Menopause: Case- based Management Friday November 11, 2016 Susan Goldstein MD CCFP FCFP NCMP Assistant Professor Department of Family and Community Medicine University of Toronto 1
Menarche Menopause: Straw + 10 Final Menstrual Period (FMP) STAGES - 5-4 - 3b - 3a - 2-1 +1a +1b +1c +2 Terminology MENOPAUSAL REPRODUCTIVE TRANSITION POSTMENOPAUSE Early Peak Late Early Late Early Late PERIMENOPAUSE DuraKon Variable Variable 1-3 yrs 2 yrs (1+1) 3-6 yrs Remaining lifespan PRINCIPAL CRITERIA Menstrual cycle Variable to regular SUPPORTIVE CRITERIA Endocrine FSH AMH Inhibin B Antral Follicle Count DESCRIPTIVE CHARACTERISTICS Symptoms * Blood draw on cycle days 2-5 á = elevated Regular Regular Subtle changes in flow length Low Low Variable Low Low Variable length Persistent 7- day difference in length of consecuove cycles á Variable Low Low Interval of amenorrhea of 60 days á >25 IU/ L** Low Low á Variable Low Low Stabilizes Very low Very low Low Low Low Low Very low Very low 0 Vasomotor symptoms likely Vasomotor symptoms most likely Increasing symptoms of genitourinary syndrome of menopause (GSM) ** Approximate expected level based on assays using current internaoonal pituitary standard Adapted from Harlow et al. Menopause. 2012;19(4):387-95.
Common Complaints During the Peri- menopause Hot flashes/night sweats Vag dryness/ dyspareunia/ lowered libido Urinary changes Sleep disturbance Depression, anxiety, tension/irritability CogniOve complaints Achy/sOff joints* Rapid HR/PalpitaOons Tingling hands & feet Hair thinning/loss Wt gain Dennerstein, L et al, A prospecove populaoon- based study of menopausal symptoms, Obstet Gynecol, 2000; 96: 351- - 358
Genitourinary Syndrome of Menopause (GSM) DefiniKon CollecOon of symptoms and signs associated with estrogen Involves changes to: Ø Labia majora/minora Ø Clitoris Ø VesObule/introitus Ø Vagina Ø Urethra Ø Bladder Symptoms Genital dryness, burning, irritaoon Urinary urgency, dysuria, recurrent UTIs Sexual lack of lubricaoon, discomfort/pain, impaired funcoon *Adopted by the InternaKonal Society for the Study of Women s Sexual Health and NAMS; GSM: genitourinary syndrome of menopause; UTI: urinary tract infeckon. Portman et al. Menopause 2014; 21: 1063-8.
MQ-6 1 2 3 4 5 6 The Menopause Quick 6 Screen KEY QuesKons to help address menopausal symptoms: Any changes in your periods? Are you having any hot flashes? Any vaginal dryness or pain or sexual concerns? Any bladder issues/ incononence? How s your sleep? How s your mood? Goldstein, S., Can Fam Physician Pending publication
Guidelines & PosiOon Statements 2016 IMS Recommendations on Midlife Women s Health and Menopause Hormone Therapy hkp://dx.doi.org/10.3109/13697137.2015.1129166 SOGC Guidelines : Managing Menopause (2014) hkp://sogc.org/guidelines/managing- menopause- replaces- 222- january- 2009/ NAMS 2016 Hormone therapy PosiKon Statement Pending publica4on NAMS: Statement on ConKnuing Use of Systemic Hormone Therapy A`er Age 65 (2015) hkp://www.menopause.org/docs/default- source/professional/pap- pdf- meno- d- 15-00241- minus- trim- cme.pdf NAMS: Nonhormonal management of menopause- associated vasomotor symptoms (2015) hkp://www.menopause.org/docs/default- source/professional/pap- pdf- meno- d- 15-00241- minus- trim- cme.pdf
Comparison of RelaKve Risk Factors for Breast Cancer Singletary SE, RaOng the risk factors for breast cancer, Ann Surg, 2003;237(4): 474-482 3.5 RelaKve Risk 3 2.5 2 1.5 RelaOve Risk 1 0.5 0 Alcohol (2/d) BMI >80%ile EPT aper 5 years Early Menarche (<12) Late Menopause (>55) Nullip/1st child>30 1' relaove PM BrCa>50 1' relaove prem Br Ca
RelaOve dosing Product Ultralow Low dose Standard High Dose Premarin (CEE) 0.3-0.45 mg 0.625 0.9-1.25 Estrace (E2) 0.5 mg 1 mg Estradot Estraderm Oesclim 25 mcg 37.5-50 mcg 50 mcg 50 mcg 75-100 mcg 100 mcg Climara 25 mcg 37.5-50 mcg 75-100 mcg Estrogel (E2) One pump(.75) 2-4 pumps Divigel (E2).25 gm.5 gm 1 gm ConverOng Between Estrogen Products, Pharmacist's Leker, Nov. 2009
An individualized approach to treatment 1. Is MHT indicated? 2. Are there contraindicaoons? 3. Are there comorbidioes? 4. Is there a uterus? 5. When was FMP? 6. Do I need addioonal vaginal ET? Goldstein, S., Can Family Physician, Pending publicaoon
MenoPro app The MenoPro app is designed to help women work with their healthcare providers to personalize the management of their menopausal symptoms and to choose the opomal treatment hkps://itunes.apple.com/ca/app/menopro- by- north- american/id922540237?mt=8
WHAT IS THE EVIDENCE FOR NON- HORMONAL TREATMENTS? NAMS 2015 PosiKon Statement: Nonhormonal management of menopause- associated vasomotor symptoms Menopause: Vol. 22, No. 11, 2015 Recommended (good evidence) Recommend with caukon (may benefit, further studies req d) Not Recommended (negakve,insufficient, or conflickng data) SSRI/SNRI (I) Weight loss (II) Exercise/yoga (I) GabapenOnoids (I- II) Soy Isoflavone: S- equol derivaoves (II) Cooling techniques (V) Clonidine (II) Mindfulness based stress reducoon (II) Avoiding triggers (V) CBT (I) Stellate ganglion block (II) Paced respiraoon (I) Hypnosis (I) OTC supps /herbals (I- II) Acupuncture (I) RaKonale: Some intervenkons may have health benefits but may be unlikely to help VMS and will delay appropriate treatment
ContraindicaOons to Hormone Therapy ContraindicaKons to HT Unexplained vag bleed Known or suspected Br CA Acute liver dx Acute CVS dx Recent CVA AcOve thromboembolic dx Pregnancy Migraine with aura
Co- morbidioes DM Hypertension Smoker Obesity High LIPIDS or other CVS risk Gallstones* MHT is NOT contraindicated, however suggest Transdermal Estrogen
Transdermal opoons Estradiol Patches/Gels Patches 2/week: Estradot Estraderm(reservoir) Oesclim Patches 1/week: Climara (weekly) Gels Estrogel (2 pumps is hi) Divigel (low & very low) CombinaKon Products ConKnuous use patches Climara pro (LNG) Estalis (NETA) CombinaKon Gel Estrogel ProPak (MP) Gel 1-25 or 1-21 Prog last 14 days Can use as cononuous
ORAL HT FormulaOons In Canada E only* P only E + P combo products CEE (Premarin) E2 (Estrace) MP (Prometrium) MPA (Provera) NETA (Norlutate) CEE + MPA (Premplus) E2 + NETA (AcKvelle, AcKvelle LD) E2 + DRSP (Angelique) TSEC CEE + BZA (Duavive) *No progestogen required in hysterectomized women. HT: hormone therapy; CEE: conjugated equine estrogens; E2: estradiol; EE: esterified estrogens; MP: micronized progesterone; MPA: medroxyprogesterone acetate; NETA: norethindrone acetate; DRSP: drospirenone.
TRANSDERMAL HT FormulaOons Available In Canada E only* E2 patch (Climara, Estraderm, Estradot, Oesclim) E2 gel (Divigel, Estrogel) E + P combo products E2 + LNG patch (Climara Pro) E2 + NETA patch (Estalis) E2 gel 0.06% + MP (Estrogel ProPak) *No progestogen required in hysterectomized women. HT: hormone therapy; E2: estradiol; NETA: norethindrone acetate; LNG: levonorgestrel.
What to say to paoents (<60 y/o or within 10 yrs of menopause) BENEFITS RISKS Symptom relief: VMS, GSM, PrevenOon of osteoporosis and # May benefit mood, sleep, joint pain, OAB and recurrent UTIs Unpredictable effect on sexual funcoon/libido May reduce risk DM Brain neutral or possible benefit May have CHD/mortality benefit No significant increase in CVA DVT: occurs rarely even in first 1-2 yrs PotenOal breast cancer risk aper 5? years Differs with regimens Will monitor & revisit yearly Oral E may Worsen stress incononence Increased risk of gallstones But Benefits in LDL/HDL There is no absolute Omeline- individualizaoon is key.
PaOent Resources SIGMA Canadian Menopause Society www.sigmamenopause.com Society of Obstetricians and Gynecologists of Canada (SOGC) www.sogc.org and menopauseandu.ca North American Menopause Society (NAMS) www.menopause.org : Menopro- app!
The NAMS Statement on Continuing Use of Systemic Hormone Therapy After Age 65 Menopause. 2015;22(7):693 Provided that the woman has been advised of the increase in risks associated with cononuing HT beyond age 60 and has clinical supervision, extending HT use with the lowest effecove dose is acceptable under some circumstances. Use of HT should be individualized and not discononued solely based on a woman s age.
THANK YOU! susan.goldstein@utoronto.ca