Transcript Post-menopausal Symptoms and Treatment

POST-MENOPAUSAL
SYMPTOMS AND
TREATMENT
James Simpson
Tuesday, April 26th 2016
Outline
■ Too long, didn’t read
■ CFPC Objectives
■ Hormone replacement therapy
■ Specific post-menopausal symptoms and treatment
TL; DR
■ Make the diagnosis of menopause - you don’t need tests, but don’t miss alternative
diagnoses (metabolic, hormonal or malignant causes)
■ For most post-menopausal symptoms – treat with estrogen – lowest possible dose,
most direct route (i.e. topical)
■ If estrogen is contraindicated, think about using SSRIs
■ Watch out for red flags or changing symptoms
Objectives
1) In any woman of menopausal age, screen for
symptoms of menopause and (e.g., hot flashes, changes
in libido, vaginal dryness, incontinence, and psychological
changes).
2) In a patient with typical symptoms suggestive of
menopause, make the diagnosis without ordering any
tests. (This diagnosis is clinical and tests are not
required.)
3) In a patient with atypical symptoms of menopause (e.g.,
weight loss, blood in stools), rule out serious pathology
through the history and selective use of tests, before
diagnosing menopause.
Objectives
4) In a patient who presents with symptoms of menopause
but whose test results may not support the diagnosis, do
not eliminate the possibility of menopause solely because
of these results.
5) When a patient has contraindications to hormonereplacement therapy (HRT), or chooses not to take HRT:
Explore other therapeutic options and recommend some
appropriate choices
6) In menopausal or perimenopausal women: Specifically
inquire about the use of natural or herbal products.
Objectives
7) In menopausal or perimenopausal women: Advise
about potential effects and dangers (i.e., benefits and
problems) of natural or herbal products and interactions.
8) In a menopausal or perimenopausal women, provide
counselling about preventive health measures (e.g.,
osteoporosis testing, mammography).
9) Establish by history a patient’s hormone-replacement
therapy risk/benefit status.
Objective 1 – Symptoms of Menopause
■ Changes in menstrual cycle
– Late reproductive years – menstrual cycle shortens (follicular phase 14  10)
– Menopausal transition –increase in menstrual cycle length (35 to 50 days)
– Late transition – episodes of amenorrhea, skipped cycles
– Throughout – bleeding tends to decrease (although for some women it can
increase dramatically)
Objective 1 – Symptoms of Menopause
■ Hot flashes
– 60 to 80% during menopausal transition
– Generally stop within 4 to 5 years of onset; 9% still have after age 70
■ Sleep disturbance
– 40 to 50% during menopausal transition
■ Depression or anxiety
– 2.5 times more likely to occur during perimenopause
Objective 1 – Symptoms of Menopause
■ Vaginal atrophy
– 20% in menopause transition, 50% postmenopausal
– Impaired sexual function
– May cause or exacerbate incontinence
■ Cognitive changes
– May be related to new onset anxiety/depression
Objective 1 – Symptoms of Menopause
■ (also, things to watch out for post-menopause):
– Osteoporosis
– Cardiovascular disease
– Urinary incontinence
Objective 2 – Make a Diagnosis of
Menopause Without Laboratory Testing
■ Menopause = amenorrhea for 12 months in absence of other biological or
physiological causes
■ Perimenopause = change in intermenstrual interval with menopausal symptoms
■ FSH not required
Objective 3 – Don’t Miss Alternative
Diagnoses
■ …i.e. don’t miss cancer, other endocrine disease (thyroid, pituitary issues)
■ ok
Objective 4 – If a patient looks like
menopause but FSH is normal, don’t rule
out menopause
■ …ok
Objective 6 + 7 – Ask about natural or
herbal therapy; advise about risks/benefits
■ Bioidentical hormones – can be prescribed by NDs, NPs…
■ Black cohosh – uncertain efficacy, rare potential for liver disease
■ Primrose oil – no evidence, rare potential for bleeding disorders, seizures
■ Dong quai – no evidence, rare potential for bleeding disorders
Objective 8 – Counsel about preventative
health measures post menopause
■ Colon cancer screening
■ Pap smear
■ Mammography
■ Osteoporosis
■ Osteoporosis – everyone age 65 and older, or women in menopause with the
following risk factors:
– Fragility fracture after age 40
– Prolonged steroid use
– Parental hip fracture
– Vertebral fracture or osteopenia
– Current smoking
– Rheumatoid arthritis
– High alcohol intake
– Low body weight or major weight loss
– Other chronic inflammatory disease
Objective 5 + 9 – hormone replacement
therapy
■ TL;DR version:
– Barring contraindications, hormone replacement therapy is safe and highly
effective for up to 5 years for vasomotor symptoms for women aged 50 to 59
Objective 9: Clarify a woman’s
risk/benefit status with HRT
■ Benefits
– Decreased vasomotor symptoms (by 75% or more vs placebo)
– Helps with vaginal atrophy
– Adjunct for SSRIs when mood is a concern
■ Contraindications
– Breast cancer
– Heart disease
– Liver disease
– DVTs, strokes
– Relative contraindication: age
Treatments:
■ Low dose estrogen – add progesterone for anyone with a uterus:
– Transdermal – lower first pass effect – i.e. climara, Estraderm, estrogel
– Oral estrogen –
■
i.e. premarin, 0.625mg/day
■
Estrace 1mg/day
■ Progesterone
– Medroxyprogesterone acetate (provera) – 2.5mg/day
– Micronized progesterone (prometrium) – 100mg/daily
Looking for a guide?
■ http://menopauseandu.ca/resources/HTbookletE.pdf
Objective 5: Alternatives to Hormone
Replacement Therapy
■ Lifestyle – diet, exercise, weight, stress, tobacco, alcohol, caffeine
■ SSRIs –
– Paroxetine only FDA approved drug, 7.5mg po daily (do not use w/ tamoxifen)
– Venlafaxine is cool too, used off-label (75mg po daily)
– Gabapentin may have some effect
Specific Post-Menopausal Symptoms
and Treatment
Post-menopausal symptoms and
treatment: Vaginitis
■ Can cause dryness, itching, burning, bleeding, urinary incontinence, dyspareunia,
infection
■ Caused by vulvovaginal atrophy (tissues rely on estrogen)
Prescribing vaginal estrogen
■ Premarin
– 0.5g PV once per day for 2 weeks, then 2 times per week
■ Vagifem
– 10mcg PV once per day for 2 weeks, then 2 times per week
■ Estring
– Insert once per 3 months (7.5mcg estradiol per 24 hours)
Vaginal estrogen: risks
■ DVT, stroke
■ Endometrial cancer (watch for bleeding)
■ Liver disease
Post-menopausal symptoms and
treatment: Urinary incontinence
■ Treat the underlying cause
■ Remember: stress incontinence, urge incontinence or overflow incontinence
■ Menopause can make these worse – vaginal atrophy contributes to irritation
– Treat with vaginal estrogen
Post-menopausal symptoms and
treatment: Bleeding
■ Causes
– Endometrial polyp – 38%
– Vaginal atrophy – 30%
– Endometrial hyperplasia or cancer – 9%
– Fibroid – 6%
– Other – 17%
Post-menopausal symptoms and
treatment: Bleeding
■ Risk factors
– Anything that increases estrogen but not progesterone
■
Nulliparity
■
Diabetes
■
Obesity
■
PCOS
■
Non-smoker
Post-menopausal symptoms and
treatment: Bleeding
■ Diagnosis
– Endometrial biopsy +/- transvaginal ultrasound for first step
– Biopsy indicated if ultrasound shows the following:
■
Endometrial lining thicker than 4mm
■
Endometrium is heterogenous
■
Endometrium not adequately seen
■
Persistent bleeding despite otherwise normal tests
Post-menopausal symptoms and
treatment: Bleeding
■ Treatment
– Treat the underlying cause
– Vaginal estrogen for vaginal atrophy
Post-menopausal symptoms and
treatment: Hot flashes
■ Tends to get much better in menopause than peri-menopause
■ Rule out systemic cause (i.e. new hot flashes in a 75 year old – think about night
sweats, malignancy!)
■ If overly burdensome, treat with systemic estrogen
■ Can also use SSRIs
Post-menopausal symptoms and
treatment: Mood disorders
■ Menopause related mood disorders should improve
■ If not, treat as mood disorder as you would with any other patient
– Counselling, CBT, medications
– SSRI/SNRI
– Estrogen can be helpful in peri-menopause but does not appear to help postmenopause
SAMP style question
■ A 75 year old female presents with vaginal spotting.
– What are four possible diagnoses?
– What are three risk factors for cancer?
– What two tests should be initiated to investigate this complaint?