What’s New in Management of the Menopause?

this program is presented by University of California television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest uctv [Music] programs [Music] welcome glad you could join us uh tonight my name is Mike poar I'm an obri gynecologist in our department at uh UCSF and I spend most of my professional time nearby at the San Francisco General Hospital uh primarily working as uh an OBGYN in our Outpatient Clinic in our Women's Health Center at uh the San Francisco General Hospital so the way I got involved in uh in menopause work actually goes all the way back to my residency I was a medical student here at UCSF and then did my training thank you at uh my residency training at UCLA which uh at that time was quite the PowerHouse in terms of research that was going on and looking at the physiology of hot flashes and uh various effects of menopause on the brain and and ultimately uh pioneering a number of treatments uh for menopause and ever since then as I've branched out into a number of areas that relate to outpatient Women's Healthcare Family Planning and uh various kinds of infections um issues related to uh cancer screening and so on menopause has always uh been one of my great loves in terms of an area that I like to lecture about primarily to clinical audiences both to OBGYNs and to Primary Care uh providers but uh it's also really fun for me to be able to discuss that with a group of uh of consumers as well so welcome and uh happy that you could join us so with that uh let's go ahead and jump in and get started also I don't know if I have to do this um the way I do at all the other medical lectures that I give uh but I have no disclosers to tell you about I'm not on any speakers bureaus and uh I don't have any Financial sorts of bias that's based on working with any sort of drug company so uh let's start with the terms that are used to describe various aspects of menopause so menopause itself is a very specific date a time in a woman's life which is basically her final menstrual period we don't use the term last menstrual period because we use that much more in reproductive age women as a way of trying to date a pregnancy so instead we use final menstrual period but we never know that it's final until at least 12 months have passed since the woman had her What U we're presuming is her final menstrual period so if for example a 52-year-old woman has a menstrual period period in January and then she doesn't bleed again until the following August she's considered to be par menopausal as you'll see in just a moment but if she goes a whole year without having any menstrual bleeding then we can look back and say that that was officially her final menstrual period now why is it that women go through menopause in the first place it's because basically they run out of eggs uh in the ovary every woman is born with somewhere between 400 and 450,000 egg cells uh in both ovaries and over time they are ovulated on a monthly or sometimes less than monthly basis but sooner or later the remaining eggs are very resistant to the hormones that cause ovulation and basically the ovary runs out of eggs uh at that point the woman is no longer at risk of pregnancy the amount of estrogen that she makes from her ovary becomes less and less uh over time uh and there's also a reduction in the production of male hormon hormones testosterone from her ovary but the interesting thing is that within a few years after menopause estrogen had previously been the dominant hormone now it becomes a fairly minor hormone and even though testosterone has dropped by H half rather it's still uh becomes sort of the dominant sex steroid in her body so that's menopause the next is per menopause so par menopause is defined as the interval from the onset of menopausal symptoms so that might be once menstrual periods start becoming irregular a woman might be noticing hot flashes or vaginal dryness until that full year uh after the final U menstrual period Then another term that you see not quite as often is called the menopausal transition and that's the time before the final menstrual period when menstrual cycles start to change particularly they become irregular and spread out up until the menopause itself so just to try to make that fairly simple in in a fairly linear way basically a woman goes through her reproductive years from the time that she starts having her menstrual periods until maybe the mid to late 40s sometimes even the early 50s then when she starts having symptoms of going through the change of life basically hot flashes vaginal Drina some of the things I mentioned a moment ago menstrual irregularity it's the beginning of the menopausal transition then she has her final menstrual period and becomes postmenopausal but again that's a retrospective diagnosis she has to go for a whole year without bleeding and so the per menopause is defined as the time from the beginning of the menopausal transition until that year after the final menstral period has elapsed and uh then she's officially considered to be postmenopausal uh after that now there are a variety of reasons why women go through menopause the most obvious reason is as I said a moment ago she runs out of eggs no longer makes estrogen from her ovaries and that's considered to be natural menopause and I've already defined that for you menopausal symptoms with no bleeding for a year there are also some biochemical markers that we can use when we're confused about whether or not a woman has actually gone through menopause most of the time we can tell and make that as a clinical diagnosis but there are some circumstances where we're just not quite sure maybe she's still having periods and um the there's a question about whether or not this is really postmenopausal bleeding or if she's still in the per menopausal period where sometimes a person just wants to know is there any test you can do to actually confirm that I've gone through menopause so there are a couple of blood tests that we look at to document whether or not she's gone through menopause one is if she's 45 years of age or older we can check a hormone that comes from the pituitary called FSH and it's usually quite elevated and her blood estrogen level or estradi level is is reduced and so high FSH low estradi tells us fairly definitively that she's gone through menopause for a woman who's under 45 let's say it's a woman who's maybe 39 or 41 who stopped having her menstrual periods that seems like a really young age to have gone through menopause and so here we check uh two hormones that come from the pituitary one called FSH and the other LH and they're both elevated uh in this younger age group and if they're both quite High diet not only tells us that she's gone through an early menopause but also that she's not going to ovulate and be at risk of pregnancy so again we don't do these routinely we reserve them only for those situations when there's some confusion or with um an early menopause but otherwise we rely on clinical findings now as I said there are other reasons that women might go through menopause so another is called induced menopause so about a third of women by the end of the of their lives in the United states have a hysterectomy for one reason or another if a woman has a hysterectomy and her ovaries removed simultaneously let's say because of endometriosis or an infection or maybe an ovarian or other type of pelvic cancer when her ovaries are surgically removed that's referred to as induced menopause another is that the ovaries can fail as a result of exposure to certain drugs particularly chemotherapy drugs or radiation uh therapy and then there is a clinical syndrome which is referred to as premature menopause and basically as you'll see in a moment basically any time that the ovaries fail at an age of 40 years of age or older it's considered to be true menopause but if a woman goes through menopause at an age younger than 40 that's called premature menopause and there are a number of reasons for that happening one is that sometimes there's a genetic problem where instead of being 46xx as most women are uh instead there might be a condition which is called a mosaicism where her chromosomes are a little different than other um chromosomally normal women and that would lead to an early menopause there's also an autoimmune condition that can lead to early menopause as well and the major risk of that is the fact that a woman's ovaries May Fail at a time when she's not done with childbearing and then she needs to see the reproductive endocrinology and infertility experts with a uh at least the question of whether or not there might be some way of either through ovam transfer or other ways of inducing ovulation for her to actually get pregnant if she'd like to be able to but it's difficult to do in a woman who's had a premature menopause now the next thing to say about menopause is when it happens and how long it is that a woman is likely to experience symptoms of her menopause so the average age of menopause in the United States is about 512 years old so anything after 40 is considered to be normal some women don't go through menopause until they're 56 or 58 but on average it's about 52 um 51 and a half or 52 years old when an individual woman goes through menopause is largely genetically determined and the single best indicator of when a woman is going to go through menopause is when her mother went through menopause that's often a question I ask of women who were going through menopause in their early 40s who have questions about why going through menopause so early is that if their mother went through menopause at an equally early age um that means that there's some genetic reason why they're um in the early part of the bell-shape curve so to speak in terms of the early age at which they've had manopause on the other hand the age of menopause doesn't seem to be related to a woman's race how many pregnancies she's had what her height or weight are her socioeconomic status or her age at her first menstrual period so if you were to start your periods at 10: instead of 13 or 14 you're not going to run out of eggs any earlier uh that really doesn't seem to have an influence on when you actually go through menopause we do know however that women who smoke cigarettes usually will have menopause about a year or two earlier than women who don't smoke cigarettes and that really hasn't been fully figured out why it is that cigarette smoking especially heavy cigarette smoking um causes the ovaries to fail a little earlier in comparison to women who don't smoke cigarettes so an interesting relationship to see is the fact that since the 1850s the age of menopause hasn't changed as you can see it's a little over 50 years of age all the way from the 1850s until um where we are currently however female life expectancy has changed hugely over that time period so that in the 1850s women would live to maybe 45 or 48 years old on average and then of course there's been an Improvement in life expectancy for a variety of reasons ever since then but the reason I show this is to say that if the average woman has menopausa 51 and the average woman is now living until 86 or 87 uh years old many women spend almost half their life being menopausal so you can see that what's really changed is that in the 1850s the average woman didn't even make it to manopause and now a majority of women actually have de Decades of full and happy lives after the time of their menopause and that's one of the things that's really led to a lot of the research in finding good quality treatments for menopausal symptoms because of the fact that wom may may experience that for an extended period of time so let's go on to the next phase and talk about what the effects are of of a woman losing her estrogen at the time that she goes through menopause and first I'll summarize what those are and then we'll talk about each of them in a little bit more detail after that so of course the most well-known and widely experienced symptom of menopause is what medically is called a vasomotor symptom you'll see that abbreviated VMS but colloquially it's women who talk about their hot flashes also referred to as hot flushes and then another manifestation of vasomotor symptoms are having night sweats which are actually due to nighttime hot flashes the next is some changes in the brain so that there are neuro neurobehavioral issues that occur in at least some women who go through menopause the most important of which is sleep problems there are many women who've gone through menopause who will tell you that you know I did okay with the hot flashes but the problem was that I had difficulty getting to sleep or I'd fall asleep and then wake up in the middle of the night sometimes drenched with sweat which again is a um when that happens is more of a manifestation of the vasomotor symptoms we'll also talk a little bit about some of the short-term memory changes that some women experience um in menopause next is um a condition that has been there all along that it has a new name it's called genito urinary symptom of menopause GSM but it refers to all of the changes that happen in the skin of the vagina and in the bladder and as I said we'll review those in just a moment but for some women that's their major complaint intercourse used to be very comfortable now it isn't or I'm having lots of new symptoms that are related to urination that I didn't have uh before so it could be vaginal dryness painful intercourse burning on urination or even losing a little bit of urine on the way uh to the bathroom next one is the fact that once a woman's gone through menopause and her estrogen levels drop there's an accelerated phase of bone loss so for about 7 years after the final menstrual period the rate at which women lose bone is accelerated and then it slows down after that initial seven years so every year after that there continues to be bone loss but not as much as there is during that first seven years uh after the final menstrual period now the result of that bone loss is an increased risk of fractures and the types of fractures which are most common and in some ways most worrisome are hip fractures which is a major problem for uh elderly women and then vertebral fractures which means that the vertebral bodies in our spine sometimes can collapse and the result of that is bending forward something which is called a Dowers hun but you may have heard that or the medical term for it which is a dorsal kyphosis and then also there is for women an increased risk of arterial vascular problems like heart attack and stroke although that really doesn't start picking up until the 60s and thereafter and it's really interesting that for men their increased risk of heart attack and stroke starts in the mid or the late 40s for women that doesn't really start until the mid-50s into the 60s or even later and so there's thought to be actually a protective effect um of the estrogen that a woman makes from her own ovaries in terms of preventing heart attacks until uh she uh goes through the time of menopause and then slowly slowly after that her heart attack uh and stroke risk increase so let's talk about each of those in a little bit more detail but I'm going to spend most of that Focus talking about hot flashes which are the most common of the complaints so the reason I added this slide is because of the fact that it gives you an idea about how common the uh various vasom motor and genito urinary complaints are and it's kind of a busy slide but if you look at the yellow bars it tells you about how often things occur in postmenopausal women in purple it's per menopausal and in green it's premenopausal women but Focus mainly on the yellow lines so the frequency of hot or the percentage I should say of women who have hot flashes in the menopause uh is way up there so about 65% so about 2third of women who have gone through menopause at some point as they go through the transition will complain of hot flashes or hot flushes as it's shown uh in this slide next is night sweats which occur in a majority of women as you can see about 55% of women followed by vaginal dryness that's present in about 40% of women and then painful intercourse which occurs in about 25% of women so obviously common symptoms but particularly the hot flashes and the night sweats are among the most commonly experienced manifestations of menopause when you look at a population of people so let's describe it in a little bit more deal what a or in a little more detail I'm sorry exactly what a hot flash is and how how it's experienced so it is described as a sudden sense of intense body heat and it has a particular progression that's associated with it so it usually starts in the trunk sometimes in the chest but particularly in the trunk then spreads to the neck and then to the face uh after that and the reason for the hot flash basically is because of the fact that think of it as a blush basically uh the blood vessels in the chest the neck and then ultimately the face dilate they open up and as they have more blood in them that's the reason that a person kind of has a red look to their face or their chest in in the way that a person would during a blush now where the hot flash is actually getting started is in the brain somehow the brain gets a signal that the body's overheating and the way that we all men or women re react to overheating is that our blood vessels open up we vasodilate and then we sweat as a way of trying to dump that excess heat so basically because of this trigger that the brain experiences thinking that it's overheated the way that we respond to it basically is with the Flushing that may be experienced as a hot flash then the redness then the sweating that occurs uh afterwards now a hot flash can last anywhere from a few seconds for some women up to several minutes a few women actually describe them as lasting up to 20 minutes or a half hour but that's unusual for most women a hot flash might be described as lasting 5 minutes or 10 minutes they're always worse at night but they can occur at any time of day so one of the questions I always ask patients as we as we discuss their hot flashes is do they have a tendency to be worse in the evening and when you're trying to go to bed or do you have them all day and most women will say I only have them at night occasionally I have them during the day and if I ever see a patient who says I only get hot flashes in the morning then I always think of something else maybe they have thyroid problems maybe they have diabetes maybe their blood sugars are too low or too high or some other rare condition but hot flashes are never finded only to the day and not to the night it'll either be at night only or during the day um and uh during the night now as I mentioned a moment ago most women who have gone through menopause have experienced hot flashes or sometime at some time or another they may start as early as the per menopause so even while a woman is still having periods she might be having hot flashes for other women The Hot Flashes don't start until their menstrual periods have stopped the conventional wisdom I'm I'm going to tell you about some new studies in just a moment but the conventional wisdom is that most women the average woman experiences hot flashes for about 2 years and then they have a tendency to get better but we've known for a long time that at least a quarter of women have hot flashes for at least five years after their menopause and we knew that the women most likely to do that were slender white women who were most likely to have those very prolonged um episodes of hot flashes but I'll also tell you about a study that you may have heard about because there's been a lot in the news today about it which is called the swan study that's an acronym for the study of women across America um and uh basically what the swan study did or I shouldn't say Across America Across the Nation so study of women Across the Nation so it looks for basically whether or not there are ethnic or racial differences in how people experience hot flashes and what they found is that as a proportion of people different ethnic and racial groups that hot flashes are more likely in African-American women less common in Chinese and uh Japanese women and uh Latino women and other white women are somewhere in between uh those two polls and just so I could move on to other things I was going to say just check this oneand study if it's something that you're uh that you're interested in I I've also me mentioned already that smoking is a risk factor for early menopause uh it is a risk factor for hot flashes and obesity is a hot is a risk factor for hot flashes kind of paradoxically because um obese postmenopausal women make more estrogen in the menopause not so much from their ovaries it's actually um sex steroids that are coming from their adrenal gland that are converted in the fat to weak estrogens um so you'd think that obese women would actually have fewer hot flashes but in reality they have more so what do I keep talking about in terms of this update I'm going to skip over this uh just this morning uh there was a publication of an article in the jamama internal medicine that was an update on information that came from the Swan and basically this part of the study included about 3,300 women the onean study was done in seven sites throughout the United States and one of its amazing attributes other than the fact that it was a fairly large study is the fact that they developed a cohort of women who they followed for 17 years so they started following these women in 1996 and Then followed them all the way through um through 2013 and so the median number that sort of the 50th percentile of visits was that women had 13 visits over the time period that they were followed uh in the swan study so what do they find and what was it that hit the New York Times this morning about uh the publication of this article well remember I said a few minutes ago that the conventional wisdom was that the average woman had hot flashes for two years it turns out that from the highquality swan study that the median duration of vasomotor symptoms was actually more like s and a half years from the time they started until the time they finish so if they start in the per menopause go through the time of the final menstral period and last for a few years after that it turns out that the median group can't call it the average it's the 50th percentile actually had hot flashes for a much longer period than what was previously uh estimated that the median time for the Post final menstral period Persistence of hot flashes was about four and a half years after your last period and that if you were premenopausal or early perimenopausal when you first started having hot flashes that turned out to be the best predictor of the fact that you would have hot flashes for a long time so if you started having hot flashes while you were still having periods the average duration of hot flashes was about 11.8 years almost 12 years and the post final menstrual period persistence was for about 9 years so kind of surprising information just because we had so many decades of information which said that for most women the period of hot flashes was lust but based on the SW this part of the Swan study that was published today it looks like um the typical woman is actually having hot flashes for a much longer period African-American women had the longest duration of vasomotor symptoms a median of 10 years women who were postmenopausal at the time that their hot flashes started actually had the shortest duration so if you were a woman who didn't have hot flashes before your last period Then you had your last period let's say a year or two after your last period then you started having hot flashes that was fairly predictive that you're only going to have them for a few years but even then it was still longer than the old um conventional wisdom and then they found other factors that were related to vasom motor symptom duration and persistence were again menopause at a younger age lower educational levels greater perceived stressed and symptom uh sensitivity in other words if you were person who really focused on your hot fashes you were likely to have the sense that you experience them even longer and then women who had symptoms of depression and anxiety when they first started having the hot flashes were more likely to have them for a longer time period so this is going to change the landscape I think primarily in terms of how long we feel comfortable offering therapy for hot flashes because in the past we said let's go ahead and treat you for a couple of years and then you may not need it after that and what this is saying is no you may may need it for a lot longer than two years 5 years 7 years 10 years uh might be necessary to keep your hot flashes under control okay so just a few more things then in detail about the various changes that happen in menopause and then we'll talk about treatments so I've already mentioned that a common problem in women going through menopause are disturbances of restful sleep and here the operative word is restful women can sleep okay but they often times feel just kind of lousy in the morning and it's true for a couple of reasons one is because it may be hard to go to sleep it may be because you wake up uh in the middle of the night and find it hard to get back to sleep but the person I mentioned earlier at UCLA a fellow named Howard Jud did some elegant sleep studies right in the UCLA hospital in our Clinical Research Unit where women were allowed to sleep overnight but they had a galvanometer on their finger which actually measured whether or not they were sweating and then he looked at a number of other parameters like How Deeply a woman was in sleep and it turns out that for women who are having lots of hot flashes not enough to wake them up but nonetheless the hot flashes were registering because of the sweats they never got into a very deep rapid eye movement sleep or a REM sleep while for the women who were not having overnight hot flashes they were able to cycle through much deeper levels of sleep and the interesting thing is that the women were having who were having hot flashes often times didn't wake up in the middle of the night but they were having these subliminal nocturnal hot flashes anyway and they just couldn't get a restful sleep because they couldn't get the Deep REM sleep that they needed so it's not surprising that the result of that for some people who are not sleeping very well is irritability fatigue poor concentration the next day just because you didn't have enough REM sleep sleep cycles overnight because you were having these hot flashes that weren't enough to wake you up so that's probably where they're coming from now some of the other neurobehavioral changes that come up are short-term memory problems so there are some women who will tell you that before I went through menopause I was really quick I could balance my checkbook without writing a single number down I'd come out to Mission Bay and I'd park my car in a parking lot and I'd always remember where it is but for some people that short-term memory sort of goes downhill shortly after menopause no question a lot of that is aging happens to men as well as women but for some women it's particularly profound in the few years after they've gone U through menopause other sorts of neurobehavioral things that come up for some women are emotional swings and anxiet maybe some of that is related to sweep sleep rather but depression itself is definitely not related to estrogen deficiency depression is a little bit more common in women who are going through menopause or have gone through menopause but you can't somehow relate that due to estrogen deficiency and if you give those women estrogen therapy it doesn't make depression any better although it may help with the um emotional swings and anxiety next is that there may be changes in sex drive and for some women their sex drive is less because of the fact that they have less testosterone than they used to it's now the dominant hormone but there's still only half as much of it as there used to be and where men and women get their sex drive is from testosterone in addition to that some women may be adverse to having intercourse because it hurts uh just with the vaginal dryness and changes that happen with uh the reduction in estrogen other women however actually are more sexually active in menop PA than they were before mainly because they're no longer at risk of getting pregnant but also um just related to divorce or maybe a partner dying um then they might have a new partner which has also has a tendency to rejuvenate sexual relationship so uh there is a researcher in Australia uh whose last name is denstein who's done a couple of amazing cohorts of studies of following women starting in their mid-40s and following them through their mid-50s and into their 60s and her expertise is just following changes in libido and sexuality and so on as women go through various phases of um of menopause and that's where this data comes from about the fact that it's not um necessarily neutral that there are those women who don't have much in the in the in the way of changes of libido but for some women they have more interest and others U have less and then as I said it in any of these studies it's difficult to separate some of the psychological effects that are directly related to estrogen as opposed to just the changes we all go through in getting older facing our mortality changes in how Society relates to us as we get older uh poor sleep cycles uh and so on now um next on the list then are some of the genital urinary changes that come up as a result of lower estrogen levels and as I said in the medical literature this has a new name which is called GSM used to be called atrophic vaginitis which really sounds sounds worse than it is for most people so they kind of medicalize the name just so it wouldn't sound like uh like the vagina is getting dry and shriveled so the kinds of changes that come up in GSM are vaginal spotting or bleeding vaginal dryness sometimes sex can be um uncomfortable because of less lubrication in the vagina is less elastic or stressy uh stretchy excuse me stressy stretchy uh and then for some women orgasm can take long longer after they've become menopausal and less intense than when they were um younger women and virtually all of these changes are directly related to the drop in estrogen levels but interestingly embryologically the bladder and the urethra where the urine comes out actually have estrogen receptors in them so the lower part of the urinary system basically has the same embryologic origin as the vagina and therefore um needs estrogen to stay healthy so in some women um the kinds of symptoms that they might have is the sense of oh I've really got to get to the bathroom that's urgency frequency meaning that I not only have to pee a lot during the day but I have to get up a few times at night burning when I urinate urgent continence means I lose a little bit of urine on the way to the bathroom often times that's misdiagnosed as being a bladder infection because most of the time if you go in and say I'm peeing more frequent it burns when I urinate I have to go way more often than I used to what comes to mind is a bladder infection but if you were to get a dipstick or a urine culture that would turn out to be negative these are simply symptoms of the loss of estrogen on the urethra and the bladder now the loss of estrogen does not have an effect on what's called stress incontinence stress incontinence is the circumstance that happens mainly in post-menopausal women of when you cough or sneeze or bend over or run for a bus all of a sudden you find that you've leaked a little bit of urine without any warning and without any sense that you had to urinate beforehand so stress incontinence has nothing to do with estrogen levels it's far more related to how many kids you've had and what your labors were like and how much the vaginal muscles were stressed estrogen doesn't cause it and doesn't fix it the same is true of what's called pelvic organ prolapse when the muscles in the vagina that hold up the bladder and the rectum uh get overstretched again from child birth um even though those problems are more likely to be seen in menopausal women they have nothing to do with the loss of estrogen and they don't get better when you give estrogen back the next is I mentioned earlier that once a woman goes through menopause that she has a tendency to lose bone mineral density and that's true for a couple of reasons number one is that we don't absorb calcium from our intestines as well whether that comes from milk or cheese or Tums or whatever the source of the calcium is we do as well in absorbing it and number two is that our bones are always going through a process that's causing that's called remodeling so all of us all the time are breaking down bone and we're building up bone and for most people those two things are inbalance and so our bone density is about the same however during that seven-year period when women seem to be losing more bone density it's because of the fact that even though laying down of the bone happens at the same rate they lose more bone so there's more bone resorption but not more formation to make up for it so ultimately bone mineral density goes down especially in that first seven years uh after menopause so 75% of bone loss that happens in the first 15 years after menopause is directly related to estrogen deficiency I already told you about the Dowers hump that can happen from multiple spinal compression fractures and it's account it's the reason why as women become elderly a lot of them start to lose height the reason you get smaller the same is true for men it's not because we're shrinking it's because of the fact that we have compression fractures in our spine and we get shorter uh as a result of that the other is that about one in five postmenopausal women will experience a hip fracture during the remainder of her life about a sixth of those are fatal not so much directly from the fracture but maybe the immobilization that happens afterwards and you might get a blood clot in your leg that flips off and goes to your lungs and about a quarter of women who've experienced a hip fracture require long-term care it's really interesting that if you look at women in nursing homes that one of the most common reasons for long-term um care in a nursing home is because of changes related to alzheimer's the second most common cause cause is loss of Mobility from a hip fracture so it not only can cause death but it really causes major changes in sort of quality of life as well if you should substain sustain rather a hip fracture and the last thing that that I want to mention is as I told you men are excuse me women are relatively protected against heart attacks in comparison to men for men that increased heart attack risk starts in the 40s for women it doesn't start until the late 50s and into the 60s however by the time that men and women are in their 70s the risk of heart attack and my stance for myocardial infarction is about equal for men and women and you probably know this already but I'll remind you is that even though we're very focused on cancer as a cause of death in both men and women the single most common cause of death in both men and women is cardiovascular disease half of all women who die die of cardiovascular disease um and even though we think about breast cancer as being a major killer next hundred women who are well it's probably not the best way to describe it but a woman's lifetime risk of dying of breast cancer is about 1 in 32 her lifetime risk of dying of of heart disease is one and two so point is is that heart disease is a much much more common cause of death in women than any type of individual cancer okay so enough about the possibilities of what change what changes in menopause let's go on now and talk about various ways of dealing with those symptoms and and in particular I'm going to focus not only on some of the traditional things we've done but some of the newer things um that are out there okay so let's just start with sort of the lifestyle changes that have been shown to help women deal with menopausal hot flashes so we know from a number of trials that exercise by itself particularly if it's at least three or four days a week has a tendency to make hot flashes less frequent and less intense when they happen the reason for that is just exercising at least 30 minutes per day 3 or four days a week causes a rele release of endorphins in the brain and those endorphins actually then have an effect on neighboring areas of the brain in terms of making hot flashes less common and less intense second is relaxation therapy so there are actually some studies that look at before and after rates of hot flashes in women who let's say do a yoga class for example so learning how to do focusing exercises for example can help some women with their hot flashes next is the ambient temperature of the room you're in and of course that just kind of becomes obvious to some people or women talking to their friends or their mother or other people who have gone through menopause one of the things that becomes clear um fairly quickly is that if you cool off your surroundings then you don't experience the intensity of the hot flash uh nearly as much so at night a woman can open a window turn on a fan turn down the thermostat by cooling the room that she's in then her hot flashes will be um less intense now during the day that may be a little bit more difficult to do while you're at work so here the recommendation is trying to dress in layers so if you're feeling overheated you can take off one layer uh at a time and still be comfortable for some women not all um hot or spicy foods can be a trigger of a hot flash so maybe uh it would be worth a try to avoid them avoid cigarette smoking and also to try to minimize alcohol so for some women that's really all they need to get their hot flashes is under control some of the things that have been found not to make much difference is that there are studies that looking look at homeopathic medications at acupuncture and at magnetic therapy and none of those things really seem to make very much difference all right let's go to the next level which are called Botanicals and phyt serms now you probably have heard the term phytoestrogen which means plant derived estrogen but the point is is that there there really are very few natural plant derives estrogen or plant derived estrogens as you'll see in just a moment there are maybe serms selective estrogen receptor modulators but not true estrogen which comes from plants so a lot of different compounds have been looked at one that's probably better than Placebo comes from a plant called black kohos the other ones that have been looked at are all the things on this list so isoflavones that come from soy like in Toof Fu or other kinds of soy um bearing uh vegetables red clover isoflavones there's a popular product which is called promensil which comes from red clover doesn't seem to help evening of primose oil doesn't danai is a herb that's used in Chinese herbal medicine and there's been a couple of studies that compared an to bbo was no better although most Chinese herbalists will tell you that they never used enai by itself they always mix it with other herbs and so they say that study shouldn't apply Jens sing vitamin E Chase Berry which has a generic name of of Agnes castus Vitex none of them seem to help so the only one that has some value is black kohos in treating hot flashes so what we know about black kohos is that it's not an estrogen it's not something which is a selective estrogen receptor modulator it's marketed as a supplement not as a prescription drug and therefore you can buy it in safe way or GNC or Trader Joe's or all over the Internet so you don't need a prescription for it you can basically buy it in any um Pharmacy or drug store or health food store uh or um grocery that's what I was looking for has a number of names like Remy femin is the common European name Estroven is the common name in the United States it's given in a dose anywhere between 40 and 80 milligrams daily and it has very few adverse effects so headaches stomach discomfort heaviness in the legs for some women so as I said there are many different brands and formulations but the one you find most commonly is called Estroven this just comes from the package label it has lots of different vitamins and minerals in it and then um basically what it tells us down here is that it does have some isoflavones it has black kohos root in this particular case 40 milligrams uh and then a few other components but there as I said there are many different ways um to to obtain black kohos without a prescription as a supplement over the counter now how well does it work the answer in these various studies that have been done looking at black kohos is that a little over half of women have an improvement in their hot flashes with black kohos compared to about a 30% response rate in the placebo group so the good news is it does seem to work better than Placebo bad news is is that there's a very strong placebo effect and of those 60% of women who have a reduction in their hot flashes maybe half of them are reacting to the chemical that's in the black cohos and the other half just are improving because of the placebo effect but in a way that doesn't matter whether or not it's the active ingredient or the placebo effect if there are fewer hot flashes then that can be a perceived benefit particularly for a product which is so easy to purchase and has relatively few side effects but there's no question that this doesn't work as well as estrogen it's much Milder in its effect as I said it has very relatively few adverse effects and it is considered to be a reasonable sort of firstline choice for women who have mild hot flashes not the kind that wake you up in the middle of the night or prevent you from going to work but if they are mild hot flashes this may help it's also a reasonable first choice for women who feel strongly about avoiding hormones and would rather be able to use something that's a little bit more sort of naturally derived and you've also got to be a person who's willing to use over-the-counter medications that are sold as supplements and not necessarily rigorously tested by the FDA but as I said the track record is that they are reasonably safe and I do recommend these commonly to patients who are having fairly mild hot flashes or who women who can't or won't use hormones I don't think I reflected it well in the slide but I want to say one other thing about it this is actually a fairly popular approach to menopause menopausal symptoms for women who really can't use particularly estrogen but really I'd say any steroid therapy that's particularly women who have had breast cancer so women who have been treated for breast cancer given the advice that they should avoid systemic estrogen and progesterone for the rest of their life because there's a ongoing concern that if not all of the breast cancer was eradicated that using estrogen or progesterone might cause a recurrence or might lead to a recurrence of a woman's breast cancer in the case of black ohos it's very clear that this has no estrogenic effect doesn't plug into estrogen receptors at all so if a woman's had breast cancer and is experiencing hot flashes what this is does is it has sort of a serotonin like effect on the brain which may help with mild hot flashes but it's certainly not going to have any negative effect on uh recurrence of her breast cancer so that may be another role that black kohos has all right the next level of treatment is to mention to you prescription drugs but drugs that don't have any hormones in them so this is a nice kind of summary of what the various Studies have shown so these are the percentage of treated patients who have at least a 50% reduction in their hot flashes these are the percentage of placebo patients who have at least a 50% reduction in their hot flashes so these are a variety of drugs with the exception of gabip Penton I'll come to that one in just a minute that are used to treat depression so as these various ssris and snris drugs came out 15 or 20 years ago to treat depression one of the side effects that was noticed for these anti-depressant medications is that for many women their hot flashes got better so there's a a NRI which is called venlafaxine its trade name is Effexor and somewhere around two-thirds of women will have a reduction in their hot flashes and in a study of Ven faxing compared to placebo it was clearly better than Placebo but again a fairly strong placebo effect peroxy tee you may know of as paxel and paxel works even better in terms of treating hot flashes in comparison to the placebo group culine is another which is not quite as effective as venlafaxine or peroxy uh esalo pram um which has a trade name of Lexapro has recently had a number of studies looking at that uh as well then there's another drug which is used basically for seizure disorders although now it's used for um chronic pain problems as well uh which is called gabapentin and Gabapentin has a fairly good track record in stopping hot flashes this kind of refers to some of the older studies the more recent studies say up to 70 or 80% of women who use Gabapentin will have a reduction in their hot flashes so now in the medical oncology Community for a woman who's had breast cancer who shouldn't use estrogen or progesterone for the rest of her life the number one recommendation is actually for her to use Gabapentin now as I said black cohash may help but it doesn't help as much as Gaba Penton does for women who can't or won't take estrogen now this is all based on really good comparative studies but a logical question is has the FDA approved any of these drugs specifically for the purpose of hot flashes and the ex yeah they did about a year ago so there's a version of peroxin again what by trade name is known of as paxel um in a low dose 7.5 milligrams because paxel is usually use like 10 or 15 or 20 milligrams or even higher but in this very low dose of peroxin it turns out that it does a fairly good job of hot flashes so there is a drug on the market that has the trade name of brisel which is the only SSRI which is actually approved by the Food and Drug Administration for the purpose of treating hot flashes now you could use any of them they all work well none of them work quite as well as estrogen but they're all perfectly reasonable choices but if you wanted to use an FDA approved drug specifically for hot flashes that doesn't have hormones in it then that would be brisdelle which is in this low dose FDA approved for the treatment of hot flashes all right so let's go to the next level then which is using hormone therapy for hot flashes so this comes from a recent statement from a group called Nam the North American medical excuse me North American menopause Society they do a really good job of writing evidence-based guidelines for management of various kinds of menopausal problems so they point out that of all those different levels of treatment that hormone therapy is the most effective treatment for vasom motor symptoms and no matter how much research we do in the other things the hormones always seem to work the best and so the options are to use estrogen by its self we do that for women who have had a hysterectomy a combination of estrogen and progesterone which is what we use for women who have a uterus there's a brand new drug that's come out within the last year it's a combination of estrogen and a serm like drug called basado doxine and I'll tell you a little bit more about that um in just a moment and another possibility for women who can't or won't use estrogen or don't tolerate it very well is just to use the progesterone part by itself then the other thing I'll tell you about in just a moment is that in women who are per menopausal let's say late 40s maybe even 50 having hot flashes but still having menstrual periods there's a small but definite risk of pregnancy and so what those women can do is actually to use oral contraceptives in a very low dose both to prevent pregnancy regulate their menstrual cycles and then also treat their hot flashes so we'll consider that possibility as well so those are all the things that are available in terms of different hormonal approaches to hot flashes now I'm not going to go through the whole list but this is the nams approved list of various kinds of abbreviation so ET is estrogen by itself EP is estrogen and progestin the kind of umbrella terms that describe a combination of hormones are HT which is hormone therapy or mhd which stands for menopausal hormonal therapy so you may see a few few of these abbreviations but I'll try to go over them uh again again as you see them so when it comes to treating hot flashes with hormone therapy the thing that really gets the hot flash is under control is the estrogen therapy and there's so many different ways to give estrogen so there are six different types of pills there are a number of preparations that go through the skin they're called transdermals so there are seven different patches two gels one Emulsion and one spray all of which have estrogen in them and then you can also deliver estrogen directly into the vagina so there are two types of creams there's one type of intravaginal tablet and there are two different kinds of estrogen rings so there's many ways of trying to get the estrogen in the body it's a matter of what's most convenient and which one seems to work best for an individual woman then there are also combination products with estrogen and progestin in them so two different kinds of pills that have estrogen and progestin and two different patches that have estrogen and and progestin as well now how do we decide what what are we going to start with well for a woman who does not have a uterus she already had a hysterectomy for one reason or another the recommendation is to use estrogen by itself but if she has a uterus and you use estrogen for her then what the estrogen can do is to cause the lining of the uterus to overgrow and at some point actually become a cancer an endometrial cancer so we never give estrogen by itself to a woman who has a uterus we always have to give estrogen to treat her hot flashes and a second drug called progestin to prevent endometrial cancer but in a woman who's already had a hysterectomy that's not an issue so then our next step is well if she has a uterus we're going to use estrogen and progestin we want to be able to give it in a way that's either going to prevent postmenopausal bleeding or if bleeding happens to at least try to make it predictable so there are two different ways to do this one is she hasn't had any bleeding at all for a few months you give estrogen every day and progestin every day which is something called continuous combined on the other hand if she's recently had some bleeding or newly menopausal we give estrogen every day but we cycle the progestin on and off and that one's called The Continuous sequential regimen but it gets a little confusing I'm not going to go through all of that in great detail but I will tell you a little bit more about how we decide which estrogen to use and what dose to use so the whole idea is to use the lowest effective estrogen and progestin dose that effectively treats our hot flashes but of course we do that with any drug we want to use the lowest dose of the drug that gets us to the point that we want to in terms of having a beneficial effect now the reason that nams had to come right out and say that is because before the Women's Health Initiative was published in the early 2000s women were usually started on sort of a middle dose of estrogen and then we kind of worked up or worked down but ever since the Whi we always start with the lowest dose and work up and it turns out that for most women low doses are all they need they're better tolerated and they're almost certainly safer than the standard doses are so we start at low doses patient gets started on that she comes back four or six weeks later patient says I feel great we leave her on the low dose if she says you know I'm doing better but I'm just not there yet then we slowly go up on the dose okay the next thing that n says is that even though you might get a woman's hot flashes under control by her taking oral estrogen or patch estrogen may not enough may be enough to get the vaginal symptoms under control so it's okay to use oral or patch estrogen but at the same time to use some vaginal estrogen just to make sure that that problem gets adequately taken care of uh as well okay so the way we do this is we start with a load pill or a low do patch and a logical question is well which one should I use and I always present this to patients in such a way of it all depends on whether you're comfortable remembering to take a pill every day or you'd rather have a patch that you change twice a week most of the patches are twice a week patches so you change every Monday and every Thursday a few of the patches are weekly patches so you only have to change every Sunday for example okay and the patches come in various sizes there's one called The viel Dot which is a DOT it's really small very translucent plastic basically and you change it um infrequently basically so as I said it's going to be either a once a week patch or a twice a week patch now if a person says I feel a little bit better but I'm still having hot flashes then the next thing you do is to start to increase the estrogen dose upward she comes back and says you know I'm still having hot flashes then the next thing is to change the estrogen preparation I told you there's six different estrogen pills so if she doesn't respond to one she might respond to another the next is if she's not responding very well to a pill try a patch she's not responding very well to a patch try a pill may have to do with her metabolism or the uptake of the of the drug the next step is if she doesn't respond to any of these things sometimes adding a little bit of testosterone may actually help with the hot flashes and there is a product which is a combination of oral estrogen and an Androgen called methyl testosterone its tray name is covic and there are some women who just don't respond very well to estrogen by itself who when you give them estrogen and androgen we'll have an improvement in their hot flashes and not only that something that people have kind of picked up on the Internet is if you're giving an androgen pill for some women that also improves their libido um to some degree now the flip side is that nams is very clear in their guidelines that pills patches rings are perfectly fine but what we don't want to do is give estrogen injections just because of the fact that we're not so sure of the dosage equivalencies and if you give a person estrogen shot and she has bleeding then you can't get it back it lasts um for a long time so again what does n say about these various approaches all these many many directions that we can go in they say you know there's really no clear benefit to one route over another however transdermal estrogen therapy using a patch or one of the gels has a lower blood clot risk than oral estrogen and I think that that is nowadays an Undisputed fact and the reason why is that when you take an estrogen pill it has a goes from your gut into the blood supply that goes to your liver and what it does is it increases your clotting factors so it does increase the risk that you might get a blood clot in your leg or have that flip off and go to your lungs that doesn't happen with patches okay and there and for a woman who uses estrogen Pat her risk of a DVT or a pulmonary embolism is the same as it is for any woman who doesn't use hormones at all so I'll tell you if it were me I'd be on a lotos patch because I do think that they're um marginally safer than using pills although I think for most people the pills are safe as well but I think the patches are a little bit safer now the next point they make is that if the only problem is vaginal dryness and painful intercourse but no hot flashes or other systemic problems than just must use topical estrogen in the vagina there's no reason to to use pills or patches with either root using a progestin is required in a woman who has a uterus to make sure that she doesn't get um endometrial cancer okay so that's where we are with the estrogen and progesterone therapy now as I also mentioned in an earlier slide there's also yet another new drug out on the market this one's been out for maybe a year or so which is a combination CE stands for conjugated estrogen and a serm which is called basado doxine so basically what this product does is that the estrogen treats hot flashes sleep problems vaginal dryness and so on but it doesn't have a progestin in it okay it has Instead This serm which is called basado doxine that prevents the endometrium from developing endometrial cancer so reduces hot flash frequency and severity prevents um loss of bone mass treats GSM symptoms no increase in endometrial cancer um and basically things like vaginal bleeding and breast tenderness were observed but about at the same rate as in the placebo group so this seems like a really good alternative particularly for women who use estrogen and progestin and they have side effects from the progestin the trouble is it's so new that most health plans don't have it on their formulary yet so if your doctor nurse practitioner tried to prescribe this to you you'd probably be told by your health plan that either they don't cover the cost or they might cover like half the cost but over time I think more and more Health Plans will cover this because it really is a although it is an expensive alternative it's a good alternative to being able to use estrogen without having to use a progestin so it's nice to be able to see that on the market so the next one to mention and I brought this up a moment ago is that for women who are sort of steaming toward menopause but who are still having periods still ovulating every now and then and at risk potentially of pregnancy then a lowd dose birth control pill can actually do three things so it prevents pregnancy it it causes very regular predictable menstrual periods which oftentimes par menopausal women don't have and it because they have estrogen in them they relieve hot flashes as well so better cycle control women who use the pill for at least a few years actually have a very significant reduction in ovarian cancer now logical question is if I'm 48 and I can use the pill how can I use the contraceptive patch or can I use the contraceptive vaginal ring and the answer is yeah they probably work although they haven't been studied as much as birth control pills in per menopausal women other methods of birth control that have hormones like progestin releasing iuds or Depo prera really good for pregnancy prevention but they really wouldn't help at all for hot flashes but for a woman who's 48 with hot flashes vaginal dryness but still occasionally ovulating birth control pills are a very reasonable Choice and then by the time she's 50 or 501 then go off the pill and see whether or not she still needs hormone therapy uh as a treatment for hot flashes now next is a topic that I know you're going to ask me about and so I'll tell you in advance and U we'll see whether or not it's a popular uh uh statement or not that I'm going to make about this but questions always always come up about bioidentical hormones so I've read on the internet my best friends told me I've read Suzanne summers's book about the fact that bioidentical hormones are somehow better than what I get at CVS or Walgreens in order to treat my hot flashes and this was from one of Suzanne Summers books called the sexy years when she said then suddenly the seven dwarves of menopaused arrived at my door without warning sweaty sleepy bloated forgetful and all dried up what was it that sent those wretched dwarfs packing natural bioidentical hormones okay so what are they and where do they come from so these are pretty much the same hormones I've been talking about estrad which is estrogen various versions of progestin or progesterone which are concocted in a compounding pharmacy and then made available to women as a way of treating their hot flashes but as I told you in the in the beginning that in general plants don't make directly available hormones the places where hormones come from that are in these various products are either from the urine of pregnant mares okay that's where you've probably heard of a brand name called Premarin it refers to pregnant Mar urine basically where these estrogens come from eight different kinds of estrogen or they come from yams um not exactly these yams they're actually y wild yams that come from Puerto Rico these are Marin Farmers Market yams but the only picture I had of a yam so what but even in a yam they don't make estrogen they make estrogen precursors and then in a huge Factory somewhere they take the precursors of estrogen that come from the AMS and then synthetically they're made into estrogens and into progesterone so the vast majority of 17 beta um EST which is the name of the estrogen that's used in all of these products that I just mentioned they come from various factories all over the world that take wild yams and use synthetic chemical steps to turn them into estrogen and progestin and that's true whether you get it from a compounding pharmacy or whether you get it from Walgreens or CVS or some other Pharmacy it's the only place where it comes from so the way that compounded hormone therapy is marketed as we only use natural hormones the same ones that come from the ovary we use a number of different varieties of estrogen estrone estrad estriol we do a salivary test looking at your hormone levels and then we tweak the dosages in your compounded hormone therapy to make sure that it's tailored to you we only use very pure products and we use very safe Delivery Systems like under your tongue okay the reality as I've told you is is that the very same hormones are used in commercial Products that come from a pharmacy and these products which come from compounding pharmacies they're basically the same thing okay so these compounded hormones will probably work as well as anything you buy in a commercial Pharmacy but if you take progesterone and put it on the skin in the form of a cream it never makes it into your skin can't be absorbed can be absorbed from the vagina but not from the skin compounded hormone doses aren't standardized salivary hormone levels which the compounding doctors Andes all often recommend are not useful and nams and the large majority of standard medical organizations say when we give people hormone therapy we find out how they're responding by how they feel doesn't matter what their blood level of estrogen or progesterone or DHEA or testosterone like who cares what matters is does the people does the person feel better when they use their hormone therapy that's how we judge whether or not the doses are important and so the bottom line is that FDA approved hormone therapy products do give you bioidentical hormones they give you a choice of different Delivery Systems whether it's pill patch ring and so on and it's much more likely that your health plan will cover it health plans don't pay for biodental hormones for the most part and they run at a minimum of around $100 a month so would you rather pay $100 a month for the compounded hormones or would you rather go to Walgreens and get your prescription for a 17 beta estradiol patch where your co- payment is $20 for something which is an equally safe and effective delivery system seems to me and certainly what I tell my patients is that it's the same drugs no matter where you get them and therefore we'll figure out what you need based on how you feel and you'll have your prescription drug coverage cover most of that cost rather than having to use the compounded therapy and the last slide that I have on this topic is just to say that the FDA has kind of caught wind of a lot of these claims that some of the compound compounding pharmacies make and they're saying to Consumers take those claims with a grain of salt that a lot of what the compounding phies claim or at least some of claim really isn't based on any fact it's based on marketing and that we really need to sort out the myths from the facts all right so one last thing and that I'm going to summarize in about five minutes or so I don't want to be accused of telling you about all the good things that these therapies do I got to also remind you that there are some risks and one of the risks I've told you about already probably the one that's the most significant is that whenever you take an oral estrogen pill and it's true whether it's a birth control pill or it's true whether it's a hormone I mean a hormone pill for menopause is that it increases the risk of developing a blood clot in your leg which can then flip off and go to your L lungs rather so those are called VTE that stands for Venus thromboembolic event but just think of it as a blood clot in the leg that then flips off and goes to the lungs an oral hormone therapy increases the risk of Venus thrombolic episodes in postmenopausal women the risk is really low but it's still more than women who aren't using hormone therapy so it starts right after you initiate hormone therapy and then the risk actually decreases over time if you're going to get a blood clot whether it's on the pill or whether on one of these products you'll get it in the first year and the reason why is that if you're a person who naturally just has more blood clotting than other people and then you make that worse by using an estrogen medication it's going to manifest itself in the first year and if you don't have the problem in the first year you won't have it afterwards that's why the risk reduces over time there's a lower risk of Venus thrombo embolism in women who are under 60 it's less likely to happen with lower doses than with higher doses it's less likely to happen with a patch rather than oral estrogen therapy and it's still a fairly rare um event the next risk and and I'm sure you would ask me about this one has to do with breast cancer risk and this is just hugely controversial and still being elucidated by new evidence all the time but the conventional wisdom is that estrogen can be aak weak promoter but not an initiator of breast cancer so what that means is that if a breast cancer is already developed if that breast cancer has estrogen or progesterone receptors ER positive or PR positive estrogen or progesterone receptor positive then the thought is is that hormones can make it grow faster and maybe spread faster but it didn't cause the breast cancer that's happening because of genetics and mutations and that kind of thing estrogen doesn't cause it but maybe it C it causes it to grow faster and spread cancer uh spread faster okay and then based on 30 or 40 Years of research and including the Women's Health Initiative the progestin seems to be a little riskier than the estrogen does therefore the conventional wisdom is that women who have had a history of breast cancer shouldn't use either estrogen or progestin for the rest of their life because it might cause a recurrence of their tumor now there are few exceptions to that rule but in General we still follow it okay now how much more risk does it add and this comes from the women's health initiative so if you use estrogen and progestin therapy for more than four or five years it would cause an additional about five cases of breast cancer per 10,000 women per use of estrogen and progestin therapy but we don't start to see that increased risk until year four year five so for a few years of using estrogen and progesterone therapy your breast [Music] breast cancer then the last thing to mention about risk is does is hormone therapy related to heart attacks and the answer is it all depends on how old you are when you use them so this does come from the Women's Health Initiative Whi and it says if you use hormones in your 50s your risk of a heart attack actually goes down by 7% and your likelihood of dying in comparison to women who don't use hormone therapy is reduced by 30% that's really profound to reduce your likelihood of death by that much but in your 70s your risk of a heart attack actually goes up by 26% if you use hormone therapy and your risk of death goes up by 14% so it's another reason for one of those rules that we're very willing to use hormone therapy in women who are in their first 10 years after their menopause but the older they get into their 60s and 70s then the less enthusiastic we are about using hormone therapy okay so sort of the bottom line about how we practice menopausal therapy nowadays is to be very tailored in the approach that we use and not to assume that one size fits all okay so each woman's informed of the potential benefits and risks the acceptance of of those risks kind of varies with why are you doing this you know terrible hot flashes you can't work you're willing to accept a little more risk than the woman who just has very mild symptoms that the risk benefit ratio is definitely more acceptable if you're only using it for a year or two particularly in younger women that long-term use of hormone therapy like 10 years especially in older women is far less AC uh acceptable because it's not doing very much but it's increasing risk and then women with premature menopause particularly women in their 30s and early 40s who just have a early menopause or who have a surgical menopause they can have terrible hot flashes and we try very hard to to help those women get treated just to avoid the kinds of hot flashes that have that women can have with an early menopause so this is just sort of a summary of what I've said already the the step by step we do of treating hot flashes is if you have mild symptoms just try exercise Lifestyle Changes maybe a yoga class and Botanical therapy the or yeah like black coash the indications for hormones is if you have severe hot flashes if you've tried non- hormone therapies and they just haven't worked and then there are some women who say geez these hot flashes are killing me I can't work I can't sleep uh I feel tired all the time will you please give me industrial strength hormones and I think it's perfectly reasonable just to go straight to that level for women who lifestyle is just completely disrupted okay and then of course when women can't use estrogen I've already told you about the ssris Gabapentin or using progestins alone vaginal dryness symptoms or painful intercourse one of the things I want to point out is probably one of the best treatments for vaginal dryness and painful intercourse is actually not a hormone it's a lubricant so there's a variety of products sold in every drugstore and every um grocery store that are called intimate lubricants okay you see them advertised on late night TV all the time but it's not just KY it's things like Astroglide and Squid things that are water-based but have a little silicone in and they try really hard to recreate natural vaginal lubrication they do a really good job of it and so I will never prescribe vaginal estrogen for a woman until she's at least try to lubricant because for a lot of people that's all they need that's different from a vaginal moisturizer and there's a product called replans which helps with vaginal dryness during the day but it gets really clumpy during intercourse so it shouldn't be used during intercourse instead one of the lubricants and of course they're sold it everywhere including the internet uh without a prescription but if that's not enough then vaginal estrogen therapy is available for some women who have hot flashes and vaginal dryness systemic hormone therapy will also take care of their vaginal dryness and there's yet another new drug on the market which is called emine or Osphena I'll tell you a little bit more about that in just a second you've probably seen this um advertised on television so again if you only want to to treat vaginal symptoms then you only use vaginal estrogen when you give vaginal estrogen even to a woman who has a uterus she does not need to use a progestin because so little of that estrogen makes it from the vagina into the bloodstream that there's no risk of hyperplasia or cancer so that's the one case where we're willing to give estrogen by itself without a progestin and I've already told you about the lubricants alone helping vaginal dryness and uh and painful intercourse so this gives you an about some of the products that are out there there are two different kinds of vaginal creams estrace cream and Premarin Cream they used to be really inexpensive and unfortunately their retail price has gone up to like $150 even at Costco it's ridiculous but you can get different kinds of coupons and stuff for a lower price there are two different Rings one is called EST ring it's a lower dose ring the other is called fem ring it's a higher dose ring but each of these Rings last for 90 days so a woman gets a prescription for a ring puts it in her vagina it's going to work for the next 3 months but what a lot of women find is that it kind of gets in the way during intercourse it's a little bit but let's say about the same size as a contraceptive diaphragm so a woman just slips the ring out when she's going to have intercourse and then puts it back in U after she has intercourse but they work really well and for some of my older women who have pessaries we also use the estring right behind the pesy and it really helps and then there's actually a vaginal tablet which which is called vagem where just a tablet is tucked into the vagina so there are lots of different ways to get estrogen into the vagina and then the newest product again that you've probably seen on late night TV is called asina and it's another one of those selective estrogen receptor modulators but in this case it's very specific for the vagina so let's say this is a woman who had breast cancer a woman who's tried estrogen and has had lots of side effects but she has substantial vaginal dryness or painful intercourse that's what dis brunia is then here's an oral tablet that's FDA approved to help for that so there's an improvement in painful intercourse an improvement in vaginal dryness and the vaginal pH goes down into the acidic range where it should be so again a new drug not on a whole lot of health plan formularies yet relatively more expensive but for a woman in whom uh using a intimate lubricant is not enough maybe they've tried a vaginal estrogen preparation or tried it and it didn't work then EMA is another alternative in terms of treating um vaginal dryness now I also mentioned at the beginning that there can be urinary tract problems and estrogen may help that as well particularly top topical estrogen so what estrogen therapy in the vagina may do is to help with overactive bladder or urge in continents it's very clear that for postmenopausal women who have frequent bladder infections recurrent C it's called recurrent cystitis that using vaginal estrogen really cuts down on recurrent bladder infections and then the that burning on urination that can happen doesn't help stress incontinence and in the Whi it actually made it worse there is no product approved in the United States which is specifically for bladder health but we use estrogen topically to do all these different things that are on the list now is there any value of hormone therapy to improve sexual function and the answer is yeah it makes intercourse much more comfortable but and I've already told you about osina it doesn't do anything to libido so estrogen by itself doesn't help with with a lagging sex drive it doesn't make you want to have intercourse anymore neither does progesterone testosterone absolutely and there's been tons of research done with a product that didn't quite make it to Market which was a progest I'm sorry testosterone patch for women to improve libido and that's exactly what it did but the FDA didn't improve it because of the fact that there weren't enough people involved in the study if it were a bigger study it probably would have been improved and then again in the paper this morning I didn't make a new slide you might have read about a product which is called fanin which actually has an effect on the brain to improve sex drive and that probably will be approved by the FDA within the next year or so but it's not um estrogen or estrogen like so estrogen makes sex more comfortable but it doesn't increase sex drive at all now we're running out of time so I won't go through this in much detail what about the value of estrogen to prevent hip fractures or to prevent vertebral fractures and so the answer is it works it does help to replace some of the Lost bone okay but it doesn't do it as well as some of the other medications that are out there so the bis phosphinate drugs like Fosamax and uh actin and Boniva clearly work better to prevent fractures than estrogen does now the value of estrogen is the fact that if you're taking it for another reason taking it for hot flashes or vaginal dryness then it may also protect your bones but we very rarely use estrogen by itself as a way of preventing fractures because we have many better Alternatives um in the form of the misis phosphinates then the very last point then is what about using hormone therapy just for sort of quality of life I still see women who are in their 60s 70s even occasionally in their 80s who say my doc put me on estrogen back when I went through menopause it makes me feel better it makes my skin feel more Supple it helps me sleep at night it gets rid of my hot flashes I feel younger and peier and every time I stop it I feel worse okay so we never give estrogen to try to improve quality of life because we're not so sure that it actually does does that but for a woman who's been on it and she's not having problems with it and she's absolutely convinced that it improves her quality of life then basically what Nam says is that it's reasonable to continue using hormone therapy in women who feel better on it and worse when they go off it but we should use the lowest dose possible and every few years see if we can go ahead and discontinue it okay last slides I'm just going to skip over but they basically say I've told you a lot about how you start this and when you use it then the last question is how do you stop it so after a couple of years of using hormone therapy we say you know you may not need this anymore so we recommend what's called a drug vacation you can just stop using this then the next question that comes up is should you wean yourself off slowly slowly and then stop it or just go cold turkey and the best scientific answer seems to be doesn't really matter whether you go cold turkey or whether you wean yourself off the likelihood you go back on is about 25% the likelihood you won't need it anymore is about 75% here respective of whether you wean or whether you um continue and again I I apologize that I didn't have the time to go through the whole issue of the women's health initiative but I'll tell you in a in just a sound bite that the Whi was intended to answer the question if women take hormone therapy over an extended period of time will it prevent heart attacks or Strokes in the the answer to that particularly in older women seems to be no doesn't really increase the risk much but it doesn't decrease the risk much either okay but after the results of the Whi were published hormone therapy got a very bad name hormone therapy dropped by about half as a result of the Whi and it's been slowly coming back up ever since then and this was published about a year ago no a little bit more than that no a couple of years ago in 2012 decade after the Women's Health Initiative the experts do agree and this was endorsed by 15 different medical associations and that is that systemic hormone therapy is an acceptable option for healthy women in their 50s who are less than 10 years from menopause who have hot flashes not for everybody not to prevent heart attacks not to prevent Strokes or even fractures but if you're suffering from menopausal symptoms and you're within 10 years of menopause it's a perfectly reasonable choice for you to make but again we're going to individualize therapy it's not one size fits all and it's a matter of trying to balance quality of life priorities and risk factors okay very last slide and that is if you want more information there just so many books and websites and all that kind of stuff this in my opinion is the best book for consumers ever written about menopause called hot flashes hormones in your health it was it's written by an internal medicine doc who's at Harvard whose name is Joanne nanson she's also currently the president of the North American menopause Society but she's a really good writer and I I thought did a really good job of taking all this information about the Whi and making it very clinically understand uh understandable and readable in her books so there many different Alternatives out there in regard to books but I think Joann's is the best in terms of just a single easy read that um will tell you even even more than what I was able to tell you tonight so with that I'm going to go ahead and wrap up and thank [Applause] [Music] you [Music]

Channel: University of California Television (UCTV)

Views: 68,287

Keywords: menopause, hot flashes, vasomotor symptoms, hormone therapy

Id: 66MrB2AyoJU

Length: 88min 47sec (5327 seconds)

Published: Mon Mar 23 2015