WHC Blog

Menopause Q&A - Helpful Advice

November 10th, 2016

How do you define menopause? Premature menopause? Surgical or medical menopause?

The average age of menopause is 51. It is defined by when menses stop due to the ovaries stop producing estrogen. Premature menopause is when it occurs less than 40 yo. Surgical menopause is when the ovaries are surgically removed. Medical menopause is induced by medications (Lupron, chemotherapy)

            Is it necessary to check hormone levels?

We don’t typically use hormone levels to determine if patients are menopausal, because the diagnosis is clinical. Exceptions are if they don’t have menses due to hysterectomy or endometrial ablation. Occasionally if a patient is on the pill, we will check hormone levels on the 6th day of placebo pills to try to determine If ongoing pill use is needed.  

What are the most common symptoms and what are the approaches to treatment/options other than hormone therapy (HT)?

The below are the most common symptoms. Diet and exercise help the majority of symptoms at least to a small degree. Dietary changes include avoidance of excessive caffeine , alcohol, and carbohydrate intake. Eating healthy fats and proteins can help maintain energy levels and help with focus. Regular aerobic exercise , 5-6 times a week for 60 minutes a day is recommended.

            Hot flashes

75% of women have hot flashes. Women who have states of decreased estrogen have worse symptoms (thin, smokers). Avoid triggers such as caffeine , alcohol. Alternative therapies such as acupuncture, yoga. Soy decreases hot flashes, but not necessarily night sweats in studies.

            Memory loss

Difficult to know exact cause-hormone related vs. multitasking vs. stressful time of life (teenagers/aging parents)vs. insomnia linked. HT is not started for this symptom alone. Consider brain training (crosswords, lumosity)

            Decreased libido

Related to decreased testosterone levels, ?vaginal dryness, insomnia, stress, ?age related. No FDA approved testosterone RX, ?DHEA, Addyi (new drug with dizziness as side effect and contraindicated with ETOH)

            Weight gain

No magic bullet. Exercise, diet. Change in metabolism in menopause, can average 15-20 pound weight gain if patient isn’t proactive. Patient’s ask to go on HT to reverse effects on metabolism, but this hasn’t been shown to happen with starting HT.

            Insomnia

Can involve falling or staying asleep.Can be related to night sweats, stress, sleep apnea, habits, urinary symptoms. Good health habits are important: stay on schedule, avoid late night snacks, avoid alcohol and limit caffeine intake. Herbal remedies: Melatonin, Valerian root. Benadyl otc, Rx: Ambien/Lunesta

            Depression/anxiety

Can be related to lack of sleep, may need referral back to pcp for SSRI/benzodiazepine. No proven benefit to St. John’s Wort. Try meditation/yoga

            Vaginal dryness

More frequent intercourse increases blood flow and lubrication. First line is otc lubricant: KY jelly or astroglide (?coconut oil).

How can I protect my bones?

Weight bearing exercise, 1200 mg Calcium and 600 IU Vitamin D daily. Better to get calcium from sources in diet than supplement.

            Changes in recommendations for calcium intake, bisphosphonates, and screening

Bisphosphonate use is limited to 5-7 years if possible due to increased risk of femur fracture with long term use. Stays in bloodstream for long time, so benefits last well after discontinued. Treatment is based now on risk factors as well as bone density (using FRAX). Screening less often, start at age 65 if no risk factors.

Should I take hormone replacement (HT) ?

If the above remedies/lifestyle changes don’t help with symptoms and patient’s life is being disrupted by symptoms then she should consider HT. HT involves estrogen and progesterone replacement if the patient has a uterus, and generally just estrogen if she had a prior hysterectomy. Sometimes testosterone is added for libido/energy levels. We don’t use any longer for prevention of disease, just short term relief of symptoms.

            Risks/benefits/contraindications

Risks: breast cancer (after 4 years of use with estrogen/progesterone HT), endometrial cancer if unopposed estrogen, blood clots, stroke, gallbladder disease.

Contraindications: blood clots, stroke, breast cancer

Benefits: usually start feeling better with relief of most menopausal symptoms within 4 weeks

            Pill, patch, cream, or ring?

Pill affords more options in dosing, types of estrogen and progesterone.

Patch avoids liver, works well for younger women s/p hysterectomy because more steady state levels. Easier compliance.

Cream for vaginal administration or topical cream/spray for systemic dosing (not as reliable absorption)

Ring for vaginal administration (Estring). Convenience, only helps with vaginal dryness/bladder symptoms, not systemic.

             *Lowest dose for shortest period of time

Generally taper off dose after 3-4 years of use as tolerated.

What is the difference between traditional, bioidentical, or compounded HT?

Bio-identical HT is identical for what body makes. The body makes three types of estrogen: estradiol is 80% and strongest. There are several FDA approved forms of estradiol available through commercial pharmacies.

Compounded HT are made in specialty pharmacies and there is no guarantee as to what is actually in the treatment since these pharmacies are not regulated and these medications are not FDA approved.

We generally only use compounded HT if the patient requests it after being counseled regarding the risks of RX.

What are the other prescription treatments for menopausal symptoms other than estrogen/progesterone HT?

            SERMS

Selective estrogen receptor modulators: estrogen agonists/antagonists which work as estrogen in certain organs (bone, vagina, bladder) and antiestrogen in other organs (breast and uterus).

Evista has been used for years for treatment of osteopenia.

Duavee (conjugated estrogen and bazedoxifene) is one of the newer HT RX available. SERMS can be used with estrogen in order to avoid use of progesterone and protect endometrium.

Osphena: only oral pill FDA approved for vaginal dryness. Recommended for use in women s/p hysterectomy. Although can be used in women with uterus with monitoring of endometrial lining.

            SSRI/SNRIs

Selective Serotonin Reuptake Inhibitors: Brisdelle is the only FDA approved SSRI for hot flashes. Selective Norepinephrine Reuptake Inhibitors: Effexor has been used off label for hot flashes for years especially in those patients who want to avoid HT or in whom it is contraindicated (breast cancer survivors).

            Androgens/Flibanserin

Testosterone: currently there are no androgen containing prescription products government approved for the treatment of female sexual interest/arousal disorders.

DHEA converts to testosterone in body and has been used fordecreased libido, but not FDA approved and not regulated.

Addyi (flibanserin) has been FDA approved for decreased libido. Side effects: dizziness, fainting due to hypotension. Can’t drink alcohol with it. ?limited application

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