MENOPAUSE PART 2: MANAGEMENT OF MENOPAUSE and ROLE OF HORMONE THERAPY Flashcards
Lifestyle Based Measures
Cooling techniques
§ Dress in layers
§ Breathable fabrics
§ Use fan
Avoiding triggers
§ Excessive alcohol
§ Spicy foods
Maintain healthy body weight
Smoking cessation
Exercise
Yoga and relaxation techniques
Complementary Therapy
Evidence to support:
§ Cognitive behavioral therapy
§ Mindfulness based stress reduction
Inconsistent evidence:
§ Acupuncture
§ Phytoestrogen or soy based products
Smoking may cause earlier meopause by few yrs
Inuces estrogen lvl metabolism
Decrease estrogen lvl
Natural Health Products: Phytoestrogens
Plant compounds
with estrogen-like
activity
■ 500-1000 times
weaker than
estradiol
Types Examples
Isoflavones soy, red clover
chickpeas, garbanzo,
lentil, beans
Lignans flaxseed, sunflower
seeds, whole grains
Coumestans red clover, split peas,
pinto beans, alfalfa
sprouts
- Isoflavones of soy = daidzein, genistein, glycetin
Natural Health Products: Phytoestrogens
§ Soy: 30 - 50 gm per day in diet (40 – 80 mg isoflavones),
flaxseed: 1 – 3 TB (note: flaxseed needs to be ground)
§ Isoflavone supplements: soy, red clover
* 40 – 80 mg isoflavone daily
§
“Marginal effect” with hot flashes, inconsistent results in studies
§ ~ 8 – 12 weeks to work
§ Food better source
§ Caution with hormone-sensitive cancers (for supplements only)
Natural Health Product: Fermented soy bean
extract
§ Femarelle®
§ RCT showed decrease in vasomotor symptoms.
§ No adverse changes in breast or endometrium.
§ Dose: one capsule bid.
§ No safety data in breast cancer risk
Natural Health Product: Black Cohosh
§ Exact mechanism unknown
* may act as a SERM
§ Usual dose: 20 mg - 40 mg bid
§ Takes up to 8 - 12 weeks to see effect
§ Clinical trial data mixed; most recent studies have found no
effect
§ Generally well tolerated
§ Case reports of liver damage (though likely a rare event)
Making a Decision to Start MHT
Benefits:
Symptom improvement
Prevention of
osteoporotic fractures
Risks:
Cardiovascular Disease:
*CHD
*Stroke
*VTE
Breast Cancer
Quality of Life
What do the guidelines say?
Systemic MHT is a safe, effective option to initiate
in health individuals<60 years of age or less than
10 years after their last menstrual period.
For early or premature menopause, consider MHT
until the average age of menopause
Benefits of MHT: Summary
§ Systemic MHT is the most effective option for moderate to severe
vasomotor symptoms.
§ Other benefits on symptoms include
* Sleep – reduces sleep latency
* Improves mood (for example depression especially in perimenopause)
* Contributes to well-being (QOL)
§ Preventing bone loss and fractures
§ Genitourinary syndrome of menopause (GSM) – vaginal estrogen
therapy
Initiating MHT: Considerations
§ Estrogen is used for symptom management such as VMS
* Doses can be adjusted for symptom management
§ Progestogen is used to provide endometrial protection for
systemic estrogen (prevent endometrial cancer)
§ Vaginal estrogen therapy is for GSM symptoms
§ Individualize MHT to:
* Symptoms
* Medical conditions
* Risk factors
* Patient preferences
not for systemic symptoms in canada, only local like vaginal
Contraindications to MHT
undiagnosed abnormal vag bleeding
breast cancer
estrogen dependent cancers
CHD
VTE
stroke
thrombophilia
liver disease
known/suspected preg
Overview of the Women’s Health
Initiative (WHI)
Designed as a RCT to assess if MHT reduced cardiovascular
morbidity and mortality.
The WHI had two MHT arms:
■ Estrogen+Progestin arm – stopped early 5.2y
■ Estrogen alone – stopped after ~7 y
CEE and medroxyprogesterone were the MHT u
Media message was 26%
increase in breast cancer risk
and 29% increase in heart
disease
Summary Considerations with WHI
§ Mean age 63 years
§ Benefits on symptoms were not addressed as this was not an
objective of the study
§ Extrapolation of results to women NOT studied in the WHI (i.e.
younger symptomatic individuals)
§ Consideration of type of estrogen and progestogen used
(conjugated equine estrogen and medroxyprogesterone acetate
used)
Putboth arms together and re-analyzed it
For coripnary heart disease speicifcally
Highest risk for those who initiate it for more than 10 years since menopause
MHT and Venous Thromboembolism
Estrogen dose-dependent procoagulant
effect
§ Increased risk of VTE with both WHI -
EPT and ET
§ Greatest risk in first year, with familial
thrombophilia or other risk factors
§ Transdermal estrogen may have lower
VTE risk however, these are based on
observational studies only (not RCT).in starndard or low dose estrogen
transdermal don’t have the same first pass effect
Transdermal hormone tx has same risk of VTE as transdermal CHC
FALSE - why may there be less risk in MHT but not CHC?
- Comes down to potency of estrogen is much higher with our CHC Higher doses of transderm tx could still result in VTE
MHT and Cardiovascular Risk
§ Age and time since menopause matter!
§ Individuals at high risk for CVD should avoid MHT, this includes
patients who have had a VTE, stroke or CHD event
§ Individuals at moderate risk with comorbidities may want to use
transdermal estrogen or lower dose estrogen
§ Address all modifiable CVD risk factors! Comorbidities:
Hypertension
Smokers
Obesity
Diabetes
