3 - Menopause

Question 1

Define menopause, peri-menopause, and post-menopause

Answer 1

• Menopause = permanent cessation of menses for 12 consecutive months due to the loss of ovarian function
• Perimenopause = transition into menopause (beginning of sx; usually 2 years before menopause)
• Post-menopause = 1 year after menopause & beyond
• • Women now spend 1/3 of their lives in post-menopause

Question 2

Sx of menopause

Answer 2

• Vasomotor (“hot flashes”) – most common
• Genitourinary
• Mood changes
• Sleep disturbance
• Sexual function
• Skin wrinkles
• Hair thinning/loss
• Joint pain; increased risk of osteoporosis

Question 3

Describe the vasomotor sx of menopause

Answer 3

• Hot flashes or flushes, night sweats
• Average duration of sx = 7-8 years
• • 60% have < 7 years; 15% persist > 15 years
• ~80% perimenopausal women & ~40% postmenopausal women have hot flashes 3+ times/day

Question 4

Genitourinary syndrome of menopause

Answer 4

• Associated w/ decreased estrogen, & will generally persist or worsen w/ aging
• Vaginal atrophy doesn’t improve overtime (unlike hot flashes)
• Genital – dryness, burning, itching, discharge, irritation
• Urinary – loss of bladder control, recurrent UTIs
• Sexual – lack of lubrication, discomfort/pain, impaired function

Question 5

Menopause quick 6 screen

Answer 5

• Any changes in your periods? *
• Are you having any hot flashes? *
• Any vaginal dryness or pain or sexual concerns?*
• Any bladder issues or incontinence? *
• How is your sleep?
• How is your mood?
• If yes to any of the first 4 questions = may be a candidate for tx

Question 6

Goals of therapy for menopause

Answer 6

• Relieve sx (vasomotor, urogenital, mood-related changes)
• Improve QOL & well-being during & after this transition period
• Minimize adverse effects of therapy (endometrial/breast cancer, MI, stroke, VTE)

Question 7

What are the pharm options for menopause?

Answer 7

• Hormone tx (estrogen, combination estrogen & progestogen)
• Non-hormone tx (SSRI, SNRI, gabapentinoids, clonidine)

Question 8

Who should get hormone therapy for menopause?

Answer 8

• Unremitting sx affecting QoL
• No absolute contraindications
• Other non-drug options not effective
• Risks and benefits discussed
• Agree to limited duration of tx

Question 9

What are the contraindications to hormone therapy use in menopause?

Answer 9

• Unexplained vaginal bleeding
• Acute liver dysfunction
• Estrogen-dependent cancer (endometrial & breast cancer)
• Coronary heart disease, previous stroke, active thromboembolic disease

Question 10

Does hormone therapy work for menopause?

Answer 10

Most effective tx option for moderate to severe vasomotor sx

Question 11

What are the risks associated w/ hormone therapy use?

Answer 11

• Increased risks of breast cancer, coronary heart disease, thromboembolic events, stroke
• Continuing HT w/ the lowest effective dose beyond age 60 w/ clinical supervision may be considered in some circumstances
• Women should be advised of the increased risks; HT should be individualized & not stopped solely based on age
• Highest risk for breast cancer after 4-5 years of combo HT; ovarian cancer after 4 years; CV disease after 4 years in those age > 60, > 10 years after menopause

Question 12

What are the available formulations of hormone therapy? When should one be used over the other?

Answer 12

• Systemic (combined vs. estrogen only; cyclic (sequential) vs. continuous; oral vs. transdermal)
• Local (cream, ring, tablets)
• If LMP < 1 year -> recommend cyclic timed to endogenous cycle; minimizes risk of breakthrough bleeding
• If LMP > 1 year -> consider continuous to avoid monthly withdrawal bleed
• Breakthrough bleeding generally resolves < 3-6 months (longer than this = referral)
• Consider topical/ transdermal if increased CVD risk, HTN, DM, smoking, obesity, gallstones
• Consider vaginal estrogen for urogenital sx b/c less systemic effect; ok even if breast cancer hx if failed non-hormonal tx
• Low-dose vaginal estrogen (0.5 g twice/week) doesn’t necessitate a progestogen for women w/ a uterus

Question 13

What are the non-hormonal tx options for vasomotor sx?

Answer 13

• SSRI (off-label)
• SNRI (off-label)
• Gabapentinoids (off-label)
• Clonidine 0.05 mg BID (4-6 week trial)
• Rule of thumb – low doses are often effective; start low & titrate up if necessary to minimize SEs; allow 2-4 weeks for effect

Question 14

Which NHPs are marketed for menopause? Do they work?

Answer 14

• In general, these appear ineffective, but evidence is limited
• Watch for DI’s & CI’s
• Purity of compounds a concern
• Soy/isoflavones – phytoestrogen w/ estrogenic effects? – may or may not be more effective than placebo
• Black cohosh – modulation of 5-HT pathways? Estrogenic activity? – Cochrane review = no different than placebo
• Dong quai, fennel, evening primrose oil – likely no better than placebo

Question 15

Describe some non-pharms for menopause

Answer 15

• Useful – vaginal moisturizers (alternative to vaginal estrogen) for urogenital sx (vaginal dryness, dyspareunia)
• • Apply HS 3 times/week
• Some evidence to support – weight loss, clinical hypnosis, cognitive behavioural therapy
• Reasonable to try, but limited evidence – smoking cessation, healthy diet, cooling techniques, exercise, yoga, avoidance of triggers
• Limited or no evidence, but potential harm/cost – NHPs, acupuncture

Question 16

Monitoring for menopause

Answer 16

• Symptoms
• When lower doses are used, the delay before adequate relief may by up to 6 weeks -> advise women to be prepared to wait 6-8 weeks before modifying the regimen
• Side effects -> if secondary to progestin (ex: mood swings, bloating) may decrease dose by ½ or decrease duration by 7-10 days
• Bleeding -> if bleeding heavy or erratic on sequential regimen, consider increasing progestin dose (ex: x2)
• Women receiving MHT (menopausal hormone therapy) must be evaluated annually, w/ the risk-benefit profile as well as the woman’s expectations reviewed
• Always use the lowest dose that adequately addresses sx & use for the shortest period of time

Question 17

Describe tapering of hormone therapy

Answer 17

• Varying data about abrupt d/c vs. taper
• Abrupt d/c may worsen VMS in first 3 months
• Tapering methods:
• • Alternate doses of oral meds then reduce to lower dose
• • Drop 1 pill/week every couple of weeks