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Contemporary Approaches for Managing Menopause Symptoms

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Contemporary Approaches for Managing Menopause Symptoms Menopause 2017 Guidelines: Looking at Special Populations and Building on Existing Practice Patricia Geraghty, MSN, FNP-BC, WHNP Disclosures • Speaker Bureau • AbbVie • Therapeutics MD • Advisory Board • AbbVie (endometriosis) • Sharecare Inc. • Procedure Proctor • Bayer (Contraception) • Off label discussion will be included and identified in this discussion. Objectives • Identify the benefits and risks of estrogen, progesterone, and non-hormonal pharmacological management of menopause symptoms based on dosage, route of administration, pharmacokinetics, treatment population and duration of use. • Develop treatment strategies for special populations including premature ovarian insufficiency, prolonged symptoms, and women who are not candidates for estrogen. • Incorporate the NAMS 2017 Position Statement into patient counseling on the timeline of menopause symptoms and the termination of hormone therapy. Lifespan Lifespan Median 34 322 BC Aristotle describes transition Ages the Through Menopause yr JAMA. JAMA. Investigators. Initiative Health the Women's for Group Writing 2002;288(3):321 - 333. doi:10.1001/jama.288.3.321 Treated with plants s/a 1800’s cohosh, cannabis, opium 1821 French physician DeGardanne 53 lifespan lifespan calls it “Menopause” Adult - 1900’s Deficiency disease 55 1942 Premarin” copyright yr 1960’s “Forever Feminine” by Robert Wilson MD 1980’s-1990’s “Politics of Menopause” by Frances McCrea 2002 WHI- First large randomized control trial “My periods are different. Is This Menopause?” • Random cycling, sometimes early, sometimes late. • Flow variable with prodromal spotting, a long taper, or stopping and starting. • She has a day of very heavy flow. • 77% have duration 10+ days, heavy bleeding 3+ days, spotting 6+ days Paramsothy P, et al. BJOG. 2014 Nov;121(12):1564-73. doi: 10.1111/1471- 0528.12768. Epub 2014 Apr 16. A Well Controlled Conversation Harvard Women’s Health Watch. Perimenopause. September 1999 from Santoro N et al. J Clin Enodrinol Metab. 1996;81:1495-1501. As The Follicles Age (180 days) Harvard Women’s Health Watch. Perimenopause. September 1999 from Santoro N et al. J Clin Endorinol Metab. 1996;81:1495-1501. Managing Cycle Irregularities • Combined Hormonal Contraceptives • Only intervention that provides cycle control • Exposes patient to known risks of CHC • Progestin-Only Contraceptives • Levonorgestrel IUS • Endometrial Ablation Non-Pharmacologic • Hysterectomy True Menopause: Cessation of Menses Harvard Women’s Health Watch. Perimenopause. September 1999 from Santoro N et al. J Clin Enodrinol Metab. 1996;81:1495-1501. Steroid Formation CHOLESTEROL PROGESTERONE CYP-450* Pregnenolone Dehydroepiandrosterone PROGESTERONE (DHEA) 60% Androstenedione Androstenediol Aldosterone Cortisol * * 5 α-Reductase TESTOSTERONE Aromatase CYP-19 Dihydrotestosterone (DHT) ESTRADIOL ESTRIOL ESTRONE EFFECTS OF ESTROGEN Estrogen Target Organs DECREASE Vasomotor symptoms Cognition ? Decrease arterial compliance, Increase BP, Endothelial change Decrease HDL, Increase LDL & triglycerides Bronchoconstriction Vasospasm Endothelial change Vulvovaginal Osteoporosis Atrophy Arthritis Collagen loss “If Only I Could Sleep.” North American Menopause Society. Menopause 2010: 17(2);242-255. Predicting Menopause: Final Menstrual Period (FMP) ▪ Salivary hormone levels not reflective of serum levels- no role in monitoring therapy ▪ Blood tests of little value Wren BG et al. Climacteric 2000;3(3):155-160. Fuch-Berman A. Bythrow J. J Gen Intern Med 2007;22(7): 1030-1034. Harlow SD, et al. Menopause 2012; 19(4): 387-395. Duration of Menopause Symptoms (SWAN) • Median duration frequent vasomotor symptoms (≥ 6 days in previous 2 weeks) • Total duration 7.4 years with post-FMP persistence 4.5 y • 11.1 years: Women with symptoms before FMP (post- FMP persistence 9.4 y) • 3.4 years: Women w/symptom only after FMP • 10.1 years: African American women (longest total duration) Avis NE, et al. JAMA Intern Med. 2015 Apr 1;175(4):531-9. doi: 10.1001/jamainternmed.2014.8063 15 Top Medical Organizations Agree: Joint Statement 2012 ▪ Hormone therapy is an acceptable option up to age 59 or within 10 years of menopause for moderate to severe symptoms ▪ Women need progestogen along with estrogen if uterus is intact Steunkel CA, et al. Fertil Steril. 2012; 98(2):0015- 0282. http://dx.doi.org/10.1016/j.fertnstert.2012.05.051 Indications for Hormones: 2017 ▪ Systemic estrogen therapy FDA approved for: ▪ Vasomotor Symptoms* ▪ Vulvovaginal Atrophy (Genitourinary Syndrome of Menopause)* ▪ Osteoporosis Prevention ▪ Premature hypoestrogenism ▪ Variable effectiveness in treating other sx ▪ No protection from pregnancy The 2017 Position Statement of the North American Menopause Society Menopause. 2017 Nov;24(7):728-753. Addressing the Needs of All Women, Individually • Risk Assessment • <10 y since menopause, <60 y age • >10 y since menopause, >60 y age • Health Promotion • USPSTF says NO role postmenopause • Ignores QOL and associated risks of GSM • Symptom Management Final Recommendation Statement: Hormone Therapy in Postmenopausal Women: Primary Prevention of Chronic Conditions . U.S. Preventive Services Task Force. December 2017. accessed online 7 Jan 2018 https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFin al/menopausal-hormone-therapy-preventive-medication1 Risk Assesment: Relative or Absolute? • Relative- WHI 26% Increased risk • Absolute- WHI E+P: 8 additional cases per 10,000 w/y use • E+P increase node positive cancer at 11 years • Absolute risk 2 deaths per 10,000 women/year at 11 years Attributable breast cancer risk WHI- mean age 63 y, CEE+MPA Two daily glasses of wine ESTROGEN ONLY GROUP? Obesity, Low physical activity One daily glass of wine Mortality Breast Cancer & Dementia 18-yr f/u Rossouw. JAMA. 2007; 297:1465. Chlebowski RT, et al. JAMA. 2010; 304(15): 1684-92. LaCroix AZ, et al. JAMA. 2011; 305(13): 1354-55. The 2017 Position Statement of the North American Menopause Society. Menopause. 2017 Nov;24(7):728-753. Manson JE, et al. JAMA. 2017; 318:927-938. Duration of Use • E+P: no increased risk < 5 years use ▪ Women who initiate E+P use soon after menopause, and continue for many years, appear to be at particularly high risk. ▪ 5-Year Estimated hazard ratio 1.64 (1.00, 2.68) ▪ 10-year estimated HR 2.19 (1.56, 3.08) ✗ • Personal History Breast Cancer (ER positive) • Dense breasts mammogram and biopsy but not cancer ✓ • Genetic risk breast cancer not further increased ✓ Prentice RL, et al. Am J Epidemiol. 2008 May 15;167(10):1207-16. The 2017 Position Statement of the North American Menopause Society. Menopause. 2017 Nov;24(7):728-753 15 Top Medical Organizations Agree: Joint Statement 2012 ▪ Hormone therapy is an acceptable option up to age 59 or within 10 years of menopause for moderate to severe symptoms ▪ Women need progestogen along with estrogen if uterus is intact ▪ Breast cancer risk increases with 5 or more years of continuous estrogen with progestin therapy, possibly earlier ▪ The risk decreases to rare (< 1:1000) after hormone therapy is stopped Steunkel CA, et al. Fertil Steril. 2012; 98(2):0015- 0282. http://dx.doi.org/10.1016/j.fertnstert.2012.05.051 Safety Issues • Endometrial Cancer • If she has a uterus, use progestin with estrogen • Cancer risk r/t dose and duration unopposed E • Cancer risk persists after discontinuing HT • Hx endometrial cancer, menopause symptoms • Low grade, early stage, surgically treated: benefits may outweigh risks particularly in younger women ✗ • Higher grade, more advanced: HT not recommended The 2017 Position Statement of the North American Menopause Society Menopause. 2017 Nov;24(7):728-753 Best Endometrial Protection EFFECTIVENESS • Continuous combined E + P • No hormones • E with long cycle sequential P Jaakkola S, et al. Obstet Gynecol 2009;114:1197-1204. Somboonporn W. et al. Menopause 2011;18:1060-1066. 2012 Hormone Therapy Position Statement of the North American Menopause Society. Menopause. 2012; 19(3):257-271. Progestin Lowest Effective Dose ▪Medroxyprogesterone 2.5 mg qd ▪Micronized progesterone 100 mg qd ▪Progestins oral ▪ Norethindrone acetate 0.1 mg ▪ Drosperinone 0.5 mg Products ▪Progestins transdermal ▪ Norethindrone acetate 0.14 mg } ▪ Levonorgestrel 0.015 mg Combination Off Label Progestogen ▪ Vaginal administration progestogen and LNG-IUS not FDA approved in postmenopausal women ▪ Progestin IUS protection equivalent to continuous E+P and superior to sequential E+P in one small study ▪ Close monitoring of endometrium recommended 2012 Hormone Therapy Position Statement of the North American Menopause Society. Menopause. 19(3):257-271. Estrogen + SERM: Vasomotor Sx and Osteoporosis Prevention • Conjugated equine estrogen/bazedoxifene 0.45 mg/20 mg (Duavee®) • “Purposely paired” with non-progesterone • Yet still protects endometrium • For women with a uterus and should have risk osteoporosis • 4% trial population age 65 – 74 years • 74% reduced severity/freq vasomotor sx 12 wks • No incidence VTE clinical trials- boxed warning • Unknown risk for breast cancer Pinkerton JV, et al. Climacteric. 2012 Oct;15(5):411-8. doi: 10.3109/13697137.2012.696289. 2012 Joint Statement: Safety Issues Both estrogen alone and estrogen with progestin increase the risk of blood clots. The risk is rare in • VTE women aged 50-59 • Strong evidence increased risk all ages- oral • Cochrane Review RR 1.74; CI 1.11-2.73 ✗ • Do not use with hx VTE or inherited risk • Ameliorate risk • Transdermal estrogen (II+++) Largely Observational + • Lower dose estrogen (I
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