{"id":1000,"date":"2016-03-14T14:22:52","date_gmt":"2016-03-14T14:22:52","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1000"},"modified":"2017-08-21T11:03:58","modified_gmt":"2017-08-21T11:03:58","slug":"primary-care-corner-with-geoffrey-modest-md-menopause-symptom-treatment","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/03\/14\/primary-care-corner-with-geoffrey-modest-md-menopause-symptom-treatment\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Menopause Symptom Treatment"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest <\/strong><\/p>\n<p>There was an intriguing editorial written by JoAnn Manson and Andrew Kaunitz suggesting that the pendulum has swung too far, and that too few women are receiving hormone therapy for menopausal symptoms (see\u00a0N\u00a0Engl J\u00a0Med 2016:\u00a0374; 803).<\/p>\n<p>Their points:<\/p>\n<ul>\n<li>We are an\u00a0aging population: by 2020 there will be &gt;50 million US women &gt;51 yo (mean age of menopause)<\/li>\n<li>75% have symptoms of menopause; women with moderate-to-severe symptoms often have them for more than 10 years. Symptoms include poor sleep, mood changes, difficulty concentrating and impairment of short-term memory.<\/li>\n<li>The\u00a0most effective therapy for moderate-to-severe symptoms is hormone therapy.<\/li>\n<li>Overall, about 20% of women have such severe symptoms, have no contraindication to hormone therapy (e.g. excessive risk of breast cancer\/cardiovascular disease; and I would add thrombotic events, active liver disease, stroke, and, to be safe, any thrombophilic disorder), and most remain undertreated<\/li>\n<li>Background here: in the past\u00a0huge numbers of women received hormone replacement therapy in an attempt to decrease cardiovascular events\/mortality and preserve bone strength, until the Women&#8217;s Health Initiative found increased cardiovascular mortality in its initial report in 2002. This\u00a0lead\u00a0to an 80% decrease in hormone prescribing [I would add that at that time\u00a0we were also getting better,\u00a0well-tolerated meds for these issues: statins and bisphosphonates, which seemed a much more reasonable and well-studied approach]<\/li>\n<li>But the WHI looked at long-term therapy in older women (mean age 63), and may have little relevance to women in their 40s-50s on shorter courses of therapy for these\u00a0distressing and sometimes\u00a0functionally-impairing symptoms<\/li>\n<li>One consequence of our not treating menopausal symptoms well is the proliferation of non-regulated compounded hormone products (a recent survey found that 35% of current hormone users are on these products)<\/li>\n<li>But hormone therapy is really well-studied, with:\n<ul>\n<li>Much lower risk of adverse events in those in their 50s vs older, including, in events per 1000 women over 5 years (the data is significantly better for those on conjugated equine estrogens CEE\u00a0alone vs with medroxyprogesterone MPA):<\/li>\n<li>Death from any cause: -5.5 (i.e. benefit) in those on CEE vs -5.0 on CEE\/MPA<\/li>\n<li>\u200bFractures: -8.0 with CEE vs -12.0 for CEE\/MPA [though actually hip fractures may be worse with CEE but better with CEE\/MPA]<\/li>\n<li>All cancers:\u00a0-4.0 with CEE vs -0.5\u00a0for CEE\/MPA<\/li>\n<li>Diabetes:\u00a0-13.0 with CEE vs -5.5\u00a0for CEE\/MPA\u200b<\/li>\n<li>Coronary heart disease:\u00a0-5.5 with CEE vs <strong>+<\/strong>5 for CEE\/MPA<\/li>\n<li>Deep venous thrombosis: <strong>+<\/strong>5\u00a0with CEE vs <strong>+<\/strong>5.0\u00a0for CEE\/MPA<\/li>\n<li>Breast cancer:\u00a0-2.5 with CEE vs <strong>+<\/strong>0\u00a0for CEE\/MPA [the decreased risk of breast cancer in those on just CEE was found in the Women&#8217; Health Initiative]<\/li>\n<\/ul>\n<\/li>\n<li>The data are reasonably robust that transdermal estrogens are even safer [bypass the first-pass hepatic metabolism of oral meds, with documented decreases in vitamin K-dependent\u00a0clotting factor induction, and observational data of many fewer DVTs; also oral estrogens more associated with high triglycerides and CRP levels]<\/li>\n<li>Also undertreated is vulvovaginal atrophy, occurs in 45% of women,\u00a0adversely affects physical and sexual health\/quality of life, and responds well to topical vaginal estrogens<\/li>\n<li>And there is a concern that new physicians are not receiving training in prescribing\u00a0hormones,\u00a0as verified in studies showing that 3\/4 of\u00a0internal medicine residents understand the importance of treating menopausal symptoms, yet\u00a03\/4 felt they did not get adequate\u00a0training<\/li>\n<\/ul>\n<p>A few comments:<\/p>\n<ul>\n<li>Although I do prescribe medications for\u00a0disconcerting\u00a0menopausal symptoms, I usually will suggest to the patient\u00a0trying nonhormonal meds first (e.g. SSRIs, SNRIs,\u00a0clonidine, gabapentin, the data on herbal medicines is pretty mixed, as are the data for exercise. Weight loss can help. I have prescribed\u00a0mostly venlafaxine but it seems that pretty much all SSRIs and SNRIs work). But the vast majority with severe symptoms do require estrogens. Almost always, I suggest transdermal estrogens, for reasons noted above, and typically have had great success with that.<\/li>\n<li>Women with intact uteri should have a\u00a0progestin prescribed, since endometrial hyperplasia can happen within months of starting estrogens. Though not great data for this, I tend to prescribe micronized progesterone (as opposed to MPA, micronized progesterone\u00a0does not decrease HDL levels). Aome people do well with\u00a0progesterone-secreting IUDs, though there is some (probably minimal concern) that\u00a0increased blood levels of progesterone can occur and one observational study did find a higher breast cancer incidence. I have not prescribed this so far, but it sounds pretty good to me&#8230;<\/li>\n<li>Also, my experience is that most women spontaneously stop the therapy within a couple of years, though some have recurrent symptoms (tapering the dose sometimes works)<\/li>\n<li>So, the risk of hormone therapy is really very low in young, healthy\u00a0women taking these meds for 5 years. I share the editorialists concerns that we are probably undertreating a condition which really affects women&#8217;s lives\/functioning, and that we are not adequately training residents\/new physicians in feeling comfortable with well-researched therapies.<\/li>\n<\/ul>\n<p>For more detail on menopause treatment studies and other recommendations, see practice guidelines by the Endocrine Society:<strong>\u00a0<\/strong>\u00a0J Clin Endocrinol Metab 100: 3975)<\/p>\n<p>See blog\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/02\/21\/primary-care-corner-with-geoffrey-modest-md-length-of-menopausal-symptoms\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/02\/21\/primary-care-corner-with-geoffrey-modest-md-length-of-menopausal-symptoms\/<\/a>\u200b which noted that 20% of women have menopausal vasomotor symptoms 13 years post-menopause, much longer than noted in many\u00a0published guidelines.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Menopause Symptom Treatment  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/03\/14\/primary-care-corner-with-geoffrey-modest-md-menopause-symptom-treatment\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1000","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1000","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1000"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1000\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1000"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1000"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1000"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}