Menopause: Aging Gracefully

Menopause: Aging Gracefully

We want to have it all!

Ann Steiner MD, CNMP, FACOGClinical Professor of OBGYN

Director Menopause Clinic, Dickens Center for Women, HUPPenn Health for Women

U.S. population aged 65 and older

Jacobsen LA, Population Reference Bureau66(1),1–20(2011).

APGO Objectives Videos and teaching cases, item#47 Menopause,https://www.youtube.com/watch?v=vB6x5tDGqDE&list=PLy35JKgvOASnHHXni4mjXX9kwVA_YMDpq&index=37, accessed 10/25/2015.

What happens to us when the estrogen goes away?

Your hormones aren’t out of balance!This is maybe your new normal

But you may have bothersome symptoms which need to be treated

VMS FrequencyAs many as 75-80% of peri/postmenopausal women in U.S. report hot flashes• Severe in 10%-15% of women• Highest occurrence during perimenopause and first 2 years of

postmenopause• Typically last 5-7 years• Some persist for a lifetime but usually decrease in frequency

and intensity over time• 9% after age 70

Freeman EW Climacteric 2007;10:197-214Cray LA Menopause 2012;19:864-9; Butts L et al., Hum Reprod Update 2007; 13SF JCEM 2012;97:E1032-42Huamd et al, 2008, Arch Int Med 168: 840-846Dennerstein L et al., Hum Reprod Update 2007; 13:551-557

TREATMENT OF VMS

Treatment based on her symptom severity, risk factors, and her personal preferences and expectations

• Lifestyle changes• Non FDA approved dietary supplements and

nonhormonal prescriptions• FDA approved formulations of Oral Contraceptive

Pill (off label), Hormone Therapy, SSRI http://www.menopause.org/docs/professional/htcharts.pdf?sfvrsn=6

Nonhormonal management of VMS:Summary levels of evidence and recommendations

POSITION STATEMENT Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society Menopause, Vol. 22, No. 11, 2015

Gabapentin for treatment of Hot Flashes (800 mg TID vs CE 0.625mg qd vs placebo)

Reddy S et al. Obstet Gynecol 2006; 108:41

On the Horizon: Nitroglycerin patch

What About Hormones?

FDA ApprovedNonoral vs Oral Estrogen

NAMS Recommendations

• The lowest dose of HT should be used for the shortest duration needed to manage menopausal symptoms• Hormone therapy should not be

prescribed for chronic disease prevention

Menopause, Vol. 21, No. 10, 2014

2 drinks a day

4-5 drinks a dayBritish Journal of Cancer (2002) 87, 1234–1245. www.bjcancer.com

Published online 12 November 2002

Compounding Pharmacy Industrymakes $2.6 Billion a year

more.com | october 2013

• Estrogens were mostly superpotent, rangingfrom 95.9 to 259 percent of the prescribed Estradiol• Progesterone data showed that most samplesdelivered about 80 percent of the prescribedamount, although one sample contained less than 60 percent of the progesterone prescribed.

more.com | october 2013

Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey

Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284

Sexual function

• Pain with sex• Partner• Self image• Incontinence• Sleep disturbance and fatigue• Stress• Medications such as SSRIs, Beta blockers• Substance/ETOH abuse• Low desire

Flibanserin approved for hypoactive sexual desire disorder in premenopausal women -norepinephrine-dopamine disinhibitor

Vulvovaginal Atrophy (VVA)Genitourinary Syndrome of Menopause (GSM)

Nonhormonal treatment

• Regular sexual activity to promote blood flow to the genital area

• Vaginal lubricants and moisturizers• Practice sensible vulvar hygiene-Avoid

abrasive cleaning and products such as harsh soaps etc, wear cotton

Local Vaginal Estrogen Therapies

Fractional Laser Treatment ofVulvovaginal Atrophy

Fractional Laser Treatment ofVulvovaginal Atrophy and

U.S. Food and Drug Administration ClearancePosition Statement

The American College of Obstetricians and Gynecologists andThe American Congress of Obstetricians and Gynecologists

The purpose of this Position Statement is to advise obstetrician–gynecologists and patients that

this technology is, in fact, neither approved nor clearedby the FDA for the specific indication of treating

vulvovaginal atrophy.

Approved by the Executive Board: May 2016

Remember to take care of yourself!

Stress reduction MindfulnessExerciseHealthy diet and weightEliminate unhealthy habits

The North American Menopause Society Menopause.org

Menopause and sleep

Women in the menopause transition are more likely to report perceived sleep disturbance, but objective reports do not confirm an association between perimenopause/menopause and sleep disruption– Nocturnal urination– Sleep disorder i.e. sleep apnea– Pain– Mood – Stress– Night sweats

The association of acupuncture with changes in sleep disturbances in perimenopausal and postmenopausal women

Chiu et al OBSTETRICS & GYNECOLOGY VOL. 127, NO. 3, MARCH 2016 pp 507-515

Weight Gain: Aging vs. Menopause

Menopausemenopause

Anatomy a HOT FLASH

Kronenberg F Maturitas 1984;6:31-43; Freedman RR J Clin Endocrinol Metab 1995;80:2354-8; Molnar GW J Appl Physiol 1975;38:499-503

PATHOPHYSIOLOGY OF A HOT FLASH

Freedman, RF, Sem Repro,Med, 2005; 23(2): 117-125

Purthi, S et al, Current Overview of the Management of Urogenital Atrophy in Women with Breast Cancer, The Breast Journal, vol. 17, issue 4, pp. 403-408. July/August 2011

MsFlashMenopause Stratagies, Finding Lasting Answers for Symptoms and Health: Change in Hot Flash Frequency

Guthrie KA, et al. Obstetric Gynecol VOL. 126, NO. 2, AUGUST 2015

New on the Horizon: Stellate ganglion block

“Natural” Hormones

Producing compounded estrogen requires a minimum of 15 chemical reactions in a laboratory, yielding an end-product that is no longer ‘‘natural,’’ even if the original source is plant based. In addition, there are opportunities for unrecognized errors in production of C-HT products because FDA oversight is lacking.

Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284

Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey

Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284

Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey

Menopause: The Journal of The North American Menopause Society Vol. 22, No. 12, pp. 1276-1284

HT Summary

• FDA approved HT is an appropriate treatment option for healthy women with moderate-severe VMS

• HT is not indicated for primary or secondary disease prevention

• Younger and recently menopausal women are the best candidates for HT when indicated

• Breast cancer risk does not increase appreciably with short term use of HT

• Use the lowest dose of HT for the shortest duration needed

Hormonal treatment

• Estrogen has been proven to restore vaginal blood flow, decrease vaginal pH, and improve the thickness and elasticity of vulvovaginal tissue

• Ospemifene (SERM) an oral agent recently approved for vaginal atrophy

• If vasomotor symptom relief or osteoporosis prevention is not required, low-dose local estrogen, not systemic estrogen, is recommended

NAMS Menopause 2012;19:257-71

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Sexual function

• Libido decreases with age in both men and women

• Psychosocial, interpersonal, biologic factors• Distressing sexual issues peak ages 45-64,

lowest after age 65

Vaginal Laser