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Integrative management of menopause

Review the pathophysiology of menopause, discuss key recommendations for practice when dealing with menopausal symptoms, review the risks/benefits of hormone therapy, highlight important aspects of health maintenance for postmenopausal women, and discuss alternative therapies for menopause management. Learn about menopause and its clinical implications, genitourinary syndrome of menopause, vasomotor symptoms, hormone therapy, and more.

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Integrative management of menopause

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  1. Integrative management of menopause Annamarie Hofstetter, R3 Family Medicine Residency of Idaho

  2. objectives • Review the pathophysiology of menopause. • Discuss key recommendations for practicewhen dealing with menopausal symptoms. • Review the risks/benefits of hormone therapy. • Highlight the important aspects of health maintenance for postmenopausal women. • Discuss alternative therapies for menopause management and review their efficacy.

  3. Let’s review…what is menopause? • Clinically defined as 1 year without menses. • Average age of menopause: 51.2 years.

  4. pathoPhysiology of menopause • 3 types of estrogen produced mainly in ovaries: estradiol, estrone and estriol. • In menopause, estrone becomes the most prominent (less potent) form of estrogen.

  5. Genitourinary syndrome of menopause • New term for atrophic vaginitis. • Affects >50% of postmenopausal women; remains underdiagnosed. • Implications • External genitalia • Urological • Sexual • Symptoms generally worsen with time, even if estrogen levels remain stable.

  6. Pathophysiology of GSM

  7. Clinical findings

  8. Diagnostic Pearls • Symptoms: decreased vaginal lubrication during intercourse • Pelvic exam: • Atrophic vaginal epithelium/loss of rugae • Things to check for: lacerations or lesions, labial fusion, introital stenosis, friable epithelium. • Clinical diagnosis • Lab tests (not necessary) • Vaginal pH >5 in absence of infection • Cytology of vaginal epithelium • Wet mount • Pap test • Hormone levels and TVUS are not recommended. • Serum estradiol <20pg/mL and thin endometrial stripe <4-5mm are suggestive of hypoestrogenic state. • Differential diagnosis: • BV, trich, candidiasis, contact irritants, foreign bodies, sexual trauma • Neoplasia and/or precancerous lesions

  9. Treatment • First line: lubricants, moisturizers, tissues stretching • Smoking cessation • Estrogen therapy • Topical is best (tablet, ring, cream) • Use for 6 months, discontinue temporarily, then resume • Also limits systemic absorption • Insufficient data to recommend annual endometrial surveillance • Other options • SERMs (Ospemifene; Lasofoxifene) +/- estrogen • Laser treatment: CO2 laser therapy or radiofrequency-based therapy

  10. Vasomotor symptoms of menopause • Most common indication for hormone therapy • 70% of women affected

  11. Treatment • Hormone therapy • Contraindications include undiagnosed vaginal bleeding or a history of breast cancer, VTE, or severe liver disease • Nonhormonal prescription medications • Clinical hypnosis • Lifestyle modifications

  12. hormone therapy • Estrogen alone: oral, transdermal patch, transdermal gel, transdermal spray, vaginal • Based on observational studies alone, transdermal estrogen avoids first-pass liver effect and therefore may have a lower risk of VTE compared with oral estrogen. • Dosage may be increased after evaluating for effectiveness during the first 8 weeks of therapy; reassessment annually or as needed • Estrogen/progesterone combination- all women with a uterus

  13. Nonhormonal therapy • Low-dose paroxetine (Brisdelle) • Patients taking tamoxifen should not use Paroxetine (inhibits hepatic enzyme cytochrome P450) • Desvenlafaxine and venlafaxine are alternative options • Other SSRIs also reasonable options • Recommendation against use of Clonidine- secondary to side effects

  14. Risks/benefits of hormone therapy • Women’s Health Initiative (WHI)- 2002 • 16,000 women • Compared combined oral regimen consisting of conjugated equine estrogen and medroxyprogesteronevs placebo • Combined regimen increased risk of CAD, breast CA, CVA and VTE • Decreased risk of colorectal CA, hip fx, total fx • Caveat: cannot generalize to all women (avg age of participants was 63 years) • Estrogen-only arm of WHI- 2004 (women without uterus) • Compared to combined regimen- no significant change in risk of CAD or breast CA; same increased risk for CVA and VTE • “Timing Hypothesis” • Starting hormones early can be cardioprotective

  15. Compounded bioidentical hormone formulations • Estrone, 17-beta estradiol and estriol (identical to human hormones). • Limited data on safety and effectiveness. • Lack of FDA regulation. • Add mcironizedprogestogen (100mg or 200mg per day) in women with a uterus.

  16. Deciding when to discontinue hormone therapy • Potential for rebound symptoms (esp hot flashes) • In general, women will have a difficult time stopping therapy • No consensus on stopping cold-turkey vs weaning

  17. Other symptoms of menopause • Dizziness, rapid irregular heartbeat, mood changes, sleep disturbances, headaches, myalgias, arthralgias, difficulty concentrating, memory impairment, and general malaise.

  18. Additional management ideas • Start discussion with women early! • Anticipation is key • Transitioning of cOCP • Check FHS, estrogen level • Menopause support groups • Apps to assess benefit-risk profile of hormone therapy • MenoPro

  19. Health maintenance • Osteoporosis screening • Calcium and Vit D supplementation • Exercise • Coronary heart disease prevention • Smoking • Cancer screening • Breast CA • Cervical CA • Colorectal CA • Immunizations

  20. In summary:Key recommendations for practice • Systemic estrogen, alone or in combination with a progestogen, is the most effective therapy for menopausal hot flashes (A). • Low-dose topical estrogen is effective and has little increased risk for endometrial hyperplasia in women with genitourinary syndrome of menopause. • Effective nonhormonal therapies for genitourinary syndrome of menopause include vaginal moisturizers and oral ospemifene (Osphena) (B). • Combined estrogen/progesterone therapy, but not estrogen alone, increases the risk of breast cancer and venous thromboembolism after 3-5 years of use (B). • There is no high-quality, consistent evidence that black cohosh, botanical products, omega-3 fatty acid supplements or lifestyle modifications alleviates hot flashes (B).

  21. References • Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013 Jul;10(7):1790-9. PubMed ID: 23679050. • Chang OH, Fidela M, Paraiso R. Revitalizing research in genitourinary syndrome of menopause. American Journal of Obstetrics and Gynecology. Volume 220, Issue 3, March 2019, Pages 246.e1-246.e4.

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