Postmenopausal Symptoms

Clinical problem 50 mil US women > 51 yr by 2020 3/4 have hot flashes, some for > decade Symptoms Vasomotor Symptoms (late in menopausal transition or early into post menopause) Vasomotor symptoms but cannot use Hormone therapy Vaginal Symptoms or Geniournary syndrome of menopause  Additional Climacteric symptoms  Disrupt sleep, Mood Instabilty, Decreased Day time effectiveness Symptoms can last for yrs, (NOT True: symptoms last for 2-3 yrs) Consider Menstrual History as a Vital Sign  ref:  Menopause Management — Getting Clinical Care Back on Track NEJM 2016 Clinical practice. Management of menopausal symptoms NEJM 2006 Definition Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 Postmenopausal symptoms and mimics      Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 What to do  Evaluate CV risk (Framingham Risk Score): High risk do not go for hormone replacement therapy http://www.mdcalc.com/framingham-coronary-heart-disease-risk-score/ Evaluate the Breast Cancer Risk : Gail model questionnaire  http://www.cancer.gov/bcrisktool/ Low  Intermediate High > 5: Skip Does patient have Uterus If yes: Estrogen + Progesterone If yes: Estrogen + SERM  If no: only estrogen is enough Overall quality of life impaired - overall risk and benefit matters App: MenoPro (NAMS)  Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015   Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015    Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 Pyramid of treatment Lifestyle modification CBT (Cognitive Behaviour Therapy) and Clinical Hypnosis : Will help them cope the symptoms  Self guided CBT or group CBT were both good  Non-prescription therapy Prescription therapy: SSRI (Paroxetine (7.5 mg / day; FDA approved; Not associated with sexual dysfunction or bleeding at this age), or Citalopram (10-20 mg) or Escitalopram (10-20 mg)  or Venlafaxine (37.5 - 75 mg - needs tapering down, has withdrawal symptoms), Dysvenlafaxine enlafaxine, administered at doses of 37.5 mg/d to 150 mg/d, decreases hot flush severity and frequency in approximately 60% of patients (as compared with 30% who experienced benefit with placebo treatment) Ref: MKSAP or SNRI or  gabapentinoids : Patient with sleep or pain issues (300-900 mg / day) Pregabalin (75-150 mg) ,  Clonidine 0.1 mg daily less effective than SSRI / SNRI or gabapentanoids  Estrogen Not for prevention of symptoms (as used in the past), but more for the treatment of symptoms  Estrogen Treatment Postmenopausal woman <60 <10 yr since menopause Without uterus, only estrogen; combined if uterus is present  When Not to Use (contraindication) Pregnant Endometrial Cancer (obese DM patient) VTE  MI or stroke  Hepatic dysfunction  Trasnsdermal Estrogen Oral more risk of stroke and VTE than transdermal Custum-compunded hormones  Regulated by state pharmacy association, and not FDA  No standardization of these medication  Hence, Recommended not to use Low-Dose Estrogen  Conjugated equine estrogen with basedoxifen no long term data Non-hormonal Management  Moderate to severe VMS: SSRI / SNRI  Placebo response: High 20-30 % response.  Mild to moderate improvement with VMS (better than placebo, but near hormone therapy) Not Recommended or proven benefit to hot flashes . May benefit  Cooling techniques  Avoiding of triggers  Exercise  Yoga Paced respiration  Relaxation  OTC supplements and herbal therapies  Acupuncture  Chiropactice Intervention  Stellate Ganglion Block - Level II Not sure how it works for VMS Why discontinue Medical Hormonal Therapy? Weighing the risks and benefits  100 women NO Hormones, 10 yrs: 3 bresast cancers 100 women EPT 10 yrs: 4 breast cancer  How to discontinue? Slow taper is perhaps better than sudden stoppage No data to say one way is better than the other  If on Oral estrogen: check TSH  Progesterone absolutely needed until all estrogen is topped  Age > 65 as a contraindication by Beers criteria can be used by insurance companions, but ACOG and other societies have come up with saying that is not correct in their guidelines  Vaginal Symptoms or Genitourinary Syndromes of Menopause (GSM; Formerly: Volvovaginal Atrophy)  To tie with Menopause Urinary symptoms can be a sign of estrogen deficiency  Removing the term Atrophy  Affects 50 % of post-menopausal women 32 million have this; only 7 % are treated  GSM progresses w/o treatment  10 % of women even on systemic MHT will continue have symptoms, that can be treated with local hormonal therapy  Big Deal: Associated with various symptoms: Clinical Diagnosis:   Reduced quality of life Los Oil based and Condoms do not mix Silicon based (damages vibrator, affects male patient )  Moistorizer:  No need of progesterone  Side effects are possible, not clear  Cream vs Ring vs Tablet  Super dry in external part: Cream is better  Ring: Difficut to use when severe atrophy  Ospemifene (Oral SERM) Not the best option as hot flashes occur in 8 %  Before prescribing the cialis, be mindful if female partner has sexual symptoms, and may need to use hormone for 8-10 week  Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. JCEM 2015 Menopause Management — Getting Clinical Care Back on Track NEJM 2016 Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition JAMA Internal Medicine 2015 Diagnosis and Management of Menopause The National Institute of Health and Care Excellence (NICE) Guideline JAMA 2016 References:  Vasomotor Symptom Duration in Midlife Women—Research Overturns Dogma (invited commentary) JAMA 2015 Other References Telephone-Based Cognitive Behavioral Therapy for Insomnia in Perimenopausal and Postmenopausal Women With Vasomotor Symptoms (MsFLASH) Postmenopausal Hormone Therapy and Stroke Role of Time Since Menopause and Age at Initiation of Hormone Therapy JAMA internal med 2008 Women's Health Initiative (WHI) Study Case Based Study  Case 1 SM 38 yo F is seen for 6 yrs of hot flushes, night sweats, mood swings, irregular menses. Her symptoms have been worsening. Was started on Welbutrin 6 months back. This visit patient complaints of significant insomnia.  Her TSH done 5 months back were normal.  FSH done was 13.4 mlU/ml.  Does this patient have premature ovarial failure?  First of all, it is important to know the timing when FSH was drawn.  FSH level varies with different time of menstrual phase.  Follicular phase (the first half of the menstrual cycle before ovulation occurs) : 3.5-12.5  Leutal phase: 4.7-12.5 Ovulation phase:1.7-7.7 Menopausal phase: 25-134 It is unclear when this lab was drawn. While we can say it is not near Menopausal phase, for most part, this should be considered as normal.  Patients symptoms are consistent with menopausal symptoms, FSH is not - Why? How useful is FSH in the evaluation of menopausal symptoms? To answer this question, lets learn the following Late reproductive years Menopause transition / Perimenopause  Menopause A review of hormonal changes during the menopausal transition: focus on findings from the Melbourne Women’s Midlife Health Project Human Reproduction Update, Vol.13, No.6 pp. 559–565, 2007 http://press.endocrine.org/doi/pdf/10.1210/jcem.81.4.8636357 Ref: Up-to-date Ref: Up-to-date How should this patient be managed?