1. POST-MENOPAUSAL SYMPTOMS AND TREATMENT James Simpson Tuesday, April 26 th 2016

2. Outline ■Too long, didn’t read ■CFPC Objectives ■Hormone replacement therapy ■Specific post-menopausal symptoms and treatment

3. 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

4. 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

5. 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 hormone- replacement 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

6. 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. Objectives

7. 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)

8. 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

11. 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

12. Objective 1 – Symptoms of Menopause ■(also, things to watch out for post-menopause): –Osteoporosis –Cardiovascular disease –Urinary incontinence

13. 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

14. Objective 3 – Don’t Miss Alternative Diagnoses ■…i.e. don’t miss cancer, other endocrine disease (thyroid, pituitary issues) ■ok

15. Objective 4 – If a patient looks like menopause but FSH is normal, don’t rule out menopause ■…ok

16. 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

17. Objective 8 – Counsel about preventative health measures post menopause ■Colon cancer screening ■Pap smear ■Mammography ■Osteoporosis

19. ■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

20. 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

21. 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

23. 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

24. Looking for a guide? ■http://menopauseandu.ca/resources/HTbookletE.pdf

25. 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

26. Specific Post-Menopausal Symptoms and Treatment

27. Post-menopausal symptoms and treatment: Vaginitis ■Can cause dryness, itching, burning, bleeding, urinary incontinence, dyspareunia, infection ■Caused by vulvovaginal atrophy (tissues rely on estrogen)

29. 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)

30. Vaginal estrogen: risks ■DVT, stroke ■Endometrial cancer (watch for bleeding) ■Liver disease

31. 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

32. Post-menopausal symptoms and treatment: Bleeding ■Causes –Endometrial polyp – 38% –Vaginal atrophy – 30% –Endometrial hyperplasia or cancer – 9% –Fibroid – 6% –Other – 17%

33. Post-menopausal symptoms and treatment: Bleeding ■Risk factors –Anything that increases estrogen but not progesterone ■Nulliparity ■Diabetes ■Obesity ■PCOS ■Non-smoker

34. 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

35. Post-menopausal symptoms and treatment: Bleeding ■Treatment –Treat the underlying cause –Vaginal estrogen for vaginal atrophy

36. 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

37. 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 post- menopause

38. 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?