[NP-Clinical] Re: Perimenopause

Sat Jan 20 12:24:03 PST 2007

Skipping periods does not make a woman "menopausal" nor does an FSH of 80. By definition, a woman must go without any bleeding at all for a minimum of 12 months before menopause can be considered. Research shows that FSH levels DO in fact increase during the perimenopause.....this is not in response to lower estrogen levels as originally believed but rather changes in inhibin. 

Having hot flashes just means that her hormones are fluctuating a great deal - going from high to low levels .....also characteristic of the perimenopause. This woman needs to know that she can still get pregnant during this period which can last several years.......and in fact, because of the increasing levels of FSH, there is a higher probability of multiple gestation.

Unless you plan to do serial hormone readings, single levels of FSH or estrogen don't tell you very much and are not recommended. 

Pat

Pat Camillo PhD,RN,APN,C
Certified Nurse Practitioner in Women's Health,
Gerontology and Menopause
Carmenta Health
1 Kalisa Way Suite 103
Paramus, New Jersey 07652
(201) 265-9042
  ----- Original Message ----- 
  From: Julie Orfirer 
  To: np-clinical at nurse.net 
  Sent: Thursday, January 18, 2007 10:54 AM
  Subject: [NP-Clinical] Re: Perimenopause

  Ellen,

  Welcome from lurk mode.

  I do not use any hormone testing in perimenopausal women unless there's something particular going on as you said.  FSH and estradiol are normal as long as women are having regular periods.  One doesn't usually need lab tests to come to clinical diagnoses like perimenopause or menopause.  That said, I saw someone recently who has had irregular periods since the birth of her child at 32, she's now 40 and had suddenly started skipping periods.  I did some lab work assuming secondary amenorrhea and her FSH was in the 80's!  I got to call and tell her she was menopausal at 40 and she said, "You know, I just started having hot flashes last week...."

  Re thyroid you're right again.  TSH is the most sensitive marker for following hypothyroidism and replacement.  The T4 is going to be there because you're giving it but it doesn't tell you what the feedback of the T4 is - as in is it enough to supress putuitary output of TSH.  This is also a bit of a tricky clinical thing too - some people still feel crappy at 4 even if 4 is normal.  You can safely bring them down to 1 if they feel better there.  Tho so many people blame everything (especially those extra 10-20#) on thyroid and they may not disappear with adequate treatment.  (My boss and I just had a LONG conversation to that with a patient the other day.)  I'll help them to get to a lower TSH if it helps but I always keep the TSH within normal.  You're absolutely right that overdose of thyroid can cause lots of problems.  Remember also that you need to wait at least 8 weeks after a dose change to recheck the TSH - takes a long time to equilibrate.

  Sounds like the doc you work with could use a little endocrine update.

  Julie

    Message: 1
    Date: Wed, 17 Jan 2007 17:55:47 -0600
    From: "Ellen Vander Galien" 
    Subject: [NP-Clinical] Perimenopause
    To: "NP Clinical" 
    Message-ID: <001401c73a93$03865fd0$2f01a8c0 at u8j9m0>
    Content-Type: text/plain; charset="iso-8859-1"

    Have two endocrine questions for all of you

    1. How useful do you find the measurement of FSH and estradiol during the perimenopause? I do not routinely use these test rather look at patients age, signs and symptoms and make a clinical diagnosis. May on occasion rule out thyroid problems or diabetes if clinical situation dictates. My physician colleague does FHS and estradiol routinely and they are always normal even in the women with a clear picture of perimenopause. 

    2. How do you all monitor adequacy of thyroid hormone replacement. I was taught to use the TSH and what I have read supports this. My physician colleague on the other hand,monitors only Free T4. He believes that as long as the free T4 is within normal range increasing the thyroid hormone replacement is justified if the patient continue to complain of fatigue and inability to lose weight even if it results in a "undetectable" TSH. I was taught that the was oversuppression and a subclinical hyperthyroidism that could result in osteoporosis or atrial fib. 

    Any thoughts appreciated. Thanks

    Ellen Vander Galien *usually lurking"
    Family Nurse Practitioner
    Beaver Dam. Wisconsin
    -

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