Menopause & Cancer: Anticipatory Guidance Diana L. Bitner MD 2012 MICHIGAN BCCCP / WISEWOMAN / MCRCEDP ANNUAL MEETING 2
Why Are We Here? Knowledge is power! VS. 3
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
Why am I here? OB/Gyn 20 years Menopause specialist Director of the Spectrum Health Medical Group Women s Health Network 5
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
Rectangularization of Life
What is Normal? Ovary Function: 8
Menstrual Physiology 9
STRAW 2001 Diagram
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
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
Symptoms Hot Flashes Mood Changes Disturbed Sleep Body Complaints Weight Change Sexuality Urogenital Irregular Bleeding 13
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
Thermoregulation 100.6 Midbrain thermostat 99.6 98.6 97.6 96.6 15
Mood changes New depression and anxiety can start in midlife Sleep disturbance Non-hormonal events Medical conditions: thyroid, diabetes, obesity, CAD
Mood changes Risk factors: PMS, PPD, family history midbrain Related: brain chemicals and estrogen fluctuations 17
Disturbed sleep Interrupted sleep is bad for you! More likely after first REM Linked to all other symptoms: mood, vasomotor 18
Body Complaints Menstrual Migraines Aches and pains Heart racing Breast pain Acne
Weight change Weight gain in middle age is linked to perimenopause and aging With loss of muscle, metabolism slows More pronounced with co-morbidities
Weight Changes 21
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
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
Urogenital Symptoms Vaginal Dryness Painful Sex Frequent UTI 24
Menstrual changes in Perimenopause Perimenopause Heavy Irregular Lighter More frequent Rare 25
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
IV. Treatment Knowledge Is Power Understand co-morbidities Hormones SSRI/SNRI Healthy Lifestyle, SEEDS Counseling, resources 27
Co-morbidities Cancer Obesity Depression/Anxiety Diabetes Type II Cardiovascular Disease 28
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?
Heart Disease Women are different than men HDL most important and CRP Models to predict Pre-midlife and midlife most important prevention period 30
What numbers to know? Waist circumference HDL Pedometer steps Presidential Fitness Test HgA1C Blood pressure BMI 31
Mood Disturbance Concept of activation or deactivation Flight or Flight 32
Brain Chemicals Are like gas in the engine/$ in bank Increase: sleep, genetics Decrease: unresolved to-do s poor sleep low estrogen 33
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
Forms of EPT OCP ET: oral, transdermal, topical, vaginal Oral progestogen: synthetic and bioidentical PT: Transdermal, oral, vaginal, intrauterine 35
IUD Birth control Uterine protection 3 vs. 5 year types, size difference 36
FDA Approved Indications Distressing Vasomotor Symptoms Vaginal dryness Prevention of Osteoporosis Protection of the endometrium with progesterone 37
Off-label uses Sleep disturbance (night sweats) Mood disturbance Libido 38
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
NAMS Position Statement Joint statement of many societies (except ACOG) Individualization is key 40
If Not Hormones Know symptom triggers SEEDS=lifestyle modification Non-prescription Therapies: soy, black kohash Prescription, non-hormonal: Clonadine, SSRI, SNRI, Gabapentin 41
Symptomcircle : Triggers Lifestyle affects symptoms!!! Address co-morbidities Triggers identified which causes symptoms Empowers lifestyle change 42
SEEDS Water Sleep Exercise: aerobic, strength training, stretching Macronutrients Micronutrients Fiber Metered breathing 43
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
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
Dietary Intake Recommendations Balance of carbs, protein, fat Body for Life for Women, Dr. Peeke 5/5/3/1 treat 46
Micronutrients Food source is good: but taking in enough?? Vit. D average dose: 2000 iu per day Vit. B complex Iron Calcium Multivitamin 47
Fiber 35 grams are hard OK to supplement 48
Physical Activity: need all 3 components Stretching Aerobic Training Strength Training 49
Metered Breathing 5 minutes Close mouth Open eyes Stare/focus on breath Breathe 50
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
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
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
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
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
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
What makes it hard? Possible barriers Time Money Lack of Plan Disability, Cancer Family Needs 57
Thank You! Info: shmg.org/womenshealthnetwork My Blog: spectrumhealthblogs.org/menopause Follow me on Twitter: @bitnermd NAMS website: menopause.org 58