Managing Menopause: Overview of Symptoms, Update on Therapies

by: University of California Television (UCTV)

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okay welcome good evening and welcome to the Center for healthy aging and the Stein Institute for Research on Aging's monthly public lecture series my name is Danielle Glorioso and I'm the executive director of the Center for healthy aging for those of you that are new to us the Center for healthy aging is mission is to advance lifelong health and well-being through research training and community outreach this public lecture series is an example of our community outreach programs some of you may know that we've been hosting these for over 20 years to the community for free and the idea is that we want to bring exciting advances that are happening in the areas of Aging to the public and we've been supporting these lectures for the last 20 years for free through generous donations from the community and as some of you may know we host all of these online on UCSD TV and they are wildly popular some of our lectures have over 4 million hits to them so we really appreciate your donations and your support if any of you are interested in supporting our lectures you can contact us at aging UCSD edu as this is a tradition we'd really like to continue doing it's a real honor to introduce our speaker tonight dr. Catherine McAuley she's an associate clinical professor at UC San Diego School of Medicine and she's also director of UC San Diego's menopause health program and has extensive experience with hormone replacement therapy as an ob/gyn she provides comprehensive care to women of all ages and pre appreciates the continuity she is able to provide she considers it a privilege to be involved with patients over time and through different phases of their life please join me in welcoming dr. Catherine McAuley thank you very much and thank you for the invitation to speak here tonight speaking about menopause is one of my favorite things to do I've been taking care of menopausal women for more than 10 years I started the UCSD menopause health program in 2003 after the publication have the Women's Health Initiative study in 2002 which many of you may have heard about before at that time there was a lot of confusion about hormones managing menopause what to do and it just seemed in the best interest of everyone to start a designated clinic and program to help women in menopause and I've loved doing it ever since and the home base is in La Jolla but we're actually expanding to Encinitas next month so we're excited about that so thank you again for coming and the title of my talk is managing menopause overview of symptoms and update on therapies so what we're going to do is talk about some of the common symptoms of menopause and do an overview of the different health effects that can potentially happen after the menopause and then I'd like to update you on the latest with how we're managing menopause symptoms and complaints and what some of the newer therapies are so menopause matters why does it matter well because a lot of women are going through menopause every day by the year 2020 the number of women over age 55 is estimated to be forty five point nine million about six thousand US women reach menopause every day that's over two million per year and women's life expectancy in the United States is now much longer than previously in the year 1900 a woman's life expectancy was about 48 years and now we're talking about eighty years more than 80 years so women will spend more than one-third of their lives or more after the menopause transition and what is menopause well usually it's a natural process so it's not a disease it's a normal part of the reproductive span and women's lifespan it's defined as the permanent cessation of menses for 12 consecutive months or no menses for one year and it usually occurs naturally we call that spontaneous menopause at the age of 51 it's a result of ovarian aging the decline in ovarian follicles and ovulatory cycles and with that comes a decline in the production of estrogen from the ovary with decline and ovulation progesterone production also declines so the two major hormones we're talking about usually are is estrogen and progesterone and we talked about premature menopause when patients have had medical interventions such as chemotherapy surgical removal of the ovaries radiation Medicaid or have overall impaired ovarian function in those cases women can sometimes undergo menopause much earlier in their early 40s and and maybe in need of treatment sooner so the perimenopause is also referred to as the menopause transition and this starts when the menstrual cycle length begins to vary by more than seven days lasting up until the final menstrual period that's when menopause has reached levels of FSH or follicle stimulating hormones start to rise and fluctuate and this fluctuation in hormones which can last for even several years can result in a more symptomatic period for some women in terms of their hot flashes or even mood symptoms and bleeding patterns could vary typically we see more light or sporadic bleeding but also women can develop heavier periods during that time and they can be at risk for endometrial pre-cancers and mutual cancer so that can often be sometimes be an issue a question I get asked frequently is from my patients is how do I know if I'm in menopause and I educate them the same way I just did for you discussing the change in the bleeding patterns that's usually the first sign of perimenopause and go over the the definition of menopause absence of period for one year and the age range the average age in the u.s. is about 51 and with a range from age 40 to anywhere up to age 58 in women under the age of 40 they comprise less than 1% of women who stopped menstruating and we call this primary ovarian insufficiency while blood tests can confirm menopause it's not usually needed usually we can go just by the clinical history the age of the patient and the bleeding pattern if we do get blood tests because I certainly do have patients coming in and asking for I want to know where I'm at or I want to know how much more I have to go until I'm in menopause it's hard to predict that with these tests really we can't predict it but if we do the tests typically what would confirm the perimenopause would be a high FSH stands for follicle stimulating hormone an FSH level and a low estrogen I should also take a moment to explain that there are going to be a lot of abbreviation here and I'll explain them as I go but it's just that we use a lot of the same terms over and over with abbreviations but I will explain them so we'll review next the common menopause symptoms and some of the other symptoms we see the most common symptoms are vasomotor symptoms that comprises the hot flashes and night sweats hot flashes occur in the day and night sweats are basically hot flashes that occur in the sleep or by night and about 75% of menopausal women experience vasomotor symptoms so they are really kind of considered the hallmark of menopause vaginal dryness is also very frequent and the concern over vaginal dryness other than just day-to-day symptoms is that it can lead to painful intercourse so this is a very common reason for changes in sexual function and painful intercourse other symptoms that can occur include mood changes depression and anxiety sleep disturbances other than night sweats that can be difficulty falling asleep or multiple awakenings during the night cognitive concerns such as impairment and memory poor concentration described to be moment described to me by many women as the brain fog and reduce libido and or change in sex drive so other health concerns women have after menopause include bone health osteoporosis weight management cancer risks as they age cardiac health sexual function and changes in that function and even skin complaints skin hair changes a study that is pending publication that I'm preparing for publication actually done here in the menopause clinic at UCSD looked at the questionnaires that I gave to about 200 women over a two-year period and at the end of the questionnaire I asked them what is your reason for seeking care here today and so what we found was the top reasons that women seek care in a specialty menopause clinic is not too surprising but for advice on hormones and hormone therapy sometimes called HRT I put that abbreviation in there because many people use the old term HRT hormone replacement therapy when they talk about hormones we've taken the r out of the HRT because the replacement suggest that they that your estrogen and progesterone are hormones that need to be replaced as opposed to using them to treat symptoms so we now just call it hormone therapy or HT you'll see and another common reason is treatment of bothersome symptoms such as hot flashes night sweats sleep disturbances and vaginal dryness issues with sexual function it's a very common reason for women to come see me it's either painful intercourse or reduce sex drive or libido so I take care of women with both issues and weight management that surprised me a little bit but a little bit over 50% of patients coming to me we're actually interested in either losing weight or maintaining the healthy weight that they were at so that was something useful for me to know because now I'm going to be more prepared to help them with weight issues so what are hot flashes they are recurrent transient episodes of warmth or flushing of the skin usually starting in the upper face and chest and rising up to the or upper chest and rising up to the face women can feel flushed and and almost look red during that time and they can start perspiring they last thirty Seconds to five minutes on average two minutes and the duration frequency and severity are variable among patients some women have them to have the symptoms so severely that they actually can sense that increase in heart rate perceive that sometimes is even heart palpitations and can get anxiety as well and night sweats as I said or hot flashes by night they are hot flashes that induce an intense perspiration and this occurs during the sleep women will often describe to me that they wake up feeling drenched it's a it's a pretty dramatic description and they literally use the word drenched over and over again different women to describe this and all of these symptoms can adversely affect quality of life so on the surface talking about hot flashes some I teach students and residents and they don't always really they're young and they don't always really understand what what's a hot flash but then when they come to work with me in the clinic and they listen to women tell their stories that's I think the most beneficial part of their education is listening to women tell their story then they get a sense of the impact the symptoms have on their daily life so hot flashes are associated with declining estradiol levels during the menopause transition we don't exactly know what exactly how hot flashes arise but we know that there is a thermo neutral regulatory zone in the hypothalamus that has a certain threshold for estrogen and due to declining estrogen this area is affected the hot flashes vary in number per day and severity as I said and are experienced by most women during menopause and even maybe more who've had their ovaries surgically removed 10 to 15 percent of women experience severe symptoms so the majority have more mild to moderate symptoms and 25% of women in the US will seek medical care for their hot flashes we usually tell patients they typically resolve in about 3 to 5 years but we are having more data published showing newer studies looking at women for more years over the menopause transition and these studies suggest that actually hot flashes lasts for an average a longer average duration and I have some slides on that in a bit right here so hot flashes how long will they last a few trials here that show more than just a few years so to tell women to tough it out for a year or two I don't think is necessarily realistic anymore if they're very bothered by their symptoms but the last study the study of women across the ages was a multi-ethnic study looking at women for up to 18 years and found that the mean duration of hot flashes in their sample was 7.4 years and that there was a longer duration if they had an earlier onset of their symptoms or coexisting mood symptoms such as depression African African American women experience hot flashes for a longer duration and Japanese and Chinese women a slightly shorter duration so this study is powerful as well in that it's a multi-ethnic group of women of different backgrounds now what can we do well I always start with the lifestyle modifications it makes sense and give patients a printout of just these recommendations keeping the core body temperature as cool as possible by dressing in layers you having a cooler ambient air temperature sipping cold drinks the bottom one I mentioned the cool drinks but the hot drinks avoiding known triggers such as alcohol some women finally become very sensitive to certain alcohols like red wine hot drinks caffeine spicy foods and this doesn't mean all menopausal women have to avoid these things but if they recognize that as a trigger for their hot flashes then obviously they want to reduce that exposure maintaining a healthy body weight is going to be important as well because there has been an association seen with higher BMI or body mass index with an increase in hot flash frequency refraining from smoking is always a good idea exercising regularly while the studies are a bit mixed on the effects of exercise on hot flashes there is some some studies to suggest that regular exercise may attenuate severity of hot flashes and practicing relaxation techniques as well as important there's been a lot of studies looking at paced respiration and more controlled deep breathing and that can be helpful mood cognitive changes are also important the perimenopause seems to be a vulnerable time for women with mood changes particularly women who have a pre-existing history of depression anxiety they can experience an exacerbation of their symptoms during that time and the hot flashes night sweats themselves have been associated with depression and anxiety hard to say how much of this particular with the night sweats is this due to sleep deprivation causing irritability and daytime mood changes but it may be part of the same spectrum in terms of cognition I mentioned women describing a brain fog and there is studies have shown a slight transient decline in cognitive function during the perimenopause but this seems to resolve post menopausal II so if there is any change it should be transient and certainly though subjective complaints of memory impairment is high and menopausal women with one study showing more than 70% of women felt like they had some memory change or difficulty with memory during menopause so vaginal atrophy I put a little asterisk after atrophy because the name has been changed just to make it harder for all of us so I don't have a good abbreviation yet for genitourinary syndrome of menopause but the the term atrophy is kind of a scary term the the merriam-webster dictionary definition describes as a wasting away from lack of use or disuse often referring we think of it in terms of muscles and such so atrophy when I when I sometimes I'm examining a woman and I comment out loud oh it does look like atrophy that's scary to her I've had patients say what do you mean atrophy it's shriveling up and and what's going on down there so the other concern about the term atrophy it doesn't encompass the urinary complaints that women get the urethra and the vagina are in the same area and they can have similar sensitivity to estrogen and the changes in estrogen so what we're talking about though I will say atrophy again because I still don't have it out of my vocabulary yet so the genitourinary syndrome of menopause I'm working on it but the estrogen effects on the vagina and vulva are well documented we know that estrogen helps maintain a healthy vaginal pH which can affect your vaginal flora it can help with natural lubrication also affects the collagen in the vaginal walls which can affect elasticity of the walls and comfort with intercourse and then the volver skin as well sometimes can get very thin dry can have fissures and abrasions and such other symptoms we mentioned the vaginal dryness painful intercourse but a propensity towards certain vaginal infections chronic vulva pain burning with urination urinary tract infections and sometimes even bleeding from contact from vaginal tissues I have another slide though coming up to talk a little bit more about what the genitourinary syndrome of menopause encompasses so sexual function is another big issue and mostly what I see are women complaining a painful intercourse or women complaining of changes in their libido or sex drive generally a reduction in the libido distressing sexual problems can be more common in menopause and studies show that this this complaint peaks at the ages of 45 to 64 and then kind of plateaus after that and doesn't continue to decline testosterone levels we know do decline naturally with aging the testosterone level of a 40 old woman is going to be probably about half the 20 year old woman it declines gradually however after menopause so while we look at estradiol as going through and progesterone a more abrupt decline the testosterone actually continues at the same level so you have an imbalance for a period of time between your testosterone estrogen and sometimes that can result in women feeling like they're getting acne maybe little hairs on their face other studies have shown that the your level of blood testosterone because women do come in again asking for hormone tests asking for testosterone to be checked but we haven't seen in studies a clear correlation of an actual a low testosterone level with a low sexual desire so it's a little bit difficult to look at a testosterone level in a given woman and predict what her sexual function will be and as I mentioned before changes in the vaginal wall due to low estrogen leads to painful intercourse for some women and that is a frequent cause of sexual dysfunction after menopause osteoporosis I think there was another talk last year from one of my colleagues on osteoporosis so I'll talk about it briefly but it's defined as compromise bone strength it is a significant health concern for women 13 to 18 percent of white American women over the age of 50 have osteoporosis of the hip lower estrogen levels account for about two-thirds of the bone loss during the five to seven years around menopause and I put the definitions of BMD that's bone mineral density the type of scan is called a DEXA scan and there the t-scores or how we define osteoporosis basically looking at your bone density compared to that of a healthy young adult and that's listed in standard deviations urinary symptoms are also common urinary complaints such as urinary incontinence both stress incontinence and urge incontinence overactive bladder weight loss and Kegel exercises can be helpful for both and there are several medications that are approved for overactive bladder as well weight gain I mentioned that as one of the common concerns for my patients or reasons for seeking care with me and it's mainly related to aging and lifestyle though many women feel like they're gaining a lot of weight around the time of menopause the studies that's been conflicting what studies have shown but over the menopause transition you can expect about an average weight gain of five pounds during those those years and there are changes in body composition and fat distribution however that have been shown to be independent of aging and this includes an increase in fat accumulation in the abdominal region decrease in lean body mass and an increase in visceral abdominal fat so that's the bad fat that surrounds your organs that can be associated with cardiovascular disease diabetes and metabolic syndrome and then also decrease metabolic rate or energy expenditure has been shown to be associated with menopause so do hormones help you lose weight no but they may ester estrogen may attenuate some of this these metabolic changes and some studies have shown that estrogen may also attenuate the propensity to accumulate fat in the abdominal region but I have yet to see any patients lose weight on their hormone therapy so going toward to hormone therapy next I'm going to spend some time talking about this because this also seems to be an area where there's a lot of confusion I'll try to clear that up for you talking about our standard hormone therapy is talking about kind of where we've been in this country with using hormones for menopause symptoms and then towards the end I'll talk about the bioidentical hormone therapies and and the alternatives to kind of the conventional approach so a hormone therapy refers to the estrogen or if you have a uterus the estrogen progesterone combination products and it's been available for more than 60 years some it still seems to be the most effective treatment for hot flashes and vasomotor symptoms and it's FDA approved for moderate to severe hot flashes and night sweats that are bothersome to a woman symptoms of vaginal atrophy though if those are the sole symptoms generally the recommendation is to use the estrogen vaginally and not use it to the point where you would raise your blood estrogen levels also FDA approved for prevention of osteoporosis though not generally a first-line therapy for that anymore so the benefits include as I already mentioned highly effective for the treatment of the vasomotor symptoms positive effects on preserving bone density and reducing the risk of osteoporotic for Jill fractures positive effects on mood including depression and anxiety mostly in the perimenopausal not not necessarily in the postmenopausal women but not also a primary treatment for depression and anxiety so this would be potentially in patients who have pre-existing mood disorders they may they may do better on estrogen therapy also beneficial for as we mentioned already prevention of vaginal atrophy and its associated problems including dryness bleeding and painful intercourse so where have we been with menopause hormone therapy in the u.s. menopausal hormone therapy has been used for menopausal symptoms since the 1960s at that time it was given just as estrogen so it was formulated in a way that women could take it orally and they were using estrogen for their symptoms and then in the 1970s it was discovered that there was this strong association of estrogen use with endometrial cancer cases and women who obviously had a uterus so there were more endometrial cancer cases and this was discovered and after that was the development of progestin thetic progesterone type products which we call progestins to add to the estrogen and what that does is antagonize the effect of estrogen on the endometrium and it basically brings your risk of endometrial cancer back to baseline so in the 1980s there was a bit of a resurgence in use of hormone therapy with just with this discovery with the addition of the progestin and with the development of combination products where you could take your estrogen and your progestin together in one pill this was the one-size-fits-all that I was trained on in the mid 90s where I I don't like to use brand names but I'm throwing it out there because this was Prem Pro was the most widely prescribed hormone therapy in the US and there were different dosages but only only a few and there was one standard dose that that's just kind of what we started everyone on including older women who were quite a bit older sometimes in their 70s and we had data to suggest that hormones were helpful in preventing heart disease and frac and and or helping prevent osteoporosis we didn't have the fracture date yet but and so I still remember being an intern and and the residency clinic here at UCSD trying to push a little ladies you need to take your hormones it does this this this and at that point they had never been on hormones and some of them looked at me like I was a little crazy but but that's what we thought at the time we thought there were so many benefits based on a lot of observational data that we really thought all women should be on it regardless of when they started and that's what's really changed which I'm leading up to so as I said many observational studies were there were were being published at that time showing the benefits of hormone therapy but there was also starting to be in the 90s some more papers about breast cancer risk and the association of hormone therapy with breast cancer so by the mid to end part of my residency all we talked about was hormones and breast cancer trying to figure out are these observational associations real or are they just result of the way the study was done and the Nurses Health Study is one of the largest observational studies of women's health over time and that was where we get our data really from the reduction in cardiovascular and bone benefit and decreased mortality and hormone users or how we were counseling patients back at that time so then in the mid 90s to early 2000 randomized control trials started to come out they're different from observational studies in that they're they're actually showing that the association is is causative so the two trials that looked at cardiovascular health were the Pepi trial in the hers trial the Pepi trial was in healthy women and the hers was in women who had pre-existing heart disease while the Pepi trial did show some benefits on certain cardiac risk factors didn't necessarily look at at heart attacks but looked at favorable effects of estrogen on different cholesterol measures and also showed improvement in bone density the Hearst trial did demonstrate that hormones did not reduce heart disease risk and women with pre-existing heart disease so they seemed to do worse on hormones so what we learned from that was still a little bit confusing because now we're saying well one trial looks kind of favorable and the other one well okay we're not going to give it to them with heart disease so again starting to kind of tease out what the real benefits are but but with the addition of these randomized control trials we were developing more getting more data then July 2002 came along and that was the month that we had the publication of the initial findings from the very large Women's Health Initiative study the primary outcome was to answer this question that we saw that that or this observation that we saw in the other studies the observational studies do hormones prevent heart disease and other secondary outcomes they looked at were osteo product fractures colorectal cancer dementia and risks let's also do a secondary analysis at what what are really the risks so part of what's behind this study is that the company that produced one of the hormone products that was used in the in the trial which was goes by the brand name creme Pro and the estrogen only part is premarin they were actually asking the FDA to have an indication labeling on the package label even for hormones stating that hormone therapy reduces the risk of heart disease based on all this observational data we have and interestingly in 1991 the FDA advisory committee voted in favor of that of giving the company an indication for estrogen therapy and reducing risk of heart disease at postmenopausal women and then they said well wait a minute you know bring us a randomized control trial that demonstrates this and then we'll give you your labeling and that didn't happen so so you know the study is I'm sure a lot of you are familiar with the study but it stopped early due to an increase in breast cancer risk and this is the the first arm of the study that stopped early after a little bit over five years was the women who had their you to had the uterus and we're taking the prim Pro so they were on the combination of the conjugated estrogen and the synthetic progestin so they were taking both hormones combined in one pill they found an increase in risk of breast cancer an increase in blood clots stroke heart disease but they did also seen a reduction in hip and spinal fracture and a reduction in colorectal cancer so this was actually an important finding this was the first randomized control trial showing that estrogen reduced the risk of hip fracture so that was exciting but really the focus in the media and for patients was the risk and the question of what what they should be doing the WHI ii was the other arm of the study where women had had hysterectomies and they were taking the estrogen only and that stopped early as well it went on for 7.1 years and interestingly it stopped because there was a statistically significant increase in the risk of stroke in women at and that's why they closed the study and blood clots but they did not see an increase in breast cancer risk if anything there was a trend towards decreased risk so this was really important for us very important for us to understand the different effects of this particular estrogen versus the combination of estrogen with progestin and we started to think actually that there may be something with the progestin we use or the combination of both hormones that may be having an adverse effect on the breast so it also gave us more comfort in giving our patients who had had history who had already had hysterectomies estrogen only at least for the period of time in this study we had some data to to support that the breast cancer risk you know probably isn't increased so what's happened since then well a lot of papers were written on the anniversary of the Women's Health Initiative study July 2012 about kind of the 10 years since the Women's Health Initiative study where have we come and since that time there were many sub analyses done of the study different different versions coming out looking at risks benefits in different age groups there was a dramatic decline in prescriptions for menopausal hormone therapy in the u.s. particularly in those few years and after the publication of the initial study there was a rise in alternative therapies for menopausal symptoms herbal products which people felt were safer possibly because they were natural then there was the birth of the bioidentical hormone therapy industry where patients were looking for other alternative ways to get hormones through compounding pharmacists and there were non hormonal therapies also that that were explored and studied including a certain class of antidepressants that increase brain serotonin or some products serotonin norepinephrine levels and gabapentin which is a product used off-label for hot flashes as well there was a focus on short-term treatment of symptoms that gosh maybe we shouldn't be leaving women on hormones for the rest of their lives and a focus on the dose well maybe it's not a one-size-fits-all dose maybe lower doses different ways of giving the hormones would have different risks so where are we now well similar to the last slide I mentioned that there were seven Alexei's done of the Women's Health Initiative study and we know now in there seven alysus of women ages 50 to 59 less than ten years from menopause that they didn't see an increase in heart disease risk those women didn't have the blippin heart attacks in the first year after starting hormone therapy some of them were young healthy or most of them we think were young and healthy and even blood clots and stroke when you look at the absolute risk that the number of cases per 10,000 women was low enough to put them in a rare risk category we looking back at the WHI we remember that the median age of women in that study was 63 years old with a very wide age range women were included from age 50 to 79 so there were many older women in the study so we know now that we're no longer using hormone will no longer use hormone therapy for chronic disease prevention in older women or even for chronic disease prevention in younger women so we we don't were not using hormones to prevent diseases at this point really to treat the bothersome symptoms but we're certainly not starting older women who have never been on hormone therapy and they're more than ten years from menopause or over the age of 60 we're not recommending that they start on hormone therapy at that later age due to the cardiovascular risks however most women if they're going to tough it out it's usually not that long when they're over the age of 60 but so you don't see those patients often but I do sometimes see those women who have maybe been told to stop their hormones and have stopped and it's been a few years and now they're over 60 and they want to restart and nobody wants to restart them there's also been an idea that there's maybe there's a timing of initiation for hormone therapy perhaps there's a safe window in terms of cardiovascular risk where you have fewer risks if you start the hormone therapy within 10 years of the last menstrual period or less than the age of 60 maybe we can really attenuate the development of atherosclerosis if we start early enough as opposed to starting early or this boat as opposed to starting later when perhaps a woman maybe already has some subclinical a thorough sclerotic plaques that she's not even aware of and we have some preliminary data coming out randomized control trials showing that estrogen given in an early window may attenuate the development of atherosclerosis but larger trials are needed at this time are there safer routes of delivery well we have about five observational studies now that show that transdermal estrogen is associated with less blood clot risk than oral so perhaps giving estrogen through the skin can attenuate some of the risks in terms of blood clot and stroke and of course the focus on using lower dosages we're never going to have another Women's Health Initiative study done for every preparation every dose every every route of delivery for hormones so to some degree we won't have all the data we need but it stands to reason that maybe exposing the body to less estrogen for a shorter period of time would be optimal and then minimizing the breast cancer risk well again based on the Women's Health is study the study that stopped at five point two years the breast cancer cases really didn't start to the rise wasn't really see until about three to five years so perhaps just with the shorter duration we keep people women on in terms of breast cancer risk less than five years we can minimize that risk and maybe even it's the progesterone so some studies coming out from or that have been published from Europe show a large observational study showed that there were some different effects on the breast in terms of breast cancer risk if natural progesterone was used as opposed to the synthetic progestin s-- so where we are now again is the importance of individualized therapy so no longer a one-size-fits-all approach duration of symptoms may exceed one to two years we need to realize that though that so some women we want to minimize the risk but some women may really still have a need for hormone therapy even after just a few years so we do recognize the need for long term hormone therapy and some women and allow them to make their decision based on a good understanding of the risk fs:i already mentioned the route of administration the dose may be the type of progestin may impact risk and then we've got some new new therapies for treating menopausal symptoms so Brazil is low dose paroxetine which is SSRI or antidepressant that increases brain serotonin levels and that has been fda-approved in 2013 in a low dose doesn't seem to carry with it the same side-effects that some of those antidepressants have like weight gain and reduction in libido and not really clear if it's as effective as estrogen for treating the hot flashes doesn't appear to be based in their placebo control trials but it is a good option and then we've got Bay's of Doc's afine and Cee that's conjugated equine estrogen both a long name but it's basically for women with uterus who need estrogen and are having bothersome hot flashes they don't need to take up progestin with it because the beta toxaphene compound actually blocks the effect of estrogen on the uterine lining so how nice for especially for those women who maybe can't tolerate the progesterone have a lot of side effects from the progesterone believing breakthrough bleeding there seems to be less bleeding as well so it's a new product it'll be interesting to see where it goes but it is nice to see some new products that are being FDA approved that may actually have a better risk Pro so she ated with them or fewer risks so when we talk about using estrogen for menopause symptoms I definitely like to distinguish two patients the difference between using systemic therapy that is where you're trying to raise your blood levels of estrogen to treat say hot flashes night sweats or when you're using local therapy the systemic therapy is what we're talking about in terms of the risks of breast cancer blood clots the local therapy really should not increase blood levels of estrogen significantly it's a low dose of estrogen that's meant to be delivered to the vagina and not significally increase blood levels however some people get confused they get their vaginal estrogen they open up the package label and I now warn my patients of this and there's a black box label for estrogen and all the risks from the Women's Health Initiative study are in there outlined and I have to explain to patients it's going to say that because it has estrogen in it but it doesn't being that it's going to cause breast cancer blood clots the vaginal estrogen has not been associated when it's used in the low dose just for for local treatment has not been shown to have the same risks so patients could feel more comfortable using those therapies if that's their primary symptom the nice thing about also since the WHI is I feel like there's more options products available for how to give estrogen a variety of different formulations with a lot of different dosages I don't remember all these dosages when I was in my residency they might have been there maybe I just never learned about them but we've got oral pills transdermal patches topical creams gels mist and the vaginal ring and there's also a higher dose vaginal ring that can be used for hot flashes so you can actually deliver that systemic level of estrogen through the vagina but mostly what you'll hear about is the ring that's used for dryness and thinning or atrophy and we talked about already that the women who have a uterus should add a progesterone to the estrogen to minimize the risk of endometrial cancer we talked about the risks already so my ideal candidate for hormone therapy is a woman who's recently menopausal or perimenopausal so a younger patient relatively speaking within 10 years of menopause less than age 60 highly symptomatic so having bothersome vasomotor symptoms which i think are going to be most effectively treated with estrogen no contraindications to hormone therapy and no breast cancer history of blood clots or stroke irregular bleeding that we haven't worked up yet or active liver disease and hopefully is an overall low risk for cardiovascular disease I put these slides up not to confuse you with yet more terms names brands terminology but more to show you just how many options there are these are the oral estrogen formulations we've got the transdermal formulations patches and the gel the patches can be once or twice a week in varying sizes the gels can be given as a pump in packets and there's even a mist and then there's a combination product so the list keeps going here so we've got the oral products and then the transdermal patches so this is one situation with the transdermal patches that combination patches where progesterone doesn't have to be taken orally it can be given through the skin there's some concern with using custom compounded progesterone creams if you're also on an estrogen that's a systemic estrogen because there's conflicting studies about how well that progesterone really absorbs into the body and protects the enemy trim of the lining from the effects of the estrogen the vaginal preparations I mentioned already but it is good to know that there are three types for for vaginal dryness or atrophy vag afem the e-string and the creams either primer interested ice creams those are all brand names I don't usually like to use brand names in my talks but unfortunately we have no generics for these vaginal products so that is one situation where I have some patients asking can I go to that compounding pharmacy downtown because if it's cheaper I can't afford this it's good co-pays are getting high so so that is one case where some patients are you know will be interested in an alternative if it's less expensive but our products that we can really count on for consistent dosing are the ones that are here not so many options for the progesterone I like the micronized progesterone we talked about the studies from Europe showing possibly more favorable effects on the breast in terms of breast cancer risk it's now in a generic formulation which is really nice so that's a cost savings but the synthetic progestin czar around to the various names are there the two bottom ones the north end drone levonorgestrel we're very familiar with because they're also used in birth control pills but of course for for menopause hormone therapy there it's much lower dosages so how long should you stay on your hormone therapy well that's a question that many women come to me asking and most of the data we use is from the Women's Health Initiative study so that's really our biggest trial to date but unfortunately for those who want to use hormone therapy long term say over the age of 60 maybe they started it in their early 50s they feel well they tried to stop the hot flashes came back the whi data doesn't necessarily extrapolate to these women at least in terms of cardiovascular risk long-term use yes is going to be associated with an increase go breast cancer but in terms of the cardiovascular risk we don't know if continuing on if perhaps maybe they've already had some benefit from starting the estrogen early in that window I talked about so it's hard to compare the risk from the Women's Health Initiative study to the woman who has been on their hormone therapy for several years as she might actually have had some cardiovascular benefits we just don't know and that should say not here but heart disease risk I mentioned already that we don't put women on who are more than 10 years from menopause not typically and over the age of 60 I try to look at certainly encourage them to try other alternatives for their symptoms rather than starting hormone therapy so when women stop hormone therapy what can they expect well 50 percent chance of the vasomotor symptoms recurring when hormone therapy is discontinued this has been shown in studies and whether to taper or stop abruptly or cold turkey is not really clear one is going to be superior to the other I generally have my patients taper off the hormones over time particularly they've been on it for several years there's really no reason why they have to stop you know the next day and I think most patients like that they'd rather kind of take it slow and just kind of see how they feel and see how things go and you know clearly the decision to continue hormone therapy should be individualized so every year when my patients come back for their annual exam we talked about the hormones any new new research any new findings new recommendations and really looking at what they are interested in doing in terms of continuing the hormones nobody went out that I know none of my patients were interested in tapering in the last week when we had the heatwave by the way so that was that wasn't gonna happen ok so we talked about some of the new treatments for hot flashes there's also a new oral treatment for painful intercourse it's also kind of like the BAE's of Doc's afine and in the medication do IV it's similar it's an estrogen stimulator at some tissues in an estrogen blocker at other tissues and this is for the vagina so it's been compared against placebo and seems to improve the symptoms of painful intercourse but has not been compared against vaginal estrogen so we don't really know if it's necessarily better or superior to products we currently have so what about testosterone well we could be here I don't know another couple hours we're going to talk about the controversy with this and the controversies just with treating female sexual desire disorders there's a lot been written in the press recently about developments to get for the FDA looking or for a drug company looking to get approval from the FDA for a drug to treat low sexual desire and pre menopausal women and postmenopausal women we sometimes use testosterone off-label to treat postmenopausal women with low sexual desire but it's with mixed data it's not FDA approved it is controversial and there are many studies out there showing that testosterone for postmenopausal women with low libido works but the data the studies are different in terms of the way they deliver the testosterone the dose and you tend to see more efficacy that the testosterone works better in the studies where they were using a higher dose but then you may be getting more side effects such as acne hair growth deepening the voice so we don't want to get into problems with those risks but then other studies using a lesser lower dose seem to show a lesser degree of efficacy in terms of improving libido but seems safer so I think we're kind of in a limbo right now with it with having a testosterone product that will be FDA approved for women we've come kind of close with a couple products but there's still some concerns about safety long term effects and side effects so I mentioned already the the genitourinary syndrome of menopause but I just wanted to mention a few things with these this term as I said we we wanted to include the full spectrum of changes that also occur to the lower urinary tract with the decline in estrogen as well as the vagina and there are some studies that frequent sexual activity or use may listen some may lessen symptoms but many sexually active women still experience symptoms related to the changes in the vaginal wall so it's not just having more sex when it hurts is going to resolve the problem so we definitely need to wreck that you know we need to treat painful intercourse early on and interestingly a international survey the Viva survey from 2010 showed that women prefer a different term when they were asked with what term they would give only two percent chose vaginal atrophy as a suitable term so I thought that was pretty telling that women don't like that term it doesn't sound good to me either so this is a big list of the various symptoms signs but adding the urethra urination valve are the the external not just the vagina but the vulva area could be affected as well irritation burning itching and all the various changes you see here so up to 40% of women experience these symptoms but only 25% seek help from a health care provider and the symptoms will not necessarily just get better so while some women feel like well maybe I can my hot flushes aren't that bad I can kind of wait it out if you're having symptoms from such as vaginal dryness painful intercourse that's not necessarily going to get better just with time if anything due to the sustained low estrogen levels without treatment likely it will get worse mild atrophy though or mild symptoms we can manage with non prescription therapies more moderate to severe changes with with with significant symptoms generally we would go to local hormone therapy or those vaginal estrogens I showed you in the other slide as our first-line treatment I give a patient's a list of vaginal moisturizer vaginal lubricants different things they can try their non hormonal some of them are some of them have various depends on chemicals there's also options there that have that are more natural with fewer chemicals that people are concerned about even natural oils olive oil avocado oil so patients are often very grateful just to have that information just that this it's simple this isn't complicated science but just to have some resources for sexual dysfunction can be really helpful one more slide with all our our vaginal products so that's what we'll go to what I go to if the symptoms are more severe or if the over-the-counter products are not really helping so in terms of what to choose that's another thing these days I feel like it's more going to be cost what your insurance company will cover because as I said they're they're not available in generic form so they can be costly the cream can has the benefit of applying directly to the Volvo so it's a good option if they're having external symptoms and some women do get some direct symptomatic relief just from putting a cream on the area that's affected but a lot of patients concern complain that it can be messy and then they can feel that it kind of comes out and doesn't adhere well to the vaginal walls so you kind of have to talk about the patients in terms of what I choose is really going to kind of depend on the patient the tablets are definitely neater there's small tablets that are pre-loaded on an applicator you use them twice a week the dose used to be 25 micrograms but in the past few years has been lowered to 10 micrograms and we're hoping that may lower the risk of stimulation of the uterine lining which is not common with the vaginal estrogens but Ken you know has been reported so a lower dose and minimal increase in serum or blood estrogen e 2 is estradiol levels and the ring every three months dosing women have to be comfortable putting it in taking it out and some just like the fact that they don't have to think about two times a week with a product or having you know a messy discharge from the product so really again depends on the patient I talked about the pill already I don't have a lot of patients taking it I have a lot of patients who've seen the commercial it's a pretty cool sexy commercial and so they asked about it but for whatever reason when we talk about using it as a pill I don't have a lot of patients that seem interested at this time but it is nice to have an oral option for painful intercourse dyspareunia is the medical term for painful intercourse so what about compounded bioidentical hormone therapy well it's confusing and I think it's it's just been confusing for patients to understand what all the terms are natural versus synthetic and plant-based and compounded versus you know fda-approved it's it's it's confusing so really it's an attempt to customize the dose of hormones to in to individualize therapy more to more mimic the reproductive hormone levels it's not FDA approved if it's from a compounding pharmacy there's some concern depending on where you get the products for that there could be a lack of consistency in the product from batch to batch possibly a concern for contaminants regulation of the product so certainly women who are asking me or seeking this type of therapy I do look for certain things in a compounding pharmacy such as certain regulatory standards that they meet and also standards for sterilization some patients come to me after they've paid out of pocket for a long time seeing a provider who doesn't take insurance maybe or has them come back every few months to check their saliva levels and might be kind of tweaking their hormones based on their saliva level despite the fact that maybe the symptoms are already resolved and you know what do we have to keep kind of treating a level when my symptoms are better so I've had that happen and the cost is not so much for the compounding pharmacy I mentioned sometimes they're even a cheaper option the cost is more for patients who are coming back kind of for frequent lab tests and maybe not covered by insurance and such but really the bottom line is we really have no definitive evidence that compounded hormones are superior to conventional hormone therapy there's some suggestion with the progesterone that it might be more beneficial and not that is a bioidentical but we just don't really know so bioidentical is according to the FDA and endocrine society it's really not a medical term it's more of a marketing term a better term probably would be biosimilar where the estradiol and progesterone that are being compounded are physiologically similar to the hormones you're over used to produce natural means not artificial and there are plant-based prokhor sir's used to produce progesterone and the plant derives are sometimes perceived is more natural or better tolerated than synthetic or animal derived products so I put this up to show you the range of fda-approved bioidentical or biosimilar hormone therapies that we actually have a lot so that's kind of the first misconception that I clear up with patients is that actually if you're interested in bioidentical hormone therapy well there's there's many that perhaps your insurance will cover so we have plenty that are FDA approved it just got confused the term bio identical with compounded and so I'd like to clear that up and we also have the progesterone the bioidentical progesterone as well so bottom line I mentioned there isn't before there isn't necessarily the data that there that bioidentical hormones are safer and they can be obtained from conventional pharmacies many are FDA approved plant derived hormones still need to be synthesized into a form we can use so the term synthetic gets thrown around a lot but actually you know even in a plant based hormone is eventually going to be needed to compound it into a cream or a pill or something that you can actually use then I mentioned before that there's some evidence that the bioidentical progesterone or micronized progesterone may have more favorable side effect profile on the breast in terms of breast cancer risk than the synthetic progestin 's so that is it and just to plug my program I have a consultative service for women in Perry post menopause I give information about menopause considering starting hormone therapy or alternative therapy for symptoms I mentioned I have patients who come in looking for advice on using hormone therapies long term or trying to figure out how best to discontinue their hormones I definitely do a lot of troubleshooting with patients to try to get the the hormones right manage whatever side effects symptoms they're having and women also just interested in preventive health care in midlife and cancer screening so coming soon as of April third I'll be a nun status so I hope to see some of you there that's it thank you so much for your time

and so I'd like to open up now for questions yes you know I think our concerns in that age group are also cardiovascular health and bone health so and possibly for cognitive changes so we tend to in those younger women look at giving them estrogen at least I do you know and and others I know giving them estrogen until the time of around the age of natural menopause which is about 51 so you know giving them the hormones that would have been circulating in their body till the till the natural age of menopause but there is concern for not only the cognitive but increased osteoporosis risk and possibly increase risk of cardiovascular disease down the low down the road you know the lack of sleep it first of all the suggestions kind of depend on whether they're from night sweats no just insomnia yeah so there are some well first of all you want to do all you can with your sleep hygiene so which I'm sure you probably already have done all right so I give patients a handout of kind of ways to control your environment in your sleep environment to help with sleep things that are more conducive to getting a good night's sleep if that's not helping there are low-dose products antihistamines some women use that are over-the-counter non-sedating yeah yeah and it's hard again when you say there's a link you kind of have to look at the study again sometimes the associations don't mean causation if it's an observational study so there's lots of studies out there showing lots of associations and so that's why kind of looking at the data is important but and there's other other options too I mean there's low dose antidepressants that some women use in a very low dose that would never be at the dose to treat depression but just a fraction of the dose because of the sedating effects so that's something that I've seen other practitioners use in their patients with sleep disorders and the other thing is to really talk with your primary care doctor about kind of exactly what the pattern is of your sleep disruption possibly screening for sleep apnea things like that so that's what I would suggest so I would bring it up earth your internist because there are other options beyond just you know a benadryl or an antihistamine so alright thank you very much again for your time


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Almost 6,000 women in the US reach menopause every day. Kathryn Macaulay, M.D. explains common symptoms of menopause and its potential health effects. Learn the latest methods of managing symptoms and utilizing newer therapies. Series: "Stein Institute for Research on Aging" [5/2015] [Health and Medicine] [Humanities] [Show ID: 29117]
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