Menopause and Post Gynecological Reproductive Care

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1 Menopause and Post Gynecological Reproductive Care Nguyet-Cam Vu Lam, MD, FAAFP Associate Program Director St. Luke s Family Medicine Residency 1 Disclosure Dr. Nguyet-Cam Vu Lam has no conflict of interest, financial agreement, or working affiliation with any group or organization. 2 Objectives Understand the physiologic changes that happen to women as they move through the menopausal transition. Understand routine preventive care for postreproductive women. Recognize common gynecologic issues in postreproductive women with some understanding of diagnosis and treatment options Know the indications, contraindications, risks and benefits of hormone replacement therapy. 3 1

2 Definition Menopause is defined as the permanent cessation of menses. 12 months of amenorrhea. Median age at menopause is 51 years old (range 40-58). With life expectancy approaching 80 years, the average women is postmenopausal for 1/3 of her life. Family physician can address both management of menopausal symptoms as well as preventive health care measure. 4 Perimenopause Most women start to have physiologic changes associated with menopause in years prior to the final menstrual period. Menopausal transition has fluctuated hormone levels as ovarian function starts to decrease. Serum estradiol and progesterone decrease and follicle-stimulating hormone levels increase. These changes result in menopausal symptoms such as vasomotor (hot flushes) and vaginal symptoms. 5 Case: 54 years old woman come for routine visit Tearful, afraid that her marriage of 20 years is falling apart. She and her husband argue frequently; patient alternates between tearful and angry for no apparent reason. Last menstrual period 2 years ago 6-7 hot flashes daily disrupt her sleep several nights/week. Intercourse is painful, decreased interest Exam: thin pale vaginal epithelium, all other exam within normal limit 6 2

3 What do you want to do as her family physician? Many women with menopausal symptoms that significantly impair their quality of life never report them to their physician. Approaching the subject with perimenopausal women, rather than waiting for them to initiate the discussion is an important first step. Common menopausal symptoms including hot flushes, atrophic vaginitis, insomnia, diminished libido, and hair loss, can be treated successfully with a variety of hormonal and non-hormonal agents. Many women find it challenging to deal with both the physical and emotional ramifications of this new 7 phase in life. Hot flushes: How often? How severe? Sudden sensation of extreme heat in upper body, face, neck, chest lasting 1-5 minutes. In up to 75% of menopausal women. Most severe in the first 2 years of menopause. (lasting a median years) Broad spectrum of frequency and severity. Risk factors for greater severity and frequency: Surgically or chemically induced menopause Elevated body mass index History of tobacco use African American ethnicity 8 What is the most effective treatment for perimenopausal vasomotor symptoms? A. Compounded bioidentical hormones B. SSRI s C. Estrogen or Estrogen/progesterone combination D. Gabapentin 9 3

4 Options for treating hot flashes Hormone therapy (HT): Estrogen alone or estrogen-progesterone combination Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) or selective serotoninnorepinephrine reuptake inhibitors (SNRIs) Antiepileptic: gabapentin (900mg/day) Antihypertensive: Clonidine, Methyldopa Herbal supplements: Black cohost, Mg, Omega-3- fatty acid, Red clover, St. John s wort. Lifestyle/alternative: Acupuncture, avoidance of triggers, physical activity, yoga 10 Systemic HT-Level A evidence Systemic HT, with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms related to menopause. Low-dose and ultra low systemic doses of estrogen are associated with a better adverse effect profile than standard doses and may reduce vasomotor symptoms in some women. 11 Systemic HT-Level A evidence Given the variable response to HT and the associated risks, it is recommended that health care providers individualize care and treat women with the lowest effective dose for the shortest duration that is needed to relieve vasomotor symptoms. The risks of combined systemic HT include thromboembolic disease and breast cancer. 12 4

5 A critical look at HT Estrogen/progesterone combination for women with intact uterus, and estrogen alone for those who ve had a hysterectomy is highly effective, alleviating hot flushes and other menopausal symptoms 80-90% of the time. Women health initiative in 2002 reported increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolism in women aged years after 5 years of combined HT. 13 HT-reanalysis of the WHI Women <60 years old and within 10 years of the onset of menopause, HT appeared to be a safe short-term treatment. Women >60years old and at risk for cardiovascular disease or breast cancer or both, should not take HT. Cochrane review of HT in 2012 stated that HT should not be used for primary or secondary disease prevention because the risks of use outweigh the benefits. 14 Ways to minimize risk with HT Limit duration of HT to the shortest treatment required Use a transdermal delivery system (lower risk of thromboembolism) Prescribe low-dose HT regimen. 15 5

6 Discontinuation Discontinuation of HT may associated with recurrent vasomotor symptoms in 50% women. ACOG recommends against routine discontinuation of systemic estrogen at age 65 years. The decision to continue HT should be individualized and based on a woman s symptoms and the risk-benefit ratio, regardless of age. (Level C) 16 Contraindications to menopausal hormone therapy Active liver disease Active or recent arterial thromboembolic disease Current, past or suspected breast cancer Known hypersensitivity to the active substance of the therapy Known or suspected estrogen-sensitive malignant conditions Porphyria cutanea tarda (absolute contraindication) Undiagnosed genital bleeding Untreated endometrial hyperplasia Untreated hypertension 17 Other hormones Progestin: used as an add-on agent to estrogen therapy to prevent endometrial hyperplasia and endometrial cancer in women with a uterus. There is some evidence that progestin may improve vasomotor symptoms, but limited data on the safety of progestin alone compared to estrogen-progesterone preparations. Testosterone: no benefit for treatment of vasomotor symptoms. 18 6

7 Compounded bioidentical hormones Some women prefer compound hormones, individualized based on results of blood and saliva testing. Bioidentical hormones are plant-derived hormones that are chemically similar or structurally identical to those produced by the body. Market as safer and more effective. There is limited evidence of their efficacy. Lack of standardization resulting in variations in 19 formulations and dosages. What s the evidence? Data do not support the use of progestin-only medications, testosterone, or compounded bioidentical hormones for the treatment of vasomotor symptoms. (Level B) 20 Non-hormonal medications and vasomotor symptoms SSRIs, SNRIs, clonidine, and gabapentin are effective alternatives to HT for the treatment of vasomotor symptoms related to menopause. (Level A) Paroxetine is the only non-hormonal therapy that is approved by the FDA for the treatment of vasomotor symptoms. (Level A) 21 7

8 Antidepressants and hot flushes Both SSRIs and SNRIs help to reduce the severity and frequency of hot flushes because they target neurotransmitters involved in the hypothalamic thermoregulation center. Women who have hot flushes have 2X increase in risk for depression Venlafaxine, desvenlafaxine, and paroxetine have been shown to provide best vasomotor symptom relief (67% vs 15% in placebo). 22 Other agents and hot flushes Clonidine (central acting antihypertensive) and antiepileptic (gabapentin) may alleviate hot flushes, but none is an optimal treatment. Clonidine (0.1 mg/day) has been shown to be effective in both oral and transdermal form, but less benefit compared to HT. Gabapentin (900mg/day) reduces the frequency of hot flushes, but cause nausea, headache, dizziness, and confusion. Both clonidine and gabapentin are not FDA approved for treatment of vasomotor symptoms in menopause. 23 Behavior and lifestyle changes and hot flushes Exercise has not been found to improve or worsen hot flushes, but does improve mood swings associated with menopause. Lifestyle changes such as limiting alcohol, decrease spicy food intake, avoiding hot drinks, eliminating caffeine may decrease frequency and severity of hot flushes. Layering of clothing, maintaining lower ambient temperature, and consuming cool drinks are reasonable measures for the management of vasomotor symptoms. (Level B) 24 8

9 Alternative therapies? 25 Acupuncture/Herbal remedies and hot flushes In 2010, Cochrane meta-analysis of 30 placebocontrolled trials of high levels of phytoestrogen for treatment of vasomotor symptoms showed no evidence of benefit. Currently, there are insufficient data to support the use of herbal remedies for menopausal vasomotor symptoms. The herbal treatments that have been studied are: black cohosh, ginseng, St. John s wort, and ginkgo biloba, dong quai. Acupuncture: no benefit over placebo for vasomotor symptoms. Reflexology: not significantly reduce vasomotor symptoms compared to non-specific foot massage. 26 Menopausal symptom: vaginal atrophy Vaginal atrophy is a direct consequence of the hypoestrogenic state associated with menopause. About 10-40% of menopausal women will have 1 or more symptoms of vaginal atrophy. Symptoms: vaginal or vulvar dryness, discharge, itching, dyspareunia Thinning of vaginal epithelium, and loss of ruggae can be seen 2-3 years after the onset of menopause. 27 9

10 Vaginal atrophy Measures of sexual dysfunction are noted to be present at higher rates in women with vaginal atrophy than in unaffected menopausal women. These symptoms may have a negative effect on the woman s quality of life, self-esteem, and sexual intimacy. 28 Menopausal symptom: vaginal atrophy (continue) Common symptoms include: vaginal dryness (75%) Dyspareunia (38%) Itching, unusual discharge, pain (15%) Urinary tract infection secondary to atrophic vaginitis are common. Only 25% of women report them to their physicians. 29 Which of the following is true regarding postmenopausal atrophic vaginitis? A. Vaginal cream is the preferred vehicle for delivering vaginal estrogen. B. Urinary symptoms may include dysuria, hematuria, increased frequency of urination and incontinence. C. Regular sexually activity is harmful to overall vaginal health. D. Vaginal moisturizers help to reverse atrophic vaginal changes

11 Treating atrophic vaginitis HT Lubricants and moisturizers Topical estrogen: creams, pesary, tablets, vaginal ring Sexual activity: mechanical stretching; increased vaginal blood flow 31 Topical estrogen and atrophic vaginitis Estrogen therapy effectively alleviates atrophic vaginal symptoms related to menopause. Local therapy is advised for the treatment of women with only vaginal symptoms. Level A HT should not be considered for atrophic vaginitis alone in view of safety concern. However when using it for vasomotor symptoms, patient may find that their vaginal dryness improves. Adverse effects include itching, pain, vaginal discharge, and vaginal bleeding. Endometrial proliferation has not been found to occur within 24 months of continuous use 32 Topical estrogen and atrophic vaginitis (cont) Up to 90% patients using local estrogen show improvement in atrophic symptoms within 3 weeks. Systemic absorption of estrogen is minimal and will declines with use as the thinness of the vaginal epithelial layer resolves. Lowest effective dose should always be chosen for a patient. The 3-months estradiol-releasing vaginal ring is preferred to cream because of greater comfort, ease of use, and satisfaction

12 Estrogen Agonists and Estrogen Antagonists Raloxifene and tamoxifene are not effective for the treatment of menopausal vaginal symptoms Ospemifene (60 mg/day) improves vaginal atrophy without stimulating the endometrium The FDA approved ospemifene for treating moderate to severe dyspareunia in post menopausal women. (Level A) 34 Water-soluble lubricants and moisturizers Non-estrogen water-based or silicone-based vaginal lubricants and moisturizers may alleviate vaginal symptoms related to menopause. (Level B) Short term relief. A variety of OTC lubricants are effective at alleviating dyspareunia. Limited long term benefit Some lubricants may also damage condoms. 35 Painful intercourse Lost of interest in sex Many menopausal women notice a decline in libido, often related to frequent hot flushes or dyspareunia due to atrophic vaginitis. Treatment of the underlying conditions should be first line therapy. Sustained release bupropion (300mg/d) has been shown to increase both sexual arousal and satisfaction in women who are not depressed. Testosterone therapy can be added to HRT to improve libido 36 12

13 Insomnia Insomnia is a common complaint of menopausal women. This could be unrelated to, or as a consequences of hot flashes. Eszopiclone (3mg qhs) has been shown to alleviate insomnia related hot flashes. With sufficient sedation, night sweats and hot flashes go unnoticed and both sleep and mood improve Magnolia bark supplements: may be preferred sleeping aid for women who doesn t want sedating hypnotic. This herbal remedy has been found to decrease anxiety, irritability, and insomnia related to menopause. There is limited research on long-term benefits and adverse effects. 37 Hair thinning Up to 26% of women develop thinning hair at the onset of menopause due to the relative increase in circulating androgens that occurs as estrogen production decreases. Spironolactone has been shown to be a safe and effetive intervention Topical minoxidil (2%) may be helpful in women with hair loss. Cyproterone acetate is also effective. This is administered as an oral contraceptive agent. Up to 88% women have no progression or hair loss 38 Back to our case After discussion of treatment options, patient decided to take venlafaxine for her hot flushes and mood swings. She also use estrogen ring to decrease atrophic vaginitis. At 6 months follow up, patient reported that frequency of hot flashes is down to 1-2 /week, and rarely disrupt her sleep. Patient s mood also improved, and her pain during intercourse had resolved. She was arguing with her husband much less often and currently has a happy marriage!!! 39 13

14 Health Maintenance for Postmenopausal Women Preventive Care Recommendations: Lifestyle modifications, screening, early identification, and appropriate intervention may prevent many chronic conditions that cause morbidity and mortality during menopausal years 40 U.S. Preventive Services Task Force (USPSTF) recommendation statement The USPSTF recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. Grade D recommendation The USPSTF recommends against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. Grade D recommendation 41 The USPSTF recommendation This only applies to postmenopausal women who are considering hormone therapy for the primary prevention of chronic conditions, not for those who want to use hormonal therapy to treat menopausal symptoms such as hot flashes or vaginal dryness. Benefit: reduction of total fractures and hip fracture Harms: increase in breast cancer, PE, stroke, DVT, gallbladder disease, dementia, urinary incontinence 42 14

15 Osteoporosis: Half of all postmenopausal women will have an osteoporotic fracture during their lifetime AAFP/USPSTF: Screen women older than 65 years or starting at 60 years in women at high risk of osteoporotic fractures. Grade B 43 Calcium and Vitamin D Average dietary calcium intake for postmenopausal women in the US is about 600mg/day. NIH recommends that all women 65 years and older take 1500 mg of calcium/day, so most women will need to take supplement. The AAFP/USPSTF recommends vitamin D supplementation to prevent falls in community dwelling adults aged 65 or older who are at increased risk for fall. Grade B 44 Obesity The AAFP/USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. Grade B 45 15

16 Physical activity Regular weight-bearing exercise can reduce the risk of developing osteoporotic fracture in postmenopausal women. The AAFP/USPSTF recommends exercise or physical therapy and vitamin D supplementation in community-dwelling adults aged 65 years or older who are at increased risk for falls. Grade B 46 Tobacco use Cigarette smoking has been associated with earlier onset of natural menopause. Both AAFP and USPSTF: level A Screen all adults for tobacco use and provide interventions for smoking cessation 47 Aspirin The AAFP/USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Grade A 48 16

17 Blood pressure AAFP/USPSTF: Grade A Blood pressure screening is recommended in adults 18 years and older. 49 CHD in women Coronary heart disease is the most common cause of death in women About 1 in 2 women develops CHD and 1 in 3 dies from it 50 Cholesterol The AAFP/USPSTF recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Grade A 51 17

18 Diabetes The AAFP/USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Grade B 52 Breast cancer Breast cancer is the most common non-skin malignancy diagnosed in women and the second leading cause of caner-related death. AAFP/USPSTF: recommended biennial screening mammography for women aged 50 to 74 years. Grade B. AAFP/USPSTF: women aged to be screened with mammography; This should be an individualized decision. Grade C. 53 Cervical cancer AAFP/USPSTF: Screening for cervical cancer in women age 21 to 65 years with cytology every 3 years or, for women 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. Grade A 54 18

19 Colorectal cancer The AAFP/USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. Grade A 55 What is the USPSTF recommendation for lung cancer screening? A. Annual screening for lung cancer with low-dose CT in adults ages who have a 30 pack-year smoking history and currently smoke or have quit in within past 15 years. B. Annual screening for lung cancer with chest x-ray in adults ages who have a 30 pack-year smoking history and currently smoke or have quit in within past 15 years. C. There is no recommendation for screening since the harm of radiation and unnecessary intervention outweighs the benefit of lung cancer detection. D. Biennial screening for lung cancer with low-dose CT in adults ages who have a 30 pack-year smoking history and currently smoke or have quit in within past 15 years. 56 Lung cancer The USPSTF recommended annual screening with low-dose computed tomography in adults aged who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Grade B. Screening should be discontinue once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the willingness to have curative lung surgery

20 Lung Cancer AAFP: evidence is insufficient to recommend for or against screening for lung cancer with low-dose computed tomography (LDCT) in persons at high risk for lung cancer based on age and smoking history. ACS: clinicians should initiate a discussion about lung cancer screening with patients aged years who have at least a 30 pack-year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health. 58 References: Management of menopausal symptoms. Practice Bulletin No American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123: Dickson, GM. Menopause management: How you can do better. J of Fam Practice. 2012;61(3): Hill DA, Hill SR. Counseling patients about hormonal therapy and alternatives for menopausal symptoms. Am Fam Physician. 2010;82(7): Randel, A. AACE Releases guidelines for menopausal hormone therapy. Am Fam Physician. 2012;86(9): Rao, SS et al. Health Maintenance for Postmenopausal women. Am Fam Physician. 2008;78(5):

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