How do you determine someone is postmenopausal?
- No menses for 12 months
- A serum FSH is not required to make diagnosis
How could you tell if a 52 year old woman was menopausal if she is continuing to take birth control pills?
- Stop pill
- Measure FSH 2-4 weeks later
- Level >/= 25 indicates menopause
**There is not FSH value that would provide absolute reassurance that a patient is menopausal
Contraindications to HRT?
Pregnancy
Existing breast cancer
Estrogen sensitive tumor
Undiagnosed vaginal bleeding
Active liver disease
History of VTE or thrombophilia
Coronary heart disease
CVA or TIA
When to stop HRT?
Shared decision making
50% has recurrence of VMS
Tapering or abruptly stop doesn’t change this
Re-evaluate for risks to make sure they are still a candidate
Discuss risks and benefits again
Recommend AGAINST routine stopping at age 65
Who can get HRT?
Women < 10 years from menopause
OR
Age < 60 if no contraindications exist
**Recommend calculating CVD and Breast Ca Risk score prior to starting HRT
Why is compounded bio-identical HRT not recommended?
- doses are not consistent
- not FDA approved/regulated
- presence of impurities and lack of sterility
- lack of scientific efficacy and safety data
Non-medical options for vasomotor symptoms
- Address ambient temperature
- Dress in layers
- Avoid hot/spicy foods
- Avoid alcohol/caffeine
- Consume soy products (due to phytoestrogens, but need to consume a lot to reach a benefit)
- Increase water consumption
- Stress reduction
- Acupuncture
Medical alternatives to HRT?
SSRI/SNRI
Paroxetine 7.5 mg/d (FDA approved) = Paxil
Venlafaxine 75 mg/d (more effective) = Effexor
Desvenlafaxine 100 mg/d (most effective) = Pristiq
Veozah (FDA approved)
Gabapentin (not FDA approved)
Clonidine (not FDA approved)
MOA of Veozah? Contraindications?
Neurokinin 3 receptor antagonist
FDA approved :)
Contraindications:
Known Cirrhosis
Severe renal impairment (ESRD)
Concomitant use with CYP1A2 inhibitors
Test baseline CMP
Repeat at 3, 6 and 9 months after starting
What are phytoestrogens?
plants w/ estrogen bioactivity (soy, red clover)
Symptoms of menopause?
No one universal symptom!
Vasomotor Symptoms
Genitourinary Syndrome of menopause
Vaginal dryness/pain with intercourse
Sleep disturbances
Moods swings/anxiety/depression
Cognitive concerns
Joint pain
Change in weight distribution
Average length of menopause symptoms?
Varies!
6 months to > 10 years
Benefits of HRT?
- Most effective to treat vasomotor and GSM symptoms
- Helps prevent bone loss
- Decreased risk of colon cancer
- Reduce risk of diabetes/ small effect on addressing change in weight distribution
- May provide cardiovascular benefit when started within 10 years of menopause (not recommended for prevention)
- May decrease all cause mortality by 30%
Risks of HRT?
- Oral therapy increases clot risk
- Increased risk of stroke if started after age 60
- If started after age 65, increased risk of dementia
What about HRT and breast cancer risk?
Data does NOT show an additive effect of underlying breast cancer risk + HRT use on breast cancer incidence
Risk similar to that of modifiable risk factors such as 2 daily alcoholic beverages, obesity or low physical activity
Risk is greater with progesterone containing regimen (specifically MPA) vs with just estrogen alone
