1. Naomi Swanson MD Department of OB/Gyn
Menopause
Naomi Swanson MD
Department of OB/Gyn

2. Menopause Objectives Define menopause.
List benefits and risks of hormone replacement therapy (HRT).
Identify contraindications to hormone replacement therapy.
List various routes of HRT and their associated risks and benefits.
List alternatives to HRT and their associated risks and benefits.
Define Genitourinary Syndrome of Menopause and list options for treatment.

4. Menopause Cessation of menses for 12 months Median Age = 51 FSH>70
Perimenopause=climacteric=menopausal transition

5. Menopause Vasomotor Symptoms – The Hot Flush
Flushing, perspiration, chills, claminess, anxiety and heart palpitations
Interrupt sleep
87% of women who report hot flushes report daily symptoms
Wide variation in duration

6. Menopause The Hot Flush Risk Factors Ethnicity
African American women report most, Asian women the least (Women’s Health Across the Nation Study 2006)
Obesity
Depression
Anxiety
Low Socioeconomic Status
Smoking

7. Hormone Replacement Therapy
HRT leads to a 75% reduction in weekly hot flushes
Adverse side effects
Breast tenderness
Vaginal bleeding
Bloating
Headaches

8. Hormone Replacement Therapy
Women’s Health Initiative
Primary aim was to determine whether HRT could be used for primary prevention of cardiovascular disease.
Mean age of women – 63
Showed an increase risk of cardiovascular events in women using combined HRT after 5 years

9. Timing Hypothesis
Increasing evidence suggests that use of HRT in early menopause provides a cardio-protective benefit. - Reanalysis of WHI participants aged shows a possible cardio protective effect - WHI Coronary Artery Calcium showed decreased coronary artery calcification in women using estrogen therapy for over 5 years.

10. Hormone Replacement Therapy
Manson et al.

11. Breast Cancer Risk

12. Hormone Replacement Therapy
Contraindications
Active liver disease
History of DVT/PE, Stroke/TIA, CHD
Known thrombophilia
Untreated/Uncontrolled HTN
Breast cancer
Endometrial Cancer
Unexplained vaginal bleeding
Relative contraindications
Elevated triglycerides
Gallbladder disease

13. Hormone Replacement Therapy

14. Routes of Therapy Oral Non Oral Intrauterine Transdermal Vaginal ring
Patch
Sprays
Gels/creams
Vaginal ring
Intrauterine
-Little to no effect in elevating prothrombotic factors due to lack for “first pass effect.”
-Estrogen and Thromboembolism Risk study showed no increase risk of venous thromboembolism in transdermal estrogen users

15. Hormone Replacement Therapy

16. Hormone Replacement Therapy
Progesterone
Limited data to suggest superiority
Increased risk of breast cancer
Synthetic progesterone has vasoconstrictive effect
Natural (Micronized) progesterone has vasodilatory effect
Testosterone
No benefit for hot flushes
Improved sexual function scores with HT
Adverse effects
Lipids
Clitoromegally
Hirsutism
Acne

17. Compounded Bio-identical Hormones
Plant derived, similar chemical structure
Not tested for potency, purity or safety
Evidence to support superiority is lacking
Under dosing and Overdosing due to variable bioavailability and bioactivity
Hormone level testing with saliva is not indicated nor reliable

18. Alternative Therapies
SSRI/SSNRI
Positive effect on hot flushes
Adverse effects: Nausea, dizziness, somnolence, nervousness, sexual dysfunction
Complimentary and Natural Therapies
Efficacy data is lacking
No data for long term effects
Clonidine
Positive benefit on hot flushes
Adverse effects: Dry mouth, insomnia, drowsiness
Accupuncture
- Efficacy data is lacking
Gabapentin
Adverse effects: Somnolence, dizziness, edema
Lifestyle Modification
Clothing
Decreased caffeine and ETOH

19. Genitourinary Syndrome of Menopause
External Genital Sequelae
Urologic Sequelae
Sexual Dysfunction

20. Genitourinary Syndrome of Menopause
Lower estrogen states leads to loss of superficial epithelial cells which causes thinning of the vaginal mucosa and narrowing and shortening of the vaginal vault
Dryness, discharge, itching, dyspareunia
Loss of subcutaneous fat in the labia majora
Vaginal pH increases

22. Treatment of GSM Systemic HRT
Local vaginal estrogen - fastest and most effective
Not associated with increased risk of endometrial hyperplasia
SERM (Ospemafene)
FDA approved
Adverse effects: Vaginal discharge, hot flushes, muscle spasms, thromboembolism.

23. Treatment of GSM
- Fractional Micro-ablative CO2 Laser Therapy – Mona Lisa Touch
Early studies show high satisfaction and return to normal sexual function
No long term data

24. Treatment of GSM cont’d
Tibolone
Synthetic Steroid
Oxytocin Gel
Lubricants
Homeopathic therapies
Sex – “Use it, don’t lose it”

25. Conclusions
Early treatment of menopause symptoms with hormone replacement has overall low risk with high benefits.
Treatment of menopause symptoms should be individualized taking in to account a woman’s risk factors and the impact of symptoms on her quality of life.

26. Naomi Swanson MD

27. References/Resources
ACOG Practice Bulletin Number 141, January 2014, Reaffirmed Management of Menopausal Symptoms.
ACOG Committee Opinion Number 556, April Reaffirmed Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism.
ACOG Committee Opinion Number 532, August 2012, Reaffirmed Compounded Bioidentical Menopausal Hormone Therapy.
ACOG Committee Opinion Number 565, April 2013, Reaffirmed Hormone Therapy and Heart Disease.
The North American Menopause Society “The 2017 hormone therapy position statement of the North American Menopause Society. Menopause. 2017; 24:
Gandhi J, et al. “Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management” AJOG. Dec 2016; 215 (6):
Bhupathiraju S et al, “Exogenous Hormone Use: Oral Contraceptives, Postmenopausal Hormone Therapy, and Health Outcomes in the Nurses’ Health Study” Am J Public Health. 2016; 106:
Lobo, R. “Hormone-replacement therapy: current thinking” Nature Reviews Endocrinology. 2017; 13:
Kaunitz A, Manson J. “Management of Menopausal Symptoms” Obstetrics and Gynecology. 2015; 126 (4):
Manson J., Kaunitz A. “Menopause Management – Getting Clinical Care Back on Track” The New England Journal of Medicine (9):