Menopause 2020 Updates Naomi Swanson MD - PowerPoint Presentation

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Menopause2020 Updates

Naomi Swanson MD

Department of OB/

Gyn

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Menopause

Objectives

Define menopause.

List common symptoms of perimenopause and menopause.

Describe risk of depression in perimenopause and menopause.

List benefits and risks of HRT.

Identify contraindications to hormone replacement therapy.

List alternative therapies for treatment of menopause symptoms.

List therapy options for treating menopause symptoms in women with a history of breast cancer.

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Menopause

Cessation of menses for 12 months

Median Age (North America) = 51

Elevated Follicle Stimulating Hormone (FSH)

Perimenopause

=climacteric=menopausal transition

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Menopause

Vasomotor Symptoms – The Hot Flush

Flushing, perspiration, chills,

claminess

, anxiety and heart palpitations

Interrupt sleep

87% of women who report hot flushes report daily symptoms

Wide variation in duration

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Menopause

Severe Hot Flushes

Risk Factors

Ethnicity

African American women report most, Asian women the least (Women’s Health Across the Nation Study 2006)

Obesity

Depression

Anxiety

Low Socioeconomic Status

Smoking

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Genitourinary Syndrome of Menopause

External Genital Sequelae

Urologic Sequelae

Sexual Dysfunction

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Depression

Window of Vulnerability vs. Menopause-Associated depression

Up to 70% of perimenopausal women report depressive symptoms compared with 30% of pre menopausal women.

Longitudinal studies demonstrate a 1.5-3 fold increase risk of depressive symptoms in peri menopause and menopause.

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Risk factors for depression

Socioeconomic

Unemployment

Low Education

Race

Health

Increased BMI

Tobacco use

Underlying medical problems

Psychosocial

Poor social support

History of anxiety

At least one stressful live event

History of mood symptoms with hormone-related context

Previous depressive episode is strongest predictor for depression in midlife.

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Risk for Persistent Depression

Study of Women Across the Nation (SWAN)

13 year follow up of women of various ethnic and socioeconomic back grounds

30% of women who developed depression in menopause had persistent of recurrent depression.

Australian Longitudinal Study on Women’s Health

Demonstrated 4 patterns of persistent depression

Those with increasing and highly persistent depressive symptoms were more likely to have risk factors such a history of depressive symptoms or prolonged peri menopause/surgical menopause.

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Hormone Replacement Therapy

HRT leads to a 75% reduction in weekly hot flushes

Decreased risk for fractures

Decreased risk for colon cancer in combined HRT

Adverse side effects

Breast tenderness

Vaginal bleeding

Bloating

Headaches

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Hormone Replacement Therapy

Contraindications

Active liver disease

History of DVT/PE, Stroke/TIA, CHD

Known thrombophilia

Untreated/Uncontrolled HTN

Breast cancer

Endometrial Cancer

Unexplained vaginal bleeding

Relative contraindications

Elevated triglycerides

Gallbladder disease

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Risks of Hormone Replacement Therapy

Combined Estrogen and Progesterone

Venous Thromboembolic Events

Slight increased risk for stroke, coronary heart disease and breast cancer

Estrogen alone

Venous Thromboembolic Events

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Venous Thromboembolic Events

Overall risk is low in healthy women

ACOG Committee Opinion No. 556

Age

Risk of VTE

40s

54/100,000 per year

50s

62-122/100,000 per year

70-80s

300-400/100,000 per year

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Timing Hypothesis

Increasing evidence suggests that use of HRT in early menopause provides a cardio-protective benefit.

HRT should not be used for primary or secondary disease prevention

ACOG Practice Bulletin No. 141

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Routes of Therapy

Oral

Non Oral

Transdermal

Patch

Sprays

Gels/creams

Vaginal ringIntrauterine

-Little to no effect in elevating pro thrombotic factors due to lack for “first pass effect.”

-Estrogen and Thromboembolism Risk study showed no increase risk of venous thromboembolism in transdermal estrogen users

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Hormone Replacement Therapy

Progesterone

Limited data to suggest superiority

Increased risk of breast cancer

Synthetic progesterone has

vasoconstrictive

effect

Natural (Micronized) progesterone has

vasodilatory

effect

Testosterone

No benefit for hot flushes

Improved sexual function scores with HT

Adverse effects

Lipids

Clitoromegally

Hirsutism

Acne

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Compounded Bio-identical Hormones

Plant derived, similar chemical structure

Not tested for potency, purity or safety

Evidence to support superiority is lacking

Under dosing and Overdosing due to variable bioavailability and bioactivity

Hormone level testing with saliva is not indicated nor reliable

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Alternative Therapies

SSRI/SSNRI

Positiv

e effect on hot flushes

Adverse effects: Nausea, dizziness, somnolence, nervousness, sexual dysfunction

Complimentary and Natural Therapies

Efficacy data is lacking

No data for long term effects

Clonidine

Positive

benefit on hot flushes

Adverse effects: Dry mouth, insomnia, drowsiness

Accupuncture

Efficacy data is lacking

Exercise

Gabapentin

Positive effect on hot flushes

Adverse effects: Somnolence, dizziness, edema

Lifestyle Modification

Clothing

Decreased caffeine and ETOH

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Management of Menopause symptoms in Women with History of Breast Cancer

HT is generally contraindicated in patients with hormone-sensitive breast cancer

SSRIs and SNRI (Avoid SSRIs in Tamoxifen users)

Alternative, lifestyle and behavioral changes

Given lack of safety data, non hormonal vaginal treatments should be first line for vaginal symptoms.

ACOG Practice Bulletin No. 126

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ACOG Practice Bulletin No. 141

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ACOG Practice Bulletin No. 141

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Conclusions

Early treatment of menopause symptoms with hormone replacement has overall low risk with high benefits.

Treatment of menopause symptoms should be individualized taking in to account a woman’s risk factors and the impact of symptoms on her quality of life.

Rate of depressive symptoms is higher for women during peri menopause and menopause as compared to pre menopause

Menopause symptoms are common in women with breast cancer and safety data on hormone therapy is lacking.

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Naomi Swanson MD

NSwanson@salud.unm.edu

380-0912

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References/Resources

ACOG Practice Bulletin Number 141, January 2014, Reaffirmed 2016. Management of Menopausal Symptoms.

ACOG Practice Bulletin Number 126, January 2012, Reaffirmed 2016. Management of Gynecologic Issues in Women with Breast Cancer.

ACOG Committee Opinion Number 556, April 2013. Reaffirmed 2015. Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism.

ACOG Committee Opinion Number 532, August 2012, Reaffirmed 2016. Compounded

Bioidentical

Menopausal Hormone Therapy.

ACOG Committee Opinion Number 565, April 2013, Reaffirmed 2015. Hormone Therapy and Heart Disease.

The North American Menopause Society “The 2017 hormone therapy position statement of the North American Menopause Society. Menopause. 2017; 24: 728-753.

Gandhi J, et al. “Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management” AJOG. Dec 2016; 215 (6): 704-711.

Bhupathiraju

S et al, “Exogenous Hormone Use: Oral Contraceptives, Postmenopausal Hormone Therapy, and Health Outcomes in the Nurses’ Health Study” Am J Public Health. 2016; 106:1631-1637.

Lobo, R. “Hormone-replacement therapy: current thinking” Nature Reviews Endocrinology. 2017; 13: 220-231

Kaunitz

A, Manson J. “Management of Menopausal Symptoms” Obstetrics and Gynecology. 2015; 126 (4): 859-876.

Manson J.,

Kaunitz

A. “Menopause Management

–

Getting Clinical Care Back on Track” The New England Journal of Medicine. 2016 374 (9): 803806