1. Menopause in Women With IBD

2. Menopause Natural menopause results from gradual decline in number of estradiol-producing ovarian follicles Natural menopause results from gradual decline in number of estradiol-producing ovarian follicles Surgical menopause may occur at any age as a result of oophorectomy Surgical menopause may occur at any age as a result of oophorectomy Estradiol decreases; estrone becomes primary circulating hormone Estradiol decreases; estrone becomes primary circulating hormone Testosterone declines at varying rate Testosterone declines at varying rate No data on effect of menopause on IBD No data on effect of menopause on IBD Carr BR, Bradshaw KD. In: Braunwald E, et al, eds. Harrisons Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2002.

3. Menopausal Symptoms Bone lossmay be accelerated in CD and by corticosteroid use Bone lossmay be accelerated in CD and by corticosteroid use Vasomotor symptomshot flashes (50%–85%) Vasomotor symptomshot flashes (50%–85%) Increases in total and LDL cholesterol Increases in total and LDL cholesterol Urogenital symptoms (45%) Urogenital symptoms (45%) –Dyspareunia –Dysuria –Incontinence –Urinary tract infections U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. 1996. Available at: http/www.ahcpr.gov/clinic/cpsix.htm. Accessed January 28, 2003.

4. Postmenopausal HRT Replaces estrogen in postmenopausal women Replaces estrogen in postmenopausal women Goal: manage symptoms caused by loss of estrogen Goal: manage symptoms caused by loss of estrogen Unopposed estrogen: only for women who have had hysterectomies Unopposed estrogen: only for women who have had hysterectomies Combined estrogen/progestin: recently found to increase risks for breast cancer, heart attacks, stroke Combined estrogen/progestin: recently found to increase risks for breast cancer, heart attacks, stroke

5. HRT Protective Against Disease Activity After Menopause Cohort of post-menopausal women Cohort of post-menopausal women Disease activity pre and post menopause Disease activity pre and post menopause Those taking HRT less likely to have a disease flare in 2 years post menopause Those taking HRT less likely to have a disease flare in 2 years post menopause Dose response for length of use Dose response for length of use Form of menopause did not matter Form of menopause did not matter Kane SV Am J Gastro 2008; 103(5):1193-96.

6. Potential Benefits vs Risks of HRT Potential Benefits Decrease in vasomotor symptoms Decrease in vasomotor symptoms Slower changes in body morphology Slower changes in body morphology Fewer osteoporotic fractures Fewer osteoporotic fractures Improvement in lipid balance Improvement in lipid balance Reduce IBD flare Reduce IBD flare Potential Risks Increase in invasive breast cancer Increase in invasive breast cancer Side effects: bloating, irritability, weight gain, depression, vaginal bleeding Side effects: bloating, irritability, weight gain, depression, vaginal bleeding Increased risk of thromboembolic events (blood clots, stroke) Increased risk of thromboembolic events (blood clots, stroke) Increase in CVD Increase in CVD Clements D, et al. Gut. 1993;34:1543-1546. Stampfer MJ, et al. N Engl J Med. 1991;325:756-762. Women's Health Initiative. JAMA. 2002;288:321-333.

7. HRT Guidelines for IBD Patients HRT Guidelines for IBD Patients As with all therapeutic choices, therapy for menopausal symptoms should be individualized As with all therapeutic choices, therapy for menopausal symptoms should be individualized For women with severe osteopenia or osteoporosis, HRT benefits may outweigh risks if alternatives are not feasible For women with severe osteopenia or osteoporosis, HRT benefits may outweigh risks if alternatives are not feasible For women at increased risk for breast cancer, HRT risks may outweigh benefits For women at increased risk for breast cancer, HRT risks may outweigh benefits CVD risk vs benefit is controversial, but risk may outweigh benefit CVD risk vs benefit is controversial, but risk may outweigh benefit