Managing Menopause 01/31/13

By the end of this lecture, participants will be able to: Objectives By the end of this lecture, participants will be able to: Define menopause and perimenopause Review common symptoms Discuss treatment options Provide appropriate patient education 2

Premature menopause: menopause occurring before age 40 Definitions Menopause: permanent cessation of menstruation resulting from loss of ovarian function Clinical diagnosis: absence of menses for >12 months in women over age 45 Perimenopause: 2-8 years preceding menopause and 1 year after final menstrual period Premature menopause: menopause occurring before age 40 3

Perimenopause Symptoms & Treatment Menopause symptoms often start in the perimenopausal period Usually involves irregular menses and hot flashes Treatment options Low-dose oral contraceptives can regulate periods and reduce hot flashes and vaginal dryness. For nonsmokers, continue to ~age 50-51, then discontinue when patient is likely to be in menopause Mirena IUD may help with heavy bleeding Cyclic progesterone can regulate menstruation 4

Average age of onset 51 years Common symptoms Menopause Symptoms Average age of onset 51 years Common symptoms Menstrual changes Vasomotor symptoms (hot flashes, night sweats) Urogenital atrophy Severity can vary by ethnicity African American women have more severe hot flashes than Caucasian women 5

Often have anovulatory cycles Potential for pregnancy still exists Menstrual Changes ~90% of women experience 4-8 years of menstrual changes before menopause Changes in: Flow Duration Cycle length Often have anovulatory cycles Potential for pregnancy still exists 6

Vasomotor Symptoms Commonly described as feelings of intense heat May cause neck and face to flush; sweating and chills are common Hot flashes vary in intensity; typically last 30 sec to 10 min 75% of women report vasomotor flushes Many experience them for ~10 years 15% report severe flushes for >15 years Greatest frequency is 2-4 years after menopause Risk factors include surgical menopause, decreased BMI, and cigarette smoking 7

Vaginal dryness/irritation +/- discharge Urogenital Atrophy Vaginal dryness/irritation +/- discharge Dyspareunia (painful intercourse) Urinary symptoms Frequency Painful intercourse Incontinence 8

Other Menopause-Related Symptoms Changes in libido Irritability Mood swings Anxiety Feeling of dread Insomnia Poor concentration Memory lapses/loss Headaches Depression Hair loss Facial hair 9

“Your body knows more about menopause than your doctor does!” 10

Hormone Replacement Therapy 11

Hormone Replacement Therapy (HRT) Initially prescribed for vasomotor symptoms in 1960s “Instead of being condemned to witness the death of their own womanhood, they will remain fully feminine—physically and emotionally—for as long as they live…Menopause is curable.” - Dr. Robert A Wilson - 12

Are hormones good or bad? HRT History HRT use increases when discovered adding progestin is protective, & prevents osteo-porosis Women and providers are confused… HRT use expands, ? prevent CAD/CVA (HERS, NHS published) HRT use declines as endo-metrial Ca linked to unopposed estrogen use HRT for vasomotor symptoms; expands to remaining “feminine forever” Are hormones good or bad? WHI results published; HRT use drops drastically 1960 “Fountain of youth” 1970 “Poison” 1980 “Good medicine” 1990 2002 “POISON” 2011 13

What we thought we knew… Estrogen therapy seemed logical based on the hypothesis that Menopause is associated with: Decreased estrogen Accelerated cardiovascular disease Thus, replacing estrogen will have a cardio protective effect For many years, HRT was prescribed based on this hypothesis and observational trials 14

Women’s Health Initiative (WHI) Prospective study of estrogen + progesterone (Prempro) or estrogen alone on risks for coronary heart disease, breast cancer, and hip fracture Women with severe menopausal symptoms were excluded Risk of CHD, stroke, DVT/PE, and breast cancer increased with estrogen + progesterone Risk of stroke and DVT/PE increased with estrogen alone 15

WHI Findings: Other Menopausal Symptoms No beneficial effect of hormone replacement therapy on cognitive function in older post-menopausal women when given for up to 5 years Women on HRT in midlife (early menopause) may have protection against cognitive impairment HRT in late menopause seems to have deleterious effects 16

Current Indications for HRT Vasomotor symptoms related to menopause Vaginal or vulvar atrophy Not recommended to start if >10 yrs after menopause For short-term use only (max 5 yrs?) Individualized decision should be made by provider and patient based on risks for CVD, breast cancer, osteoporosis, and quality of life 17

Nursing Role 18

CASE 1 Karen, a 47-year-old woman, calls the PACT complaining of severe and frequent hot flashes. 19

Nursing Goals Attempt to identify if symptomology is possibly due to a condition other than menopause Rule out possible acute conditions first: cardiac, infection, hypogylcemia, medication reaction, respiratory, etc… then determine if related to hormones Prioritize urgency

Possible Triage Questions Have you taken your temperature? Do you have a new or worsening cough, urinary tract symptoms, or abdominal pain? Do you become weak with your hot flashes? Do you notice shortness of breath with activity in general? Have you measured your blood pressure lately? Do you have chest pain with the hot flashes? Do you have pain in your arm or jaw with the hot flashes? Do you have difficulty breathing with your hot flashes? Have you ever had a heart attack or chest pain? Do you have diabetes? Have you been diagnosed with hypoglycemia? Do your hot flashes occur within one hour of eating? Describe your menstrual cycles. Have you noticed any changes? What medications (Rx and OTC including herbs) are you taking? Do you feel more anxious or depressed when your hot flashes occur? Have your hot flashes been getting worse over the past 2 months? 21

CASE 2 Sophie, a 51-year-old woman, presents to the primary care clinic for a well woman exam. While you are talking to her, you notice that her face becomes flushed and she is sweating profusely. What questions would you ask? 22

Clarifying Questions When did the hot flashes start? How often do they occur, when do they occur, how long do they last? What makes your hot flashes worse? What have you done to relieve the symptoms? Does it work? Are you experiencing other symptoms? Vaginal bleeding Night sweats and/or insomnia Memory problems Urinary incontinence Problems with sexual activity Weight gain Depression or anxiety What medications (Rx and OTC including herbs) are you taking? Do you smoke? 23

What do you tell Sophie about smoking and menopause? Case 2, continued As a result of your questions, you find out that Sophie experiences severe and frequent hot flashes that are affecting her job. Her last menstrual period was 18 months ago, although last month she had some spotting that lasted one week. She also mentioned that she smokes 1 pack per day. What do you tell Sophie about smoking and menopause? Same as before. No need for pelvic. Lab test could include TSH I guess, but not a lot of labs necessary. Definitely no role for FSH. 24

Women who smoke have more severe hot flashes and sleeping difficulties Smoking and Menopause Women who smoke >10 cigarettes/day are 40% more likely to go into menopause early than nonsmokers Early menopause can to lead to heart disease, strokes, and osteoporosis Women who smoke have more severe hot flashes and sleeping difficulties Women who smoke are 35% more likely to break a hip after menopause than nonsmokers. Former smokers have a 15% greater risk of hip fracture.

Treating Menopausal Symptoms 26

CASE 3 Marge, a 58-year-old menopausal female calls and asks if it’s ok to take Black Cohosh for her hot flashes. She says that it helped her friend. Her last visit was 3 months ago. Her BP was 130/80, and her lab work was normal. Both her mother and grandmother had breast cancer. Marge wants to know what else she can do in addition to taking Black Cohosh. She states: “My co-workers are constantly making remarks about how soaked I get. It’s embarrassing.” 27

Hot Flashes: Hormone Replacement Therapy (HRT) HRT is reasonable for women who feel that benefits of symptom relief outweigh risks All routes of systemic therapy are equally effective Transdermal estrogen has lower risk of blood clots than oral route Use the lowest effective dose of estrogen 0.625 mg per day oral, 0.5mg transdermal, or lower For women with a uterus, progesterone must be added Bioidentical hormones Typically refer to custom-compounded formulations No rigorous testing, so safety/efficacy are unknown Similar risks/side effects as traditional HRT 28

Hot Flashes: Medication Alternatives to Estrogen Therapy Progestin methods MPA 400mg Megace 20 - 80mg Venlafaxine 37.5 - 150 mg Desvenlafaxine 100 & 150mg Fluoxetine 20 mg Paroxetine 10 - 25 mg Gabapentin 300 - 2,400 mg Clonidine 0.1 - 0.2mg 29

Hot Flashes: Herbal/Vitamin Remedies Efficacy Comment Vitamin E No effect Black cohosh Mixed results Evening primrose oil Ginseng Wild yam (“natural progesterone”) Phytoestrogens (isoflavones) Soy, red clover Phytoestrogens (lignans) Crushed flaxseed Chasteberry Dong quai Licorice root Note that many herbs are estrogenic and the risks are unclear 30

Hot Flashes: Mind-Body Therapies Efficacy Comment Paced respiration May be effective Small randomized trial Acupuncture Mixed results Yoga Small pilots and 1 randomized trial Exercise Homeopathy/magnet therapy No effect 31

Hot Flashes: Lifestyle Changes Many women decide to treat menopausal symptoms through lifestyle changes Identify triggers and avoid them if possible Triggers to consider include spicy foods, alcohol, caffeine, stress, or being in a hot place Dress in layers and remove clothes when flashes occur Use fans at home or in the workplace Losing weight might help decrease flash frequency Reference: http://womenshealth.gov/menopause/symptom-relief-treatment/ retrieved 7/6/2012 32

Vaginal and Urinary Symptoms Women often have both vaginal and urinary symptoms due to the drop in estrogen which affects the vaginal and urethral tissues Vaginal dryness +/- thin watery discharge Pruritus Dysparunia (painful intercourse) Painful urination Urinary urgency/incontinence Frequent urinary tract infections 33

Appearance of external genitalia and vaginal mucosa Vaginal Atrophy Clinical diagnosis Appearance of external genitalia and vaginal mucosa Loss of labial/vulvar fullness Pale urethral/vaginal epithelium Decreased vaginal secretions pH >4.5 34

Treatment Comparisons: Estrogen Cream vs. Moisturizer vs. Lubricant Vaginal Moisturizer vs. Vaginal Lubricant Replens vaginal moisturizer Improves vaginal epithelium Vaginal lubricants (e.g., Astroglide) Make intercourse more comfortable No long-term benefit to vaginal epithelium Intravaginal estrogen cream vs. Replens Equivalent improvements in vaginal epithelium Equivalent improvement of vaginal itching, irritation, dysparunia 35

Vaginal Atrophy: Estrogen Cream Advantages Relieves atrophy and may improve sexual function Low dose is effective Not necessary to oppose with progesterone Be sure to tell women to report any vaginal bleeding which should be thoroughly evaluated All preparations are equally effective Disadvantages Not appropriate for women with a history of breast cancer 36

Vaginal Estrogen Comparison Creams Estring* Vagifem Tablet* Frequency Daily for 2 wks, then 2x a wk Replace every 3 months Daily for 2 weeks, then 2x a week Safety No reports of endometrial Ca No endometrial proliferation at 1 yr Comments Can achieve systemic estrogen levels No rise in serum estrogen No systemic or endometrial absorption Hormone Products for Postmenopausal Use in the United States and Canada. Compiled by The North American Menopause Society, ©2009. http://www.menopause.org/htcharts.pdf *Not on VA Formulary 37

Resources North American Menopause Society (NAMS). Information on menopause and educational materials. http://www.menopause.org/edumaterials.aspx PubMed Health. Fact sheet:menopause. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004974/ womenshealth.gov. Menopause and menopause treatments fact sheet. http://www.womenshealth.gov/publications/our-publications/fact-sheet/menopause-treatment.cfm womenshealth.gov. Menopause symptom relief and treatment. http://www.womenshealth.gov/menopause/symptom-relief-treatment/ NHLBI. Facts about menopausal hormone therapy. http://www.nhlbi.nih.gov/health/women/pht_facts.pdf National Institute on Aging. Hormones and menopause: tips from the National Institute on Aging. http://www.nia.nih.gov/sites/default/files/TipSheet_ HormonesAndMenopause_0.pdf National Cancer Institute. Menopausal hormone therapy and cancer. http://www.cancer.gov/cancertopics/factsheet/Risk/menopausal-hormones National Center for Complimentary and Alternative Medicine. Herbs at a glance. http://nccam.nih.gov/health/herbsataglance.htm 38

Additional Information Bozkurt B. Where do we currently stand with advice on hormone replacement therapy for women? Methodist Debakey Cardiovasc . 2010;6(4):21-5. Review. Goodman et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract 2011;17(6):949-54. International Menopause Society. Recommendations. http://www.imsociety.org/ims_recommendations.php Loprinzi et al. Newer antidepressants and gabapentin for hot flashes. J Clin Oncol 2009; 27:2831-7. Nelson et al. Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA 2006;295:2057-71. Rossouw et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the WHI randomized controlled trial. JAMA 2002;288:321-33. Shifren & Schiff. Role of hormone therapy in the management of menopause. Obstet Gynecol 2010;115:839-55. Tao et al. Knowledge, perceptions and information about hormone therapy (HT) among menopausal women. PLoS One 2011;6(9):e24661. Review. 39

Author Author: Rachel Bonnema, MD, MS Omaha VA Medical Center, Omaha, NE WH Nurse Reviewers: Barbara Robinson, RN Katrina Goldby, RN, BSN, JD Susan Johnson-Molina, RN, BSN, MAOM Connie LaRosa, RN, MSA, CPHQ Barbara Polak, RN, MSN Mary Ann Reale, MS, RN Lisa Roybal, MSN, WHNP 40