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Managing Menopause: Dealing With The Facts

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Title: Managing Menopause: Dealing With The Facts


1
Managing Menopause Dealing With The Facts
  • Matt Weinrich, M.D.

2
Womens Top Health Risks and Causes of Death
  • Perception
  • Breast Cancer 46
  • Other Cancer 16
  • Heart Disease 4
  • AIDS 4
  • Uterine/Ovarian 3
  • Reality
  • Heart Disease 34
  • Other Cancers 12
  • Lung Cancer 5
  • Stroke 8
  • Breast Cancer 4

3
Chronic Diseases
  • Screening can significantly reduce risk of
    cancer/heart disease
  • The current challenge is dealing with nonfatal,
    chronic, age-dependent conditions such as
    Alzheimer's, osteoporosis, obesity, and
    incontinence
  • Preventive health care should now be aimed at how
    a person can spend their many years as functional
    and productive ones

4
Menopausal Facts
  • The time when the body quits making estrogen
  • Average age 51
  • Genetically determined
  • Other factors involved smoking, underweight,
    high altitudes, vegetarian
  • Not related to race, height, or age of first
    menses

5
Menopausal Symptoms
  • Hot Flashes
  • Vaginal dryness
  • Sleep disorders
  • Mood disturbances

6
Hot Flashes
  • Most common symptom of menopause
  • Affects 68-93 of women
  • Symptoms usually last 6 months to 5 years
  • Primary reason women seek medical treatment
  • 25 remain symptomatic for gt 5 years

7
Severity of Reported Hot Flashes
  • Severe 51
  • Moderate 33
  • Mild 16
  • Symptoms decrease with time

8
Hot Flashes Treatment
  • Estrogen clearly the most successful (gt90)
  • Decrease night sweats
  • Decrease periods of wakefulness
  • Increase REM sleep
  • Stabilize mood

9
Alternative Therapies for Managing Hot Flashes
Phytoestrogens
  • Soy protein may decrease hot flashes
  • Limited studies, mixed results
  • Must be taken as pure soy protein
  • No long term studies to show safety
  • Dose is 20 grams pure soy protein once or twice
    daily

10
Alternative Therapies for Managing Hot Flashes
Red Clover
  • One study showed 44 reduction
  • Dose is 80 mg
  • No long term studies

11
Alternative Therapies for Managing Hot Flashes
Black Cohosh
  • Short term studies show reduction by 70
  • Dose is variable
  • No study beyond 6 months

12
Alternative Therapies for Managing Hot Flashes
SSRIs
  • Selective serotonin reuptake inhibitors
  • Decrease hot flashes by 50
  • Effexor and Paxil the most well studied
  • Reasonable option for women with breast cancer

13
Alternative Therapies for Managing Hot Flashes
Progesterone
  • High dose progesterone reduces hot flashes by 25
    85
  • High doses associated with weight gain
  • Topical progesterone has not been well studied
  • Topical absorption is variable

14
Alternative Medicine
  • 42 of adults in 1998 used some form of
    alternative medicine
  • 60 or 12 million paid cash
  • 40 of patients do not inform their doctors
  • Not regulated by the FDA
  • Ingredients are not tested
  • No scientific proof of benefits

15
Vaginal Dryness
  • A very common complaint
  • Generalized daily discomfort
  • May result in pain with intercourse
  • Primary treatment is oral or vaginal estrogen
  • If fearful of systemic estrogen vaginal route
    effective with no major side effects
  • Benefits noted in 2-4 weeks

16
Osteoporosis
  • 13-18 of Caucasian postmenopausal females have
    osteoporosis
  • 30-50 have osteopenic
  • 1998 1.5 million osteoporosis related fractures
  • 13 billion dollars in health care services

17
Osteoporosis
  • Peak bone density is reached at around age 30
  • 0.7 decline per year after that
  • Potentially 5 per year for spinal bone following
    menopause

18
Risk Factors for Osteoporosis Nonmodifiable
  • Nonmodifiable
  • Personal history
  • Fracture in a first-degree relative
  • Caucasian race
  • Advanced age
  • Female sex
  • Dementia
  • Poor health

19
Risk Factors for Osteoporosis Modifiable
  • Cigarette smoking
  • Low body weight
  • Estrogen deficiency
  • Low calcium intake
  • Alcoholism
  • Impaired eyesight
  • Recurrent falls
  • Inadequate physical activity

20
Treatment of Osteoporosis with Estrogen
  • Decreases fractures by 50 60 in arm and hip
    fractures
  • Decreases up to 80 of vertebral compression
    fractures
  • Requires beginning within 5 years of menopause
  • Protective effect lost rapidly after therapy
    ended

21
Alternative Therapies for the Treatment of
Osteoporosis Bisphosphonates
  • Binds to bone to prevent resorption
  • Reduces nonvertebral fractures by least 30
  • Reduces vertebral fractures by 90
  • Can be added to estrogen for combined effects
  • Side effects are minimal
  • Taken with a full glass of water and remain
    upright for 30 minutes without food or beverage
  • Do not lose effect after discontinued

22
Alternatives for Osteoporosis Selective
Estrogen Receptor Modulators (SERMs)
  • Synthetic agents
  • Beneficial effects on bone and cholesterol while
    decreasing the risk of breast cancer and
    endometrial cancer
  • Similar to estrogen in regards to bone
  • Full benefits currently under study
  • Increase severity of hot flashes

23
Colorectal Cancer and Estrogen
  • Third most common cancer
  • significantly decreases risk with current and
    long term use
  • Most studies show a decrease by 35
  • Reason for the benefit is unknown

24
Estrogens Benefits and Mental Health
  • Sleep disturbances
  • Energy
  • Cognitive function
  • Sexual impairment
  • Decreased depression on most depression scores
  • Overall increased sense of well-being

25
Estrogen and Alzheimer's Disease
  • Mixed studies
  • Possible decrease in Alzheimer's by 80
  • Longer treatment more beneficial
  • Estrogen increases cerebral blood flow
  • Not helpful once disease is established

26
Other Benefits of Estrogen
  • Less risk of diabetes
  • Decreased body fat
  • Decreased arthritis
  • Decreased tooth loss by 25
  • Decreased vision and hearing loss

27
Estrogens Types, Delivery Systems, and Regimens
  • There are a variety of estrogens
  • Primarily estradiol and estrone
  • All estrogens have similar ability
  • Impact on bone mineral density
  • Hot flashes

28
Oral Route Advantages
  • Most common
  • Must be absorbed through the GI tract
  • Increases HDL cholesterol
  • Decreases LDL cholesterol
  • Decreases some blood clotting factors
  • These have been shown to decrease the risk of
    cardiovascular disease

29
Oral Route Disadvantages
  • Increase in triglycerides
  • Larger doses required than the patch
  • Small risk of GI irritation and nausea
  • Increases plasminogen (a blood clotting factor)

30
Patch Advantages
  • Once or twice per week
  • Good choice for those who cannot take pills
  • No impact on triglyceride levels
  • Equal to oral forms in regards to bone protection
  • Potentially safer with a steady state release

31
Patch Disadvantages
  • Occasional rash from adhesive
  • May require progesterone
  • Combination estrogen/progesterone patch is larger
    than the estrogen patch

32
Estrogen Vaginal route
  • Easily absorbed for local therapy
  • Effective for vaginal dryness and painful
    intercourse
  • Three options for vaginal route exist
  • Creams messy, dosing less precise, absorbed
    systemically
  • Tablets twice weekly, minimal absorption
  • Vaginal ring 3 month dosing

33
Contraindications to Hormone Therapy
  • Pregnancy
  • Breast cancer
  • Estrogen-dependent cancer
  • Abnormal genital bleeding
  • Blood clots
  • Active liver disease

34
Estrogen and Blood Clots
  • A twofold increase in the risk of blood clots
    with hormone therapy
  • Confined to the first 2 years
  • Amounts to an increase of 1.5/10,000 per year
  • Risk of death is very low

35
The Womens Health Initiative
  • Exaggerated in the popular media
  • Caused fear and confusion in American women
  • No one study has changed the publics opinion in
    gynecology

36
WHI and Breast Cancer
  • Cited an increased of 26
  • 8/10,000 cases per year
  • Was not statistically significance
  • The estrogen only group was not stopped
    prematurely because of an increased risk
  • It takes 10 years for a malignant cell to become
    clinically detectable at 1 cm
  • Increased risk in years 4 and 5 consistent with
    hormonal stimulation of preexisting tumors

37
Breast cancer
  • Over 50 100 studies linking hormone therapy and
    breast cancer
  • Only a few studies shown a small increased risk
  • Ever use 1.14
  • Current use 1.24
  • Past use 1.07
  • No study links hormone therapy with a positive
    family history

38
Mortality from breast cancer when using HRT at
the time of diagnosis
  • The majority of studies have shown a decreased
    risk of dying from breast cancer when on HRT
  • Breast cancer in users of HRT appear to be
    different compared to nonusers
  • Smaller tumor size
  • More differentiated
  • Less spread to lymph nodes
  • Less likely to be invasive

39
WHI and Cardiovascular Disease
  • WHI was labeled as a primary prevention trial
  • Debated by average of the participants
  • 45 were in their 60s
  • 21 in their 70s
  • Implies that the majority of patients were
    already at risk

40
WISDOM
  • International British study involving 34,000
    women ends this year to evaluate HRT and it
    effects on
  • Fatal and nonfatal ischemic heart disease
  • Major osteoporotic fracture
  • Breast cancer
  • Quality of life
  • The study was not stopped prematurely because the
    researches felt that the WHI study was not
    statistically significant

41
Estrogen Risks/Benefits
  • Evidence to show a small increased risk of
    cardiovascular disease and breast cancer
  • Evidence to support HRT in decreasing symptoms
    such as hot flashes, vaginal dryness, and sleep
    problems
  • Evidence to show HRT decreases osteoporosis and
    colorectal cancer
  • Evidence to support other benefits of HRT
    including improved cognition, decreased
    Alzheimer's disease, urinary incontinence, and
    tooth loss

42
Reasonable Alternatives
  • Hot flashes herbal regimens may help, SSRIs
    have shown significant benefit
  • Vaginal dryness vaginal rings, creams and
    tablets with minimal absorption
  • Osteoporosis SERMs and Bisphosphonates decrease
    bone loss
  • Cardiovascular disease cholesterol lowering
    agents statins decrease the risk of
    cardiovascular disease

43
Conclusion
  • Determine what is important to you
  • Evaluating your goals may make more options
    available
  • Focus on the best way to live a healthy and
    active life

44
Alternatives to osteoporosis SERMs
  • Works similar to estrogen in regards to bone loss
  • Has been shown to increase bone in spine and
    femoral neck
  • Reduced risk of vertebral fractures by 36
  • No decrease in hip or nonvertebral fractures
    noticed

45
Cognition
  • Limited data exists that shows women have better
    memory while on estrogen
  • Estrogen has been shown to promote brain health
    by increasing cerebral blood flow
  • On going trials are being performed that suggest
    estrogen long term may decrease Alzheimer's by
    50

46
Phytoestrogens
  • Nonsteroid compounds that bind to the estrogen
    receptor
  • The most common are isoflavones which possess
    both estrogenic and antiestrogenic properties
  • Phytoestrogen rich diet is cited as a factor in
    the low incidence of breast cancer and
    cardiovascular disease among Asians

47
  • Phytoestrogens have mixed results in the
    literature in regards to alleviating the symptoms
    of menopause
  • There are been equal studies, some showing
    benefit while other show no benefit in regards to
    hot flashes, libido, vaginal dryness, after 3
    months

48
  • In regards to cardiovascular disease
    phytoestrogens have been shown to decrease LDL
    cholesterol
  • This requires the intact soy protein
  • Separation of the isoflavone from the protein has
    been shown to have no benefit from placebo

49
  • Small amount of evidence shows that
    phytoestrogens may prevent bone loss
  • This was only vertebral bone
  • Hip bone was not affected
  • Overall benefit significantly less than estrogen
    or SERMs

50
Progesterone topical
  • Progesterone used twice daily has been shown to
    have no effect on bone density, cholesterol
  • Transdermal progesterone has been shown to have
    little systemic absorption and great serum
    variability

51
  • The average age of US women at menopause is 51
    years
  • Most women spend at least one third of their
    lifetime in the postmenopause
  • 1.3 million women reached natural menopause
    during 2000
  • Induced menopause occurs at a rate of 4,900 women
    per day

52
  • Menstrual irregularities usually begin at age 40
  • Only about 10 of women have normal menstrual
    cycles from age 40 until menopause
  • It is not a declining level of estrogen that
    causes menstrual cycle irregularities, but
    depletion of eggs that the ovary can produce
  • It has been shown that estrogen levels are higher
    just before menopause and some experts theorize
    this is to extend the benefits of estrogen before
    menopause begins

53
  • Studies have shown that even if there is an
    increased risk of breast cancer the cancer is
    localized to the breast and associated with
  • Earlier detection
  • More well-differentiated tumors
  • Better survival when compared to nonusers of
    hormone therapy
  • Mortality rates are reduced in users

54
  • Menopause is not a disease
  • Can be looked at as a signal of revival and
    renewal for the better
  • We should consider is a landmark to focus on at
    least 30 years of active, healthful living.

55
  • There are more older people in the United States
    than ever before
  • Year population over 65 of pop
  • 1900 3 million 4
  • 2000 34 million 12
  • 2030 58 million 20

56
  • Along with this increase is an increase in the
    female percentage of the population
  • Year men women ratio
  • 1900 102100
  • 2000 23 in the over age 65 age group
  • 13 in over 85 age group
  • The death rate is higher for men for both medical
    and nonmedical reasons including cardiovascular
    disease, lung cancer, accidents, suicide,
    smoking, alcohol consumption, and higher risk
    taking behaviors

57
Midlife Assessment Emphasis of prevention
  • Beginning in the menopausal years is the ideal
    time to focus on preventative care and long term
    thinking with three primary goals
  • Prolong maximal physical, mental, and social well
    being
  • Surveillance for major chronic diseases
  • To help smooth the passage from reproductive to
    menopausal years

58
  • Other periodic tests may include
  • Fasting glucose
  • Thyroid
  • Kidney function testing
  • Osteoporosis screening
  • Immunization status cannot be undervalued for the
    elderly and may include
  • Pneumococcal
  • Influenza
  • Diphtheria-Tetanus
  • Hepatitis

59
  • Preventative screening may include the following
  • Height, weight, and blood pressure
  • Annual breast exam
  • Annual pap smear screening
  • Cholesterol screening every 3 -5 years
  • Colorectal screening annually to every 10 years
    depending on the screening technique

60
  • Increasing exercise and muscle mass has also been
    shown to improve strength and balance and reduce
    falls which may threaten a persons independence

61
Basics of Postmenopausal Hormone Therapy
  • The first test of hormone therapy to reduce the
    effects of aging dates back to 1889
  • Estrogen and Progesterone were isolated and
    synthesized in the 1930s
  • Hormone replacement was approved for use in 1942
  • 1970 the side effect of endometrial cancer was
    identified as a major health concern for those on
    estrogen

62
  • Progestin was added to eliminate the risk of
    endometrial cancer and soon it became one of the
    most commonly prescribed medications in the US
  • Now with the recent published report of the Women
    Health Initiative hormone replacement again has
    been criticized by many

63
  • The MORE study also evaluated breast cancer risk
    on SERMs
  • Results of study showed a reduced incidence of
    newly diagnosed invasive breast cancer by 72
  • Estrogen receptor breast cancer was reduced by
    84
  • Longer term studies are needed to fully evaluate
    the overall benefits of SERMs

64
Cardiovascular disease
  • Major risk factors
  • Hypertension
  • Smoking
  • Diabetes
  • obesity
  • Men are 3 times more likely to die of heart
    disease until women reach menopause
  • Observational data points to estrogen as the
    protective agent

65
Estrogen role in cardiovascular disease
  • Reduces LDL cholesterol
  • Raises HDL cholesterol
  • Decreases blood clotting factors
  • Together both serve to decrease plaque formation
    within the blood vessel wall
  • While the addition of a progesterone may decrease
    the HDL affect there should be no other changes
    noticed

66
  • Although there appears to be a role for primary
    prevention this is not true for secondary
    prevention
  • two large studies suggest that women taking
    hormone therapy with known heart disease may have
    increased risk of heart attack in the first two
    years

67
  • Endometrial cancer
  • It is well known that estrogen without
    progesterone is associated with endometrial
    cancer
  • Addition of progesterone negates the risk

68
  • Endometrial cancer
  • It is well known that estrogen without
    progesterone is associated with endometrial
    cancer
  • Addition of progesterone negates the risk

69
  • Follow up was not long enough to provide outcomes
    of the breast cancer in the participants

Oral Route Advantages
70
  • Creams
  • Dosing less precise
  • Messy
  • Can be absorbed systemically so progesterone is
    required for an intact uterus
  • Ring left in place for 3 months, systemic
    absorption not significant
  • Tablets twice a week maintenance dosing, little
    systemic absorption
  • All can be used with patients who have liver
    disease, inability to tolerate side effects of
    systemic hormone, and do not adversely affect
    cholesterol

71
  • Creams
  • Dosing less precise
  • Messy
  • Can be absorbed systemically so progesterone is
    required for an intact uterus
  • Ring left in place for 3 months, systemic
    absorption not significant
  • Tablets twice a week maintenance dosing, little
    systemic absorption
  • All can be used with patients who have liver
    disease, inability to tolerate side effects of
    systemic hormone, and do not adversely affect
    cholesterol
  • Osteoporosis

72
Prevention and Treatment with Estrogen
  • Inhibits bone resorption
  • Promotes absorption of calcium
  • Increased vitamin D
  • Conserves calcium lost from the kidneys
  • Increases the survival of the cells that form new
    bone
  • Estrogen is primary prevention for osteoporosis

73
  • Bisphosphonates are only indicated for bone loss
    and has no other benefits
  • Unlike estrogen, they do not lose effect after
    discontinuation

74
Alternatives to osteoporosis
  • SERMs
  • Multiple outcomes of Raloxifene Evaluation (MORE)
    trial was performed to evaluate Raloxifene on
    osteoporosis fractures
  • At 3 years vertebral fractures was significantly
    reduced
  • Did not show protective benefit of hip fractures
    when compared to placebo
  • Did increase femoral neck bone mineral density
    by over 2 over the 3 year trial

75
  • SERMs unfortunately have been shown to increase
    the frequency and severity of hot flashes

76
WHI and Breast Cancer Continued
  • WHI study results on breast cancer did not
    actually reach statistical significance
  • A analysis of 51 studies from the world
    literature found a 14 increased risk in
    ever-users, but no increased risk associated with
    past use or family history
  • This disease was localized to the breast

77
Lifestyle adjustments
  • Cigarette smoking the single most preventable
    cause of illness and death in the US since 1970
  • Possibly worse for women than men
  • 1-4 cigarettes per day increases risk of death
    from heart disease by 2.5X
  • Increases other chronic diseases such as
  • stroke
  • osteoporosis
  • pulmonary disease
  • cervical and bladder cancer
  • Alzheimer's
  • worsens cholesterol
  • urinary incontinence
  • tooth loss

78
  • Alcohol use in moderation (1-2 drinks/day) has
    been shown to decrease heart disease by raising
    HDL cholesterol
  • Greater than 2 drinks/day has been shown to
  • damage heart muscle
  • alter heart rhythm
  • constrict blood vessels
  • raise blood pressure
  • increase risk of stroke and liver disease
  • increase the risk of osteoporosis
  • Minor effects also include worsening of hot
    flashes, interfere with sleep patterns, and
    exaggerate emotional stress

79
  • Physical activity the magic cure has clearly
    been shown to
  • lower blood pressure
  • reduce weight
  • slow bone loss
  • build muscle mass
  • overcome insomnia
  • relieve stress
  • lower risk of heart disease
  • Stroke
  • Diabetes
  • high cholesterol
  • Ulcers
  • pulmonary disease
  • breast and reproductive cancers

80
  • Minimal cardiac fitness is 30 minutes 3 days/week
  • New information shows that optimal fitness is
    obtained with 1 hour 5-7 days/week
  • Nurses health study showed that brisk walking for
    3 or more hours a week decreased the risk of
    heart attacks by 30-40
  • Only weight bearing exercises can increase bone
    density

81
Nutrition
  • 20-30 of women beyond age 30 are more than 20
    overweight
  • Women have more problems with weight loss because
    of a decreasing metabolic rate with age
  • Recommended calcium intake is
  • 1000mg for premenopausal/women taking estrogen
    1500 mg for women over 65 not on estrogen
  • Vitamin D 400IU is also required for optimal
    absorption of calcium
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