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 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 (90)
• 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