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: 


Postmenopausal symptoms and mimics 

What to do 

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 

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

Ref: Up-to-date

How should this patient be managed?