an easy job and conditional styles make it automatic. A growing set of node extensions provide for details, metadata, scalable images, in- line hyperlinks and more which can be independently controlled to be visible or not. Freeplane maps can be easily integrated with Internet pages as in this wiki. And Freeplane is integrated with the Docear academic literature suite. Programmers may easily develop powerful extensions and students are stimulated to learn programming in a natural and stimulating environment. Freeplane also has a powerful mechanism to install packages of scripts, icons, images, language dictionaries for spell checking and other preferences including a different menu structure; and which can be used by non- programmers. The mind map on the right shows the basic Tutorial for using Freeplane. The actual version of this map is contained in the Freeplane program in menu Help > Tutorial. 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OPEN DISCUSSION FORUM discuss the usage of existing features (new bug reports go into the issue tracker). Freeplane's old user forum is archived here. Perimenopause (Mayo Foundation for Medical Education and Research). Article: Genitourinary Syndrome Of Menopause and Vaginal Estrogen Use. Menopause -- see more articles; Premature menopause -- see more articles; Find an. Treatment of menopausal symptoms with hormone therapy. Literature review current through. Aug 2. 01. 6. Estrogen is the most effective treatment available for relief of menopausal symptoms, most importantly hot flashes. Menopausal hormone therapy (MHT; estrogen alone or combined with a progestin) is currently indicated for management of menopausal symptoms. Long- term use for prevention of disease is no longer recommended. The treatment of menopausal symptoms with MHT (estrogen alone or combined with progestin) will be reviewed here. An overview of the risks and benefits of estrogen, available hormone preparations, and an overview of menopausal therapies for women who choose not to or cannot take estrogen are discussed separately. By convention, unopposed estrogen therapy is known as ET, combined estrogen- progestin therapy as EPT, and menopausal hormone therapy as MHT . Other symptoms associated with perimenopause and menopause that respond to ET include mood lability/depression, vaginal atrophy, sleep disturbances (when related to hot flashes), and in some cases, joint aches and pains. Perimenopause is the period of time before menopause when a womanâs body changes and. Perimenopause: Changes, Treatment, Staying Healthy. This is your bodyâs normal response to a decreased level of the hormone estrogen.The management of vasomotor symptoms and the use of vaginal estrogen for vaginal atrophy are reviewed in greater detail separately. However, we do not recommend MHT for prevention of disease given the results of the Womenâs Health Initiative (WHI), a set of two large randomized trials that demonstrated an unfavorable risk- benefit profile of MHT. Almost all women who seek medical therapy for menopausal symptoms do so in their late 4. Women in this age group should be reassured that the absolute risk of complications for healthy, young postmenopausal women taking MHT for five years is very low (figure 1). Vasomotor symptoms occur most often in the late menopausal transition and early postmenopause (figure 2). Although there are alternative therapies for vasomotor symptoms, none are as effective as estrogen. The physiology, clinical manifestations (including insomnia), and treatment of hot flashes (including intractable hot flashes) are discussed in detail elsewhere (see . This time is called perimenopause or the menopausal. Although most studies that showed an increased risk wereof women taking estrogen as a pill, women using a patch or high-dose vaginal ring can also expect to have an. Hi, I have recently started in with Perimenopause (Anxiety, insomnia, depression probably from lack of sleep) (age 47) and my doctor put the Minivelle patch on my.075. I still have my ovaries, uterus and still menstruate. Transdermal patch -- estradiol: 0.05; 1 mg: Climara: Berlex. Perimenopause; Premature Ovarian Failure (POF) Special Topics. Perimenopause promises many of the same hot flashes. Decreased estrogen can cause changes in the lining of the vagina. Perimenopause; Postmenopause. The estrogen patches helped immensely but I cannot tolerate the 10 days of Prometrium as it causes feelings of extreme anger and depression. I still have my uterus so my. Treatment of menopausal symptoms with hormone therapy. The treatment of menopausal symptoms with MHT. Perimenopause has become the object of increased scientific interest as well as the reason for an increase in visits to doctors by women in their forties seeking. An overview of the clinical manifestations of the menopausal transition and menopause are found separately. This results in GSM (also called vaginal atrophy or atrophic vaginitis), causing symptoms of vaginal dryness, itching, dyspareunia, and sometimes urinary symptoms. Both systemic and vaginal estrogen are effective for genitourinary atrophy symptoms, but we suggest vaginal rather than systemic estrogen for women who have only GSM without other menopausal symptoms such as hot flashes. In addition, we do not suggest its use for cognitive function or prevention of dementia (See . Although the risk profile appears to be more favorable in young women taking unopposed estrogen, use for prevention is still not warranted . The hormone regimen studied in the WHI was conjugated estrogens and medroxyprogesterone acetate (MPA). While it is possible that other estrogen or progestin formulations or doses might not have the same negative cardiovascular effects as conjugated estrogen and MPA, data to support their use for prevention are not available. However, in the occasional patient with persistent menopausal symptoms who cannot tolerate first and second- line therapies for osteoporosis, estrogen may be a reasonable option. Although substantial biologic evidence supports the importance of estrogen to cognitive function, clinical trial evidence has generally ruled out any global (but not domain- specific) cognitive benefits. Although some epidemiologic data suggest that estrogen may be beneficial, clinical trials of MHT administered to women over age 6. Strong evidence of cognitive benefits for women taking MHT at younger ages (eg, near menopause) is also lacking, and thus MHT should not be prescribed for preservation of cognitive function in younger women. Oral estrogens should be avoided in women with hypertriglyceridemia, active gallbladder disease, or known thrombophilias such as factor V Leiden (without a personal history of venous thromboembolism . Transdermal estrogen is also preferred for women with migraine headaches with auras. OVERVIEW OF APPROACHChoosing candidates â We consider the initiation of menopausal hormone therapy (MHT) to be a safe option for healthy, symptomatic women who are within 1. MHT (such as a history of breast cancer, coronary heart disease . Similar to most other guidelines, the Endocrine Society agrees that MHT is indicated for the management of menopausal symptoms but not for the prevention of cardiovascular disease (CVD), osteoporosis, or dementia. Calculating risks â The Endocrine Society guideline suggests calculating cardiovascular and breast cancer risks before initiating MHT . They suggest nonhormonal therapies for symptomatic women who are at high risk (> 1. CVD (table 1) or moderate (1. For women at moderate risk of CVD (5 to 1. They note that a population- based CVD risk calculator should be used to estimate CVD risk (calculator 1). An online tool such as the National Cancer Institute Breast Cancer Risk Assessment Tool can be used to assess five- year breast cancer risk . For women at increased risk of venous thromboembolism (VTE), they also suggest transdermal estrogen with a progestin that has a neutral effect on coagulation parameters (eg, micronized progesterone). Starting estrogen â Once a decision has been made to treat a postmenopausal woman with estrogen, consideration should be given to the type of estrogen and the route by which it is to be given, as well as the need for progestin and the most appropriate progestin regimen. Estrogen is available in many forms: oral, transdermal, topical gels and lotions, intravaginal creams and tablets, and vaginal rings. In some countries, estrogen can also be given as a subcutaneous implant (table 2). The potency and therefore the doses of these estrogen preparations differ, but they differ little in efficacy . Vaginal estrogen is most commonly used in very low doses for the management of genitourinary syndrome of menopause (GSM), also known as vaginal atrophy. However, high doses of vaginal estrogen can also be used to treat vasomotor symptoms, much like a transdermal preparation . We do not recommend these high doses, ie, systemic estrogen doses, in women who need therapy for genitourinary symptoms only. Route â We start many women on transdermal 1. VTE, stroke, and hypertriglyceridemia than oral estrogens. The transdermal route is particularly important in women with hypertriglyceridemia or risk factors for thromboembolism. However, the baseline risk of both VTE and stroke is very low in otherwise healthy, young postmenopausal women. Therefore, if a patient prefers an oral preparation over a transdermal one (cost or personal preference), we consider oral estrogen to be safe. We typically choose oral 1. Womenâs Health Initiative . Details on the types of estrogen preparations are reviewed separately. On the other hand, oral estrogens are associated with increases in serum triglycerides and C- reactive protein. In theory, this could result in a negative impact on libido and sexual function, but this has not been proven. Similar effects on thyroxine- binding globulin (TBG) and bioavailable thyroxine (T4) occur with oral estrogen (increased TBG and lower bioavailable T4). Oral estrogens also increase cortisol- binding globulin (CBG), resulting in an increase in total serum cortisol. Interpreting serum cortisol values in a woman taking oral estrogen can therefore be misleading. The topical spray (Evamist) has been linked to adverse effects in children and pets exposed to the drug via skin contact. The severity of hot flashes also decreased more with MHT compared with placebo. In a second meta- analysis, conjugated estrogen 0. These doses eliminate hot flashes completely in about 8. In the past, a âone- size- fits- allâ approach to estrogen dosing was used, with oral conjugated estrogen (0. If symptoms were relieved, the same dose was continued indefinitely. However, the current approach is to start with lower doses, such as transdermal estradiol (0. Lower doses are associated with less vaginal bleeding and breast tenderness . Lower doses are also associated with fewer effects on coagulation and inflammatory markers, and a possible lower risk of stroke and VTE than standard- dose therapy . If hot flashes are still present after one month, we increase transdermal estradiol to 0. If symptoms are still not relieved, we increase further to 0. An exception to this approach is the patient with severe symptoms; we start with a transdermal dose of 0. Standardâ doses of estrogen given daily (conjugated estrogen 0. An exception is younger women after bilateral oophorectomy. They often require higher doses (eg, up to 0. The lowest available transdermal estradiol dose is 0. However, about 5. Progestin doses may be lowered with low- dose estrogen, but there is no consensus on optimal regimens. Women will often get hot flashes during the days off, and there is no known advantage to stopping for several days each month. Side effects â Common side effects of estrogen include breast soreness, which can often be minimized by using lower doses. As noted above, some women experience mood symptoms and bloating with progestin therapy. Vaginal bleeding occurs in almost all women receiving cyclic estrogen- progestin regimens and is common in the early months of a continuous estrogen- progestin regimen. Increased metabolism may result in lower serum estrogen concentrations, while decreased metabolism can result in higher serum concentrations. However, there is no way to predict how much more estrogen is needed . In this situation, a transdermal estrogen may be better than oral estrogen since it avoids the first- pass hepatic metabolism. Therefore, in women receiving T4 replacement therapy, the addition of oral ET may increase T4 requirements. The hallmark of this transition is a change in the levels of the hormones estrogen, progesterone, and the androgens. Yet this is not solely a physical event. The hallmark of this transition is a change in the levels of the hormones estrogen, progesterone, and the androgens. Yet this is not solely a physical event. The hallmark of this transition is a change in the levels of the hormones estrogen, progesterone, and the androgens. Yet this is not solely a physical event. The hallmark of this transition is a change in the levels of the hormones estrogen, progesterone, and the androgens. Yet this is not solely a physical event. Approximately 4. 0 million American women are going through the menopause process today, so if you are one of them, you are in very good company. Hereâs a summary of what you need to know about this transition to help make it as smooth as possible. There are three types of menopause. About 2. 5 percent of women experience artificial menopause (menopause resulting from surgical removal of the ovaries, surgical disruption of the blood supply to the ovaries, radiation, chemotherapy, or taking certain drugs). For these women, menopausal symptoms can be severe and debilitating because there is no opportunity for gradual adjustment to the hormonal drop- off. Hormone treatments are often prescribed to help lessen these severe symptoms. The second type of menopause is premature menopause, which is diagnosed when a woman goes through menopause in her 3. Itâs usually secondary to autoimmune disease, nutritional deficiency, or some form of chronic stress (including excessive athletic conditioning) that has adversely affected hormone- related reproductive functions. Premature menopause occurs not only earlier but also faster than normal menopause, often necessitating supplemental hormones to maintain physical comfort during the transition. Most women go through the third type of menopause. Many women begin noticing changes in their menstrual cycle and/or mood years before they actually have their final period. This transitional perimenopause period usually lasts five to ten years, though the entire process can sometimes take up to 1. Thereâs normally a gradual crescendo in the beginning, a peak as one approaches mid- transition, and a gradual decrescendo towards the end, as the body learns to live in harmony with its new hormonal and emotional milieu. During perimenopause, periods may stop for several months and then return, and they may also increase or decrease in duration, intensity, and flow. Whether you need hormone replacement or alternatives for symptom relief during this time depends on what else is going on in your body and your life. It is virtually impossible to tell when youâre finished with the menopausal transition until it has been a year since your last menstrual period. In other words, menopause itself can only be diagnosed a full 1. Nevertheless, because hormone levels both in the brain and the body undergo progressive changes during perimenopause, salivary hormone levels, urine levels, or blood levels can be measured to give you an idea of where you stand. Hormone levels can also help you monitor your need for hormone replacement or your dose. In order to have the best transition possible, it is important to be optimally healthy going in. That means understanding what is happening in your body, and supporting it so that you continue to produce adequate amounts of hormones for the rest of your life. Typical Perimenopausal Symptoms: Many women sail through âthe changeâ without any symptoms at all. Others experience a wide range of symptoms, all of which have physical, emotional, and psychological aspects. During the years before menopause levels of progesterone typically decline, while estrogen levels remain stable or even increase. This is the most significant issue for the majority of women; many of the early symptoms that women feel are due to progesterone levels that are too low, in relation to their levels of estrogen. This state of a low progesterone- to- estrogen ratio is also referred to as âestrogen dominance.â Some of the symptoms that women suffer when progesterone declines include:
Testosterone levels may also start to decline well before the last menstrual cycle. While the symptoms of low testosterone are often more subtle that those of low progesterone, for some women they can be significant. Symptoms of low testosterone include:
Estrogen is often the last hormone to decline, but is the hormone that is traditionally associated with menopausal symptoms. As you approach menopause your ovaries slow their production of estrogen. While your ovaries continue to make some estrogen for the rest of your life and your body is still producing it from other sources, the overall effect is a dramatic drop in the level of estrogen circulating in your body. Symptoms of estrogen decline include:
The Wisdom of Menopause Although women have been taught to dread menopause, this life stage ushers in the springtime of the second half of life and is often accompanied by surges in creativity, vitality, newfound ambition, and the need to be of meaningful service to the community in a larger way. During perimenopause and beyond, our goals and behavior become more motivated by the demands of our souls, not just those of society. We quite naturally seek answers from deep within instead of looking for approval from the outside. The menopausal transition is actually a profound developmental stage in which unfinished business from the past comes up once again for resolution and healing, so that we can free ourselves from the outmoded beliefs and behaviors of our past. All the issues that werenât resolved during puberty and early adulthood. There are also a wide variety of options available for addressing and relieving the most common symptoms that arise during the menopausal transition. |
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