Thursday, October 11, 2012
Managing menopause in 2012
Recently I hosted an evening discussion for Personalized Primary Care Atlanta members on the topic of menopause. Here is a summary of our discussion:
--Menopause is defined by no menstrual cycle for one year.
--The average age of menopause in the U.S .is 51.
--90% if American women experience menopause between ages 45 and 55.
--Prior to menopause women go through a period of transition, often referred to as perimenopause.
--During this time of transition women may begin by having irregular menstrual cycles with changes in cycle length and periods of heavier or lighter flow.
--Later in transition women may skip one or more menstrual cycles and may begin to have symptoms related to menopause.
--Irregular menses relate to anovulatory cycles and low levels of progesterone
--For several years prior to menopause women may have higher than normal estradiol levels and lower than normal progesterone levels. FSH levels may also be high.
--Following menopause FSH levels are high and estrogen and progesterone levels are low, however menopause is not defined by hormonal levels, and because of individual differences in hormone levels and also normal fluctuations in levels throughout the cycle, hormone levels can be difficult to use as parameters of change.
Common symptoms of menopause are related to a decline in estrogen levels. For most women symptoms last several years. However, in some, symptoms may continue for up to 10 years. About 10% of women in their 60s continue to have hot flashes. Menopause symptoms include:
--Hot flashes (last 2-4 minutes, affect the upper body and face, occur frequently at night)
--Insomnia (may be a manifestation of temperature regulation trouble--hot flashes)
--Changes in sex drive
--Trouble with control of urination
--Changes in body composition such as reduced muscle mass
Menopause risks include the risk of osteoporosis. Women lose bone density quickly during the first five years following menopause. Menopause is also associated with an increased risk of cardiovascular disease. Women develop more insulin resistance, lower HDL levels and higher LDL cholesterol.
Approaches to managing menopausal symptoms include hormonal therapies, off -label use of non-hormonal therapies, and natural remedies.
Hormone Replacement Therapy
--Hormone replacement therapy is no longer recommended for menopausal women for the purpose of prevention.
--Hormone replacement therapy has been extensively studied in the form of conjugated equine estrogen in a dose of 0.625 mg and medroxyprogesterone at a dose of 2.5 mg in postmenopausal women with an average age of 63 in the Women's Health Initiative trial. This trial involved approximately 161,000 women and reported on a number of outcomes. The Estrogen and Progesterone arm of the trial was terminated in 2002 and found that women using the two hormones had a higher risk of blood clots, heart attacks, strokes, and breast cancer. The same women had a lower risk of colon cancer and bone fracture.
--Women in the Estrogen alone part of the study had higher risk of strokes and blood clots, but not breast cancer and heart attacks.
--Three years following discontinuation of the study women treated with Estrogen and Progesterone continued to have a higher risk of cancer, including lung cancer.
--A subgroup analysis of the study found that most of the risk conferred by hormone replacement therapy was related to the age of the treated women. Women treated from the time of menopause forward for five years did not experience significant increases in health risk.
--For a sense of the magnitudes of health risk I recommend looking at the handbook
Changes in Practice a Decade Later
Hormone replacement remains the most effective treatment of menopausal symptoms. However, not all women require hormone replacement to get through menopause. Currently women's health experts prefer to use the lowest dose of hormones available to control symptoms.
Today, oral estrogen is available in one half the dosage that was studied in the Women's Health Initiative study. There are several different types of estrogen and progesterone available on the market. All estrogens appear to carry a similar risk of blood clot. However, it remains uncertain whether different types of estrogens and progestins confer different health risks. In the case of progestins, they do seem to vary more in their activity and side effect profiles. The adverse effects of hormone replacement are speculated to relate to dose.
Current practice has shifted toward the use of transdermal estrogen and progesterone through patches, also available in low dose. Transdermal estrogen confers a lower risk of deep venous thrombosis, and it is thought by some that to be safer with respect to other health outcomes.
Vaginal estrogen is an effective means to treat the urogenital symptoms of menopause such as vaginal dryness and urinary symptoms, and does not require systemic progesterone to protect the uterus as do oral and transdermal estrogen. It is felt that if use of hormone replacement is limited to the first five years following the time of natural menopause (around age 51), the cardiovascular risks may be lower. Tapering hormonal therapy slowly after several years may produce fewer symptoms than stopping cold turkey and can help facilitate the transition to menopause for some women.
Some women may choose to live with the health risks related to hormone replacement and may continue treatment for longer than five years, reporting improved quality of life.
What are "bioidentical hormones?"
Bioidentical hormones typically refers to custom compounds of hormones that are also manufactured and marketed as pharmaceuticals. However, bioidentical hormones are not tested and regulated. Given the range of hormone replacement now available on the market with numerous dosing options, many women's health experts agree that it is safer to use products that have been more thoroughly investigated and that are regulated in the U.S. through the FDA.
Non-hormonal options for treating hot flashes are available as off-label use of prescription medications and include:
--Selective Serotonin Reuptake Inhibitors and Selective Norepinephrine Reuptake Inhibitors: paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), fluoxetine (Prozac)
--Gabapentin (a seizure drug)
--Clonidine (a blood pressure drug)
--Plant Based Estrogens (Phytoestrogens) /Soy: Not FDA regulated, might work in the body like a weak estrogen, might also have some health risk.
--Black Cohosh : Also not regulated by FDA, lack of conclusive evidence that it helps, but has a fairly good safety record
For more information I also recommend the North American Menopause Society (NAMS) website and the handbook: Facts About Menopausal Hormone Therapy.
Or, contact me directly at firstname.lastname@example.org.
Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.
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