#30 Mastering Menopause

March 13, 2017 | By Matthew Watto, MD

Dominate the treatment of menopause with tips from expert, Dr. Amy Tremper, Assistant Professor of Obstetrics and Gynecology at the University of Michigan Medical School. We discuss hormone replacement therapy (HRT), the Women’s Health Initiative, bio-identical hormones…and game shows?!

Check out the excellent review article below by Dr. Lipold et al for more great info on starting HRT.

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Clinical Pearls:

1. Symptoms: hot flashes, mood swings, vulvovaginal atrophy (dryness, dyspareunia, burning, UTIs, bleeding)
2. Nonpharmacologic therapy: layer clothing, lowering the room temperature, avoiding dietary triggers, use of fans
3. Pharmacologic therapy: Paroxetine (FDA approved) and other SSRIs provide relief in DAYS not weeks, but watch out for drug-drug interactions with tamoxifen
4. Gabapentin: Useful for night sweats. Start at lowest dose, then titrate.
5. Alternative therapies with some, but inconsistent evidence: soy, isoflavones, black cohosh, weight loss, exercise
6. Alternative therapies proven ineffective: acupuncture, evening primrose, and flaxseed
7. Placebo effect: Occurs in up to 50 percent of patients on any therapy for menopause
8. Vulvovaginal atrophy: daily use of water based lubricant as first line; vaginal estrogen cream, or ring as second line (risk of thromboembolic events).
9. Women’s Health study: positive effects of hormone replacement therapy (HRT) seen in women less than 60 yo and less than 10 years from menopause (30% lower mortality rate, decreased risk of heart disease)
10. HRT: effective for vasomotor symptoms and prevention of osteoporosis. Check out the MenoPro app to assist with treatment decision
11. Oral HRT:  associated with small, but statistically significant increased risk of stroke and venous thromboembolism (VTE). Combo therapy has increased risk breast cancer.
12. HRT: Start at lowest dose. Follow-up within 3 months. Ask about quality of life, side effects, and vaginal bleeding.
13. Progesterone: Oral therapy may stimulate inflammation via effects on liver. Using vaginal progesterone can potentially avoid this side effect.
14. Bio-identical hormones: Testing hormone levels in saliva and blood is pointless because levels vary throughout the day and normal values not well defined. Compounded hormones have variable absorption, non-reproducible formulas, are not FDA approved, and have no safety information.

Goal:
Listeners will identify the symptoms of menopause and apply a customized approach to symptom management.

Learning objectives:
By the end of this podcast listeners will:

1. Explain the definition of menopause and rule out secondary causes
2. Recall the role of estrogen and progesterone in normal physiology
3. Employ nonpharmacologic therapy for menopause
4. Choose pharmacologic therapy for menopause and explain the risks, benefits, and alternatives
5. Interpret the main findings of the Women’s Health Initiative
6. Choose patients who might benefit from HRT
7. Discuss the risks of prescribing estrogen and progesterone therapy
8. Appraise the use of bio-identical hormone therapy and respond to patient inquiries about this popular therapy

Disclosures:
Dr. Tremper reports no relevant financial disclosures.

Time Stamps
00:00 Intro
03:20 Rapid fire questions
11:15 Defining menopause
13:18 Hormonal changes in menopause
15:23 Diagnosis and lab work
17:50 Tailoring patient expectations and overview of therapy
27:07 Vaginal atrophy
33:54 Gabapentin for night sweats
35:42 Women’s Health Initiative discussed
40:57 Starting hormone replacement therapy
48:17 Bioidentical hormone replacement therapy
55:33 Take home points
58:54 Outro

Links from the show:
1. Endurance: Shackleton’s Incredible Voyage (book) by Alfred Lansing
2. Quiz Show (film) by Robert Redford
3. Lipold, L et al. Is there a time limit for systemic menopausal hormone therapy? CCJM. 2016; 83(8):605-612.
4. MenoPro, menopause decision-support algorithm and app from NAMS to help decide on HRT
5. The Gail model for breast cancer risk before starting HRT  www.cancer.gov/bcrisktool/.
NPR, Killer Whales and Menopause