Welcome to Menopause! LCDR Sara M. Pope MD, MPH Puget Sound Family Medicine Residency 20 March 2016

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2 Welcome to Menopause! LCDR Sara M. Pope MD, MPH Puget Sound Family Medicine Residency 20 March 2016

3 Objectives O Defined menopause and its stages O Discussed symptoms O Identified treatment & its risks O Lessened the fear about menopause

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6 The Many Myths of Menopause ① Menopause always starts at 50 ② Surgical menopause = natural menopause ③ Hot flashes are the 1st sign of menopause ④ Weight gain is inevitable ⑤ Best way to get through is to take hormones

7 #1: I need my hormones checked! O What is the definition of menopause? O What is perimenopause? O Can we test for menopause?

8 Menopause Defined O Absence of periods x 12 months O Avg age: 51.4 O Multifactorial, 5% >55, O Genetic, reproductive, lifestyle, chronic dz O Ethnic background O Perimenopause is a NORMAL transition prior to menopause (avg ~ 4 years) O Menopausal transition O Progressive decline in ovarian function

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10 Menopause Transition

11 Menopause Test? O Laboratory data not required for diagnosis O Clinical process guided by menstrual cycle history O North American Menopause Society DISCOURAGES routine assessment of hormone levels

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13 #2: Dr., I had a hysterectomy, how will I know? O Difficult to determine menopause s/p hysterectomy or endometrial ablation using menstrual bleeding criteria O Assessment of menopausal symptoms + lab data O Check FSH O A serum FSH >25 w/ hot flashes = suggestive of the late menopausal transition O FSH > = suggestive of post-menopausal

14 Audience Participation! O Surgical menopause natural menopause O Using smartphone (or smart brain), find an answer why

15 The Hysterectomy Theory O Hysterectomy has long term effect on ovarian function earlier onset of menopause O Prospective cohort study O 3.7 years earlier in premenopausal women O If 1 ovary removed, reached menopause 4.4 years earlier vs. 2 ovaries intact

16 #3: Dr., I had a hot flash. Did I start menopause? O Most common & most feared, 80% O AA experience more, Asian less O Intense heat, begin in face or chest, last 1-5 min O Can last 4-5 yrs, subset ~ 10 years O Different cultures, ethnicities experience uniquely O Not always the first thing in transition

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19 It s not just hot flashes O Heavy menses O Irregular bleeding O Fatigue O Anxiety O Depression O Irritability O Mood swings O Weight gain O Hair loss O Cravings O Fuzzy thinking O Forgetfulness O Low libido O Poor sleep

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21 #4: I ve gained so much! O Weight gain complex in menopause O Less sex hormones, body compensate by storing fat O Waist, hips, thigh fat stores produce >>estrogen O Study of Women s Health Across the Nation (SWAN) O 6-yr period, increase in weight (~2.9 kg), waist circumference (5.7 cm) O Rate of increase in waist circumference slowed 1 year after final menstrual period, whereas fat mass continued to increase w/o change in rate

22 Hot Flashes & Adverse Outcomes O Hot flashes more common in obese? O Adiposity = insulator, interferes thermoregulation O Endocrine fx mediates sxs O Hot flashes & CVD? O KEEPS study, 2013 O Self-reported sxs in recent menopause are NOT strong predictors of subclinical atherosclerosis

23 #5: Give me hormones, or give me death! O Before WHI HORMONES ARE MAGIC! O Rx for prevention of CAD, dementia, osteoporosis O After WHI HORMONES ARE EVIL! O HT most effective for VMS O Reduce by hot flashes/day, 75%/wk O Great for night sweats, vaginal dryness O Improvement in sexual fx

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25 To HT or Non-HT? O VMS O Sleep O Urogenital O Psychological O Urogenital O Skin & Hair O CV O Bone

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27 VMS O ET O Oral O Transdermal O Topical O EPT O SSRIs O Paroxetine O SNRIs O Venlafaxine O Clonidine O Gabapentin

28 ESTROGEN +/- PROGESTIN TREATMENT DOSE FDA APPROVED mg/d Yes 1 mg/d Yes mg/d Yes mg/d Yes Micronized estradiol-17β 0.25 mg/d Yes Transdermal estradiol-17β mg/d Yes STANDARD DOSE Conj. Estrogen* Micronized estradiol-17β Transdermal estradiol-17β LOW DOSE Conjugated estrogen *Cream, pill

29 TREATMENT Estrogen + estrogen agonist/antagonist DOSE FDA APPROVED Conj. Estrogen 0.45mg/d + bazedoxifene Yes PROGESTINS: Add-On for days, monthly Norethindrone 0.35 mg No Depot medroxyprogesterone 5-10 mg No

30 The Others TREATMENT Paroxetine Venlafaxine Clonidine Gabapentin DOSAGE FDA APPROVED 7.5 mg daily mg daily Yes mg daily 0.1 mg daily mg daily No No No

31 What s Not Effective O Compounded bioidentical hormones O Testosterone O Phytoestrogens O Black cohosh, red clover, primrose, dong O O O O quai Vitamin E Exercise Acupuncture Reflexology

32 Risks & The Data O Most studied: conj. E +/- medroxyprogesterone O WHI O Slight risk: O Breast cancer O CAD O Stroke O VTE O Slight risk: O Fractures O Colon cancer

33 Other Data O Reanalysis of WHI O <60 yo, within 10 years of menopause O Possible cardioprotection O F/u of 13 years data O Risk outweighed benefit for 1o or 2o prevention O Transdermal O risk of VTE vs. oral

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36 Contraindications O Don t use IF: O Breast cancer hx O CVD O Stroke O Dementia O VTE O Undiagnosed bleeding

37 Urogenital O ET O Transdermal O Transvaginal

38 Bone O Calcium, Vitamin D O Bisphosphonates O Selective estrogen-receptor modulators O Recombinant parathyroid hormone O Calcitonin

39 Psychological & Sleep O Treat depression O Cognitive behavioral therapy (CBT) O Reduce VMS O Exercise O Promote good sleep hygiene O Avoiding medications that affect cognition

40 Case Study O 50 yo G2P2 presents with concerns of no O O O O menses for the past 13 months. She reports hot flashes, mostly at night, that interfere with sleep Also endorses fatigue, vaginal dryness, feeling moody She would like to avoid hormones How would you counsel her? What could you offer her for tx?

41 Objectives O Defined menopause and its stages O Discussed symptoms O Identified treatment & its risks O Lessened the fear about menopause

42 A Great Menopause Resource MENOPAUSE, CH 106 Taylor s Family Medicine: Principles and Practices 2016

43 Questions?