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2 Menopause & Cancer: Anticipatory Guidance Diana L. Bitner MD 2012 MICHIGAN BCCCP / WISEWOMAN / MCRCEDP ANNUAL MEETING 2

3 Why Are We Here? Knowledge is power! VS. 3

4 What is New about Aging? How we age is about choices Many illnesses are predictable and preventable Hormones matter Women are different than men 4

5 Why am I here? OB/Gyn 20 years Menopause specialist Director of the Spectrum Health Medical Group Women s Health Network 5

6 Good women s health practice is knowing ovarian function physiology of thermoregulation complaints of midlife vs. symptoms of hormone change symptom triggers- it s not all hormonal! The big picture of women s health To let the patient be your guide 6

7 Rectangularization of Life

8 What is Normal? Ovary Function: 8

9 Menstrual Physiology 9

10 STRAW 2001 Diagram

11 Menopause Definition: more than 12 months without a period Early: first 5 years likely symptoms most rapid progression bone loss, weight gain Late: after 5 years symptoms better except in subset 11

12 Perimenopause Quiz 1. Is your weight becoming more difficult to control? 2. Are you more fatigued than you think you should be? 3. Are night sweats disturbing your sleep? 4. Have you or someone close to you noticed higher levels of irritability? 5. Have the new stresses in your life created relationship issues? 6. Are you yelling at your kids more? 7. Are you experiencing more bouts of depression and/or anxiety? 8. Has your diet become high in carbohydrates for energy? 9. Do you have a diminished sex drive? 12

13 Symptoms Hot Flashes Mood Changes Disturbed Sleep Body Complaints Weight Change Sexuality Urogenital Irregular Bleeding 13

14 Hot Flashes/Night Sweats Thermostat: Thermo-neutral Zone What makes zone narrow? stress, anxiety, sleep deprivation, smoking cigarettes, over-dressing, overactive bladder, low estrogen, caffeine, wine, sugar, dehydration Frequency increases in perimenopause, 2-10 years 14

15 Thermoregulation Midbrain thermostat

16 Mood changes New depression and anxiety can start in midlife Sleep disturbance Non-hormonal events Medical conditions: thyroid, diabetes, obesity, CAD

17 Mood changes Risk factors: PMS, PPD, family history midbrain Related: brain chemicals and estrogen fluctuations 17

18 Disturbed sleep Interrupted sleep is bad for you! More likely after first REM Linked to all other symptoms: mood, vasomotor 18

19 Body Complaints Menstrual Migraines Aches and pains Heart racing Breast pain Acne

20 Weight change Weight gain in middle age is linked to perimenopause and aging With loss of muscle, metabolism slows More pronounced with co-morbidities

21 Weight Changes 21

22 Sexual Function Midlife is a common time for changes to occur Decreased desire due to midlife lifestyle and physical changes Can lead to decreased intimacy Libido puzzle

23 Sexual Dysfunction The Puzzle Pieces of Libido : 23 Recent rest/fatigue stress upbringing Kids awake Self image Fun & Sense of humor Pain Physical activity Past experiences Like and respect for partner

24 Urogenital Symptoms Vaginal Dryness Painful Sex Frequent UTI 24

25 Menstrual changes in Perimenopause Perimenopause Heavy Irregular Lighter More frequent Rare 25

26 Post-menopause Bleeding Goal: R/O cancer Evaluation: U/s, Embx, sonohys, HS, D&C Causes: atrophy, hyperplasia simple vs. complex, uterine polyps, fibroids, adenomyosis 26

27 IV. Treatment Knowledge Is Power Understand co-morbidities Hormones SSRI/SNRI Healthy Lifestyle, SEEDS Counseling, resources 27

28 Co-morbidities Cancer Obesity Depression/Anxiety Diabetes Type II Cardiovascular Disease 28

29 Central fat-insulin lipid cycle Case: 19 yr. old female, FH DM II, active in HS, goes to college Summer of following year, C/O: wt. gain 40 lb., irregular cycles, acne, hirsuitism?diagnosis?

30 Heart Disease Women are different than men HDL most important and CRP Models to predict Pre-midlife and midlife most important prevention period 30

31 What numbers to know? Waist circumference HDL Pedometer steps Presidential Fitness Test HgA1C Blood pressure BMI 31

32 Mood Disturbance Concept of activation or deactivation Flight or Flight 32

33 Brain Chemicals Are like gas in the engine/$ in bank Increase: sleep, genetics Decrease: unresolved to-do s poor sleep low estrogen 33

34 Hormone: Quick Guidelines Safety First: WHI and NAMS/ES, FDA-approved, metered dosing Transdermal vs. oral Estrogen (ET) or Estrogen and Progesterone (EPT) Timing Hypothesis Appropriate expectations Specific treatment plan 34

35 Forms of EPT OCP ET: oral, transdermal, topical, vaginal Oral progestogen: synthetic and bioidentical PT: Transdermal, oral, vaginal, intrauterine 35

36 IUD Birth control Uterine protection 3 vs. 5 year types, size difference 36

37 FDA Approved Indications Distressing Vasomotor Symptoms Vaginal dryness Prevention of Osteoporosis Protection of the endometrium with progesterone 37

38 Off-label uses Sleep disturbance (night sweats) Mood disturbance Libido 38

39 Hormones: Who Can t Take >10 years from LMP: Timing Hypothesis and CVD Diagnosis of Breast cancer Prior DVT or PE CVD/CVA High-risk yet without evaluation and/or documented 39

40 NAMS Position Statement Joint statement of many societies (except ACOG) Individualization is key 40

41 If Not Hormones Know symptom triggers SEEDS=lifestyle modification Non-prescription Therapies: soy, black kohash Prescription, non-hormonal: Clonadine, SSRI, SNRI, Gabapentin 41

42 Symptomcircle : Triggers Lifestyle affects symptoms!!! Address co-morbidities Triggers identified which causes symptoms Empowers lifestyle change 42

43 SEEDS Water Sleep Exercise: aerobic, strength training, stretching Macronutrients Micronutrients Fiber Metered breathing 43

44 Water: How much? Controversy on exactly how much Takes 3 days to hydrate and 3 days to dehydrate A serving of caffeine or alcohol will dehydrate, need to replace with equivalent water Dehydration is the most common cause of daytime fatigue 44

45 Sleep: Quality and Quantity 7-8 hours per night, or 50 hours per week We can make it up Changing hormones and stress can impact Sleep hygiene so important! Tricks: metered breathing, dress lightly 45

46 Dietary Intake Recommendations Balance of carbs, protein, fat Body for Life for Women, Dr. Peeke 5/5/3/1 treat 46

47 Micronutrients Food source is good: but taking in enough?? Vit. D average dose: 2000 iu per day Vit. B complex Iron Calcium Multivitamin 47

48 Fiber 35 grams are hard OK to supplement 48

49 Physical Activity: need all 3 components Stretching Aerobic Training Strength Training 49

50 Metered Breathing 5 minutes Close mouth Open eyes Stare/focus on breath Breathe 50

51 Non-prescription Remedies CAM: Complementary and Alternative Medicine: 36% use some form Biologic-based: Isoflavones=class of phytochemical, 30% of North American women can metabolize to EQUOL, affects effect, soybeans>tofu>soy sauce Black Kohash, (Trade: Remifemin): variable benefit Evening primrose oil: no clear benefit in RCT 51

52 Prescription Remedies-not HT SSRI: Prozac, lexapro SNRI: effexor, wellbutrin Paxil Gabapentin: titrate up, 300 mg at night then BID then TID x 1 month then wean back down vs. nightly Emerging study: DHEA intravaginally 52

53 OTC Progesterone Topical: varying doses, concentrations, and ingredients RCT: no effect on vasomotor symptoms Not protective of endometrium Wild yam=diosgenin- cannot be converted into progesterone within the body 53

54 Healthy Aging is About being informed about what choices matter About knowing your options Having a strategy when times are rough Getting the big picture 54

55 Women s Rights It started out by women saying, We can have it all. Now with that we have got ourselves into We can t have it all, but we can have what we want. What do YOU want? 55

56 Picture of Self 9 Areas of Wellness Activity Obesity Cancer Diabetes Ease of Coping Phase of Ovarian Function Good Bones Heart Disease Income Security 56

57 What makes it hard? Possible barriers Time Money Lack of Plan Disability, Cancer Family Needs 57

58 Thank You! Info: shmg.org/womenshealthnetwork My Blog: spectrumhealthblogs.org/menopause Follow me on NAMS website: menopause.org 58

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