This topic was discussed in a recent version of NAMS Practice Pearl. The most pertinent studies were reviewed by Dr. Krista Varady, PhD, from the University of Illinois at Chicago.
Here is her assessment.
The cause of midlife weight gain is a combination of the following factors: loss of estradiol, age-related decreases in metabolic rate, and for some women, a more sedentary life style. Approximately 40% of women in menopause in the US can be categorized as obese.
There is so much conflicting information about which diet is the most effective for weight loss. It is difficult for physicians, and very confusing for the average women to know which strategy for weight loss has the best scientific data to back up its efficacy. Plus, the metabolism of women at midlife is very different from younger women, and also different than men, so finding studies specific or our sex and age group can be challenging.
Let’s compare low-fat diets to high-protein diets in midlife women:
Three studies of low-fat diets were randomized and controlled, which provides a high level of significance. In the first study, obese women were restricted to <30% fat, and calories were kept between 1200-2000 per day, depending on their weight. After 12 months, the average weight loss was 8.5%. If you started the diet at 180 lbs., you would lose about 15 lbs. in one year. In another study, a very low fat diet, <15% of calories consumed per day, women lost 7.7% of their body weight in 8 months. In another study, where fat was restricted to 20-35%, and calories restricted to a deficit of 500 calories per day, the participants lost 6.1% of their body weight in 4 months, about 11 lbs. for your 180 lb. women.
The Women’s Health Initiative looked at whether a low fat diet was effective in weight maintenance in mid-life women. In this study, more than 19,000 women were asked to restrict their fat intake to <20%, with no limitation in calories for seven years. In the first year, the women lost an average of 1.7%, but maintained about a 1% weight loss for the next seven years, indicating that fat restriction may be a strategy for long term weight maintenance.
Let’s look at the data for high-protein diets.
High-protein diets are effective in preserving muscle mass during weight loss. In one study, a high-protein low-calorie diet was compared to a low protein, low-calories diet, and both compared to an unrestricted diet. Both low calories groups lost the same amount of weight, 10% in six months. Again for our 180 lb. woman, this is 18 lbs. in 6 months. What was most important was that the difference in muscle mass was measured. The high-protein group last half as much muscle as the low-protein group. This is important because our muscle mass determines our resting metabolism: how many calories do you use up when you are at rest, not exercising. If you lose muscle mass, you require less calories to maintain normal functions, and you will need to restrict more to continue losing weight. Two additional studies had similar findings.
The bottom line was that restricted calories, regardless of protein composition of the diet, resulting in similar weight loss. Muscle mass was better preserved with high protein diets, but bone density was not as well preserved, and the benefit of the weight loss on insulin sensitivity was not as good as would have been expected.
Diets that incorporate fasting have become popular. One fasting day alternates with one day of “feasting” The idea is that on fasting days, caloric intake is limited to 500 calories, either at lunch or dinner. On non-fasting days. there is no restriction on what is eaten. Postmenopausal women lost about 11% of their body weight in 6 months with this regime, about 20 lbs. for our 180 lb. woman. Bone density was not affected by the alternative day fasting regime.
So, how do we compare these regimes. Caloric restriction, whether it be low-fat or high protein results in weight loss. High protein seems to be better for maintenance of muscle mass, but possibly sacrificing some loss of bone. What was not discussed was the effect on cholesterol and insulin levels, and the results if these diets were followed in the longer term.
These studies seem to raise many more questions.
Although all studies led to loss of weight, the rate of weight loss was slower than we might hope. For a person who needs to lose more than 20 lbs., it seems that a long-term strategy needs to be used. Rather than dieting, a lifestyle change might be a better approach. Increasing exercise and physical activity gradually can prevent injuries, and finding varied activities that are truly enjoyable may lead to a sustainable program. Incorporating short-term goals that are more easily obtainable may be more effective than going for the 50 lb. weight loss that will take several years to accomplish. Self-monitoring with diet apps that measure the caloric and nutritional value of foods can help to determine if your fat and protein intake are where you want them to be, and to understand the caloric value of portion size and the detriment of snacking and grazing. Many women do well with the structure of programs like Weight Watchers. A nutritionist may be helpful to organize a program individual to your lifestyle and personal preferences.
Unfortunately, long term success with sustained weight loss can be very difficult to obtain.
What is needed is more studies in women after menopause to understand their unique hormone issues how this changes metabolism, and which strategies provide the best success.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
NAMS Practice Pearl: Dietary Strategies for Weight Loss in Midlife Women, Krista A. Varady, PhD. released December 20, 2017
Two weeks ago I spent two days at the NIH at at a conference on osteoporosis: Pathways to Prevention: Appropriate Use of Drug Therapies to Prevent Osteoporotic Fractures. The goal of the meeting was to bring forward experts and the data to consolidate information regarding recommendations for treatments, understanding risks and side effects of medications, and to better understand gaps in our knowledge. This will hopefully lead to additional research to fill in these gaps.
Because this topic is so broad, I will break it down into smaller topics, and report the information as a series. Let’s start with the burden of the disease, a lecture given by Dr. Elizabeth Shanes.
Osteoporosis is a very significant public health burden. Approximately 10 million Americans have osteoporosis, but most of them do not know it. Osteoporosis is defined as weakness of the bones, resulting in increased risk of fractures. Fractures can lead to surgery, disability, immobility, loss of independence, and decreased life span. As we age, most adults want to maintain their independence and quality of life.
Here are some facts that we know for sure:
There are 1.5-2 million osteoporotic fractures per year in the US, mostly involving the spine, hip, wrist, and pelvis. Women will incur 70% of the burden of these fractures. 50% of women over the age of 50 will sustain at least one fracture in their remaining years. Caucasian women carry the highest risk.
The cause is low bone density which can be measured and monitored. The risk of osteoporosis increases with age. About 44% of women over age 50 have low bone mass. The risk of osteoporosis over age 50 is at least 10%, and may be as much as 30%.
Low bone density predicts fractures, both traumatic fractures as well as low-trauma fractures.As bone density decreases, the risk of fractures increases.
Once you break a bone, you are more likely to break more. If your break a vertebrae, you are 5 times more likely to break another vertebra, and 3 times more likely to break your hip. If you break one vertebrae, you have a 25% chance of breaking another within one year.
Adults who break bones have significant increased morbidity and mortality. After a broken hip, your risk of death in the next three months increases 5-8 times, and the increased mortality remains for the next 10 years. Studies show that other fractures including vertebral, femoral, tibial, multiple rib and other fractures are all associated with increases in mortality. About 25% of women who fracture a hip will live less than a year.
Fractures also decrease mobility. 50% of adults who break a hip will have difficulty walking one year later. Vertebral fractures are related to back pain and difficulty with managing tasks of daily living. Studies show that quality of life decreases after fractures, and the more fractures, the more rapid is the decline. Many people who fracture never regain their quality of life.
The cost to the healthcare system and individuals is dramatic. In 2005 there were 2 million fractures at a cost of 2 billion dollars. One hip fracture costs about $30,000 to treat. As the population ages, the healthcare costs related to fractures will increase. Those who are insured that fracture have twice as high health care costs as those who do not.
Fractures are preventable. All women should be encouraged to take adequate doses of calcium and Vitamin D, and exercise to improve muscle strength and balance. Fall prevention strategies should be discussed with patients. The biggest cause of falls is lack of muscle strength as we age.
Once osteoporosis has been diagnosed, medication is necessary to treat the disease. Many patients will be motivated to increase their calcium, Vitamin D and exercise at that point, but significant improvement in fracture risk is difficult to achieve. Short term use of certain FDA approved medications have been proven to prevent fractures. The long term strategies for drug use need further study.
Medications that prevent fractures are not being effectively. Bisphosphonates (Fosamax, Actonel, Boniva and Reclast) for osteoporosis treatment were approved in the mid-1990’s. Their use increased until about 2008 when media reports surfaced about side effects. The use of these drugs have sharply declined since then, although the risk are very, very rare. The perception by many patients is that the drugs do not work or make the bone more brittle, and the side effects are frequent. This is not true.
Since these reports, physicians have focused on treating those most at risk of fractures, rather than using the drugs preventatively, and have begun using drug holidays when appropriate.
Data indicates that even after hip fractures, less women are being treated for their osteoporosis. Less than 20% of women who break a hip are started on medication to prevent another fracture. New data tells us that for the ten years from 2005-2015, hip fracture rates were decreasing, then stabilized, and are now increasing. There have been about 11,000 more hip fractures and 2300 deaths attributed to the change in the trend. Medicare has markedly lowered reimbursement to doctors for osteoporosis testing in the office, so many practitioners no longer offer this service. The trend in decreased testing and concern of patients over side effects of medication, both contribute to the increase in fractures.
Physicians need to understand the concerns of patients about side effects, and understand the barriers to initiating and continuing treatment, including cost and insurance restrictions. Physicians also need to effectively communicate with patients the devastating effect of fractures, and learn how to prevent and diagnose complications sooner than later.
Here are Dr. Shanes final comments: “Osteoporotic fractures are common, costly, debilitating, disabling, and deadly. Although we have drugs to prevent them, those drugs are not being used.”
We have an opportunity to do better.
The next article in the series will look at who is at risk for a fracture, and who should be screened. We will also talk about how to interpret your results. Stay tuned.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
NIH: Pathways to Prevention: Osteoporosis
Elizabeth Shane, MD. Osteoporosis Fracture Prevention in the US, October 30, 2018
The mechanism of hair loss in postmenopausal women is largely genetic. Some women can lose up to 40% of their hair as they age! Yikes!
Bald sports or thinning areas may be a sign of a medical condition or nutritional deficiency. Having an evaluation with a medical doctor or dermatologist is a good first step.
Telogen effluvium (TE) is a non-scarring form of hair loss that often has an acute onset.
It is often a reaction to change in hormones, stress, or medication. Changes in hormones related to childbirth or menopause can be enough to cause TE. Stresses such as an injury, febrile illness, change in diet, or immunization can be implicated. The insult may have occurred 1-6 months previously. in TE, many hairs fall out all at once, instead of the usual asynchronous loss of hair. It is normal to lose about 150 hairs per day. TE can resolve in 6 months, but longer lasting episodes can occur. Patients should be reassured that time will correct this, but it is a slow process.
The most common cause of hair loss as we age is called androgenic alopecia. Androgenic alopecia is men is male-pattern baldness. In men, the hairline begins to recede, first at the temples, and then at the frontal hair line. Then balding occurs at the crown of the scalp.
In women, androgenic alopecia usually involves thinning of the entire scalp. It rarely leads to total baldness. In women, this form
of hair loss can be associated with polycystic ovarian disease, which causes irregular menses, increased hair growth on the body, weight gain and acne.
Factors for hair loss may include genetic factors and increased androgens, especially dihydrotestosterone. Androgens are important in women for sex drive and hair growth.
Each individual hair grows under the skin, and usually survives 2-6 years. Increased androgens in the hair follicle can cause shorter cycles of hair growth, as well as thinner and shorter individual hairs. Replacement of shed hairs may take longer.
There is a gene for the androgen receptor in the hair. This gene controls the activity of the androgens in the hair follicle.
So, what can you do?
First, an evaluation should be done. Taking a history includes noting changes in hormone levels, stress, family history (was your maternal grandfather bald?) and new medications. A physical exam can reveal skin changes in the scalp. Psoriasis and seborrheic dermatitis can cause hair loss. A “pull test” can be done to see if a gentle pull will remove several hairs easily. Nutritional factors should be evaluated. The diet should include adequate protein. Nutrients such as Vitamin D, zinc, and ferritin (iron) should be checked. Additionally, hormone levels should be evaluated including follicular stimulating hormone (FSH), estradiol, DHEAS, free and total testosterone. Labs should also include a CBC, CMP, and thyroid testing.
Drugs that can be implicated in hair loss include beta-blockers, anticoagulants, retinoids, propylthiouricil, carbamezapine, and immunizations.
In premenopausal women, the diagnosis of PCOS (polycystic ovarian syndrome) and congenital adrenal hyperplasia should be considered. Oral contraceptives using the progesterones drospirenone and desogestrol are better for skin and hair than levonorgestral and norethindrone which are more androgenic.
In menopausal women, estrogen is helpful. Oral estrogens, especially those using drospirenone, are most helpful. Oral estrogens increase sex hormone binding globulin which decreases the effect of androgens. Natural progesterone is also a mild inhibitor of testosterone at the hair follicle.
Nutritionally, adequate protein in the diet is recommended. Vitamin D supplementation, zinc, and adequate iron storage is also helpful. Biotin is also recommended, at doses of at least 2000 micrograms per day.
Decreasing stress is also an important consideration, and use of antidepressants may be considered in appropriate situations.
Use of Nizoral shampoo may decrease the loss of hair, and limiting the use of hair products and frequent washing can be helpful.
Other options include:
Minoxidil: This drug is independent of androgens, and works by making the the growing phase of the hair follicle more robust. It is applied topically to the scalp, and can be applied to the eyebrows with a q-tip. The high potency product will have better results, but it may take up to six months to see improvement.
Spironolactone: a diuretic that is widely used for androgenic alopecia. It blocks androgen receptors as well as decreasing production of androgens in the ovary. Side effects can include menstrual abnormalities and electrolyte disturbances, as well as low blood pressure.
Finasteride: an inhibitor of androgens in the circulation. Used more often in men, there is limited
data on the use in women, but can be considered for women with androgen excess.
Laser comb: may work by increasing heat in the scalp, increasing blood flow.
New treatments: Infusions of plasma rich protein are offered at some medical centers.
Cosmetic procedures include hair transplant and products that add fibers to the hair shafts or camouflage the visible scalp.
There is no doubt that loss of hair is troubling to women, and affects them psychologically.
As with many conditions, an evaluation with a physician is recommended to rule out treatable causes of hair loss. This evaluation includes blood work and an examination. Before taking any supplements or drugs, be fully informed about the risks and side effects.
NIH: Genetics Home Reference. Androgenic Alopecia
Clinical Interventions in Aging, 2007 June 2(20 189-199. Female Pattern Hair Loss: Current Treatment Options, Din and Sinclair
Managing Hair Thinning in Peri- and Postmenopausal Women: the Menopause Specialist’s
Perspective, Holly Thacker, MD, FACP, CCD, NCMP, NAMS Annual Meeting, October 4, 2018
Many women know that fibroids can make life miserable. Heavy bleeding and prolonged bleeding, pelvic pain and cramps, bladder pressure, anemia, and an abdominal mass can all result in making the menstrual cycle a dreaded monthly event.
The traditional treatment for uterine fibroids is surgery. Hundreds of thousands of hysterectomies are done per year, and the majority are for fibroids. We need to find alternative treatment modalities that are non-surgical, low risk, and improve quality of life for women.
Here are some of the topics discussed today at the North American Menopause Society Translational Science Symposium in San Diego.
If fibroids are not symptomatic, they do not need to be treated, unless you want to get pregnant.
Whether fibroids should be removed prior to attempting pregnancy depends on location and size. Fibroids do increase some adverse pregnancy outcomes including premature deliveries and miscarriage. It is complicated, but the message is that all fibroids do not have to be removed prior to attempting pregnancy. Before surgery is done for fertility reasons, other infertility factors should be considered.
African-American women have more fibroids and develop them younger than Caucasian women. Some studies show that fibroids grown from uterine muscle stem cells that may have a genetic mutation, and perhaps a hormonal event in utero, like DES, may be causative . African-Americans may have more hormonal sensitivity, and have been found to have more aggressive breast and uterine cancers. Learning about how to turn off this genetic change is an important area of research.
Physicians always believed that estrogen was the cause of fibroid growth, but it is now known that progesterone is also very important in fibroid development. That is why researchers are looking at drugs that can block progesterone receptors in the fibroids. SPERMS, selective progesterone receptor modulators, are being developed that can block fibroid growth.
So how do we manage fibroids in the peri-menopause. We know that fibroids are rarely a problem after menopause, as they shrink with the lower levels of estrogen and progesterone after menopause. But, those years prior to menopause can be very difficult, and there are many options
Birth control pills are very effective in reducing blood flow, without making the fibroids grow significantly. NSAID’s and can reduce bleeding about 20-40%. Tranexamic acid can reduce bleeding about 40%. A progesterone containing IUD can significantly reduce bleeding, but fibroids can increase the expulsion rate. Lupron, which creates a temporary menopause with lower estrogen, is very effective in reducing fibroid size. Fibroids in the cavity of the uterus, which are the ones that cause the most bleeding, can be removed by hysteroscopic resection. Endometrial ablation can significantly reduce bleeding. Uterine artery ablation is also
What is on the horizon?
In Europe, a procedure that uses ultrasound directed ablation of the fibroids, administered via laparoscopy is being developed. In Canada and the EU, a selective progesterone receptor modulator, ulipristal, is used that can stop heaving bleeding episodes. The FDA has failed to approve this in the US yet, due to concerns about side effects. It is expected that as more data is accumulated, this drug will be approved for use in the US. There are many other drugs in this category that are being developed.
Here are some other medications or supplements that show promise and are currently being studied that may reduce the size of fibroids: simvastatin, aromatase inhibitors, green tea extract,
retinoid acid, Vitamin D, and berberine (a Chinese herb).
The research on how fibroids grow and change is very interesting on a molecular level.
We look forward to additional treatments that will reduce surgery in the near future, while making quality of life much better for women with fibroids.
Marilyn Jerome, MD
2018 Wolf Utian Translational Science Symposium, Tuesday, October 2, 2018
New Therapies for Leiyomyomas: When Surgery May Not Be the Optimal Approach
Understanding the relationship between menopause and cardiovascular disease
Cardiovascular disease will kill more than 400,000 women this year, more than all cancer deaths combined. The good news is that mortality for deaths from coronary artery disease decreased 68% from 1979-2011. Unfortunately, there has been a larger decline for men than women. There is certainly less awareness and recognition of coronary disease in women than men, and this can be contributory. It is important to understand the gender differences when studying heart disease. For example, there is believed to be a larger burden in women of disease of the tiny blood vessels in the heart, which leads to heart failure without major coronary obstruction. Also,certain medical problems unique to women such as gestational diabetes, pre-eclampsia, recurrent early pregnancy loss, polycystic ovarian syndrome, and certain breast cancer treatments all increase the risk of heart disease in women.
Whether menopause itself or simply aging is associated with the increase in heart disease is still being debated. It is certain that surgical menopause, especially in women younger than 45, is associated with increased heart disease and all cause mortality. Because of this, it is recommended that women who undergo surgical menopause continue estrogen at least until the average age of menopause, but more importantly, it is recommended that the ovaries remain at hysterectomy unless involved in the disease progress.
Premature menopause is also associated with increased risk of cardiovascular disease, but now some researchers are considering the hypothesis that the underlying cardiovascular disease may contribute to the shortened reproductive life span.
In the 1990’s it was widely accepted, even by internal medicine doctors, that hormone replacement after menopause would decrease the risk of heart disease and HRT was offered to almost all women during the transition. Studies during this time demonstrated that markers for cardiovascular disease were favorable with HRT, including cholesterol, glucose, blood pressure, and markers of thrombosis. Another studied published in 1998, which gave women with heart disease hormones, was unable to show a definite benefit, and actually found an increase in heart attacks in the first year of treatment.
Next came the Women’s Health Initiative (WHI) which gave hormones to women who did not have heart disease. The study was abruptly terminated in 2002 when the researchers found more heart attacks, strokes, blood clots, and breast cancer in women who were taking HRT. The widely publicized results of the study was the impetus for many women stopping HRT immediately and many more in the next 15 years refusing to begin treatment. If hormones were to be used for the prevention of vasomotor symptoms, the lowest dose for the shortest period of time was recommended.
By 2007, the WHI data was further analyzed, and it was found that women in their 50’s, within the first ten years of menopause, had minimal cardiovascular risk, with risk increasing for women greater than age 60. The women who took estrogen only in the WHI had significant reductions in heart attacks while they were taking hormones, and no increase in CV mortality when followed 18 years later. The timing hypothesis was born, which said that it mattered how soon after menopause hormones were started.
Lessons learned from the WHI demonstrated that early use of HRT in menopausal women had less risks, and use of estrogen alone was even safer. The current use of transdermal estrogen and micronized progesterone may have less risks, but have not been studied to prove this.
Current practice today involves evaluating women for cardiac risks, and avoiding HRT in women at increased risk of CV disease. For women of intermediate risk, transdermal estrogen is thought to have less cardiovascular risk, and lower doses expected to be less risky. Instead of limiting use of HRT for a certain number of years, current recommendations suggest yearly evaluations and tailoring duration of use depending on symptoms and current health concerns.
Prescribing HRT today deserves a detailed discussion of symptoms, risk factors, family history, and treatment goals with a physician who is knowledgeable about the risks and benefits of hormone replacement.
Marilyn Jerome, MD
Foxhall Ob-Gyn Associates
Editorial: Deciphering the complex relationship between menopause and heart disease: 25 years and counting. Cynthia A. Stuenkel, MD
Menopause: The Journal of the North American Menopause Society, Vol. 25, No. 9, September, 2018.
Peri-menopause, hormone replacement, and GSM (genitourinary syndrome of menopause) Lecture presented by Dr. Jerome 9/13/2018
First, let’s define menopause.
When I talk about menopause, many women say, “I have done that already.”
The truth is that menopause begins the day after your last period is over, and lasts the rest of your life. Menopause means that your body has stopped producing estrogen. Your eggs have been spent, you can no longer become pregnant, and your intrinsic levels of estrogen decline. Your body can produce some estrogen in fatty tissue from the conversion of steroids produced in the adrenal gland. That is one of the theories of why women gain weight at menopause.
So, how to define the peri-menopause?
Sometime in your 40’s your cycles begin to change. The remaining eggs in your ovaries are not as healthy as they were when you were younger. That is why fertility declines in the 40’s.
Women notice at first subtle changes in their menstrual cycle. Instead of cycles being about 28 days apart, they occur closer together, somewhere between 21-28 days.
An occasional very short cycle can occur, perhaps two weeks from the last. The amount of bleeding can change, too. Many women notice that they get almost all of their bleeding on one or two days. Many women complain of changing a pad or tampon every hour or two on their first two days, with a marked decrease in bleeding for the next several days, and spotting than can go on for several more. After the cycles get closer together, then, in the next stage, the cycles become farther apart and erratic. The amount of bleeding can vary from cycle to cycle. Symptom wise, I think women feel more of the ups and downs of their hormone levels. Many women notice more bloating, breast tenderness, headaches, and irritability related to their cycles. Hot flashes can occur several days before the cycles begin. And, women with a history of depression may have more difficulty treating their depression during this time, or notice the new onset of depressive symptoms.
So how do we manage this?
I think that the first thing that we as physicians must realize is that this is a very significant time that women begin to see changes in their bodies and need support. We cannot be dismissive and chalk this up to getting older. Women can often benefit from treatment.
I think that low dose oral contraceptives are an excellent choice for many healthy women during this time. The birth control pill will regulate the frequency of cycles, decrease bleeding, and alleviate some of the ups and downs of hormone levels, thereby decreasing some of the symptoms related to hormonal changes.
What about cancer? There is very good news about the benefits of oral contraceptives and the risk of cancer. Women who take OC’s during peri-menopause can reduce their risk of getting ovarian cancer by up to 60% and the benefit can last up to 20 years. This is huge. Studies have also demonstrated a decrease in endometrial and colon cancers in women who took birth control pills. What about breast cancer? Although some studies have shown a small increase in breast cancer, the best study done did not show an increase in breast cancer.
A progesterone containing IUD is an excellent choice to deal with heavy cycles during the peri-menopause. The Mirena IUD is being used frequently in younger women now, and can really improve quality of life in women with heavy bleeding.
Of particular interest to me are women who undergo premature menopause. The average age of menopause is 51.5. Women who undergo menopause prematurely should be maintained on hormones at least until the age of natural menopause, because of the benefits for the heart and bones.
But we know that many of our cancer patients face early menopause due to surgery for cancer or chemotherapy. These patients require support in so many ways. The rapid decline in hormone levels can affect sleep, mood, cognition, productivity and quality of life. We do have non-hormonal options for women that include anti-depressants, gabapentin and clonidine that can relieve some of the vasomotor symptoms. We need to be very vigilant regarding a declining bone density , and use drugs specific to the bones to maintain density. Some of these drugs can also prevent bony metastases from breast cancer.
Decrease in sexual function and enjoyment due to dryness and pain can be very significant. I will talk about his more when we discuss GSM.
Hormone replacement therapy:
Most of us are aware of the results of the Women’s Health Initiative. This was the study whose results were published in 2002 that said that hormones increased the risk of breast cancer, strokes, heart attacks and blood clots in women. Many, many women stopped HRT that day, and the concerns about the results of this study and the negative feelings about hormone replacement remain to today.
As a practitioner, I saw so many women who suffered from the symptoms caused by lack of estrogen and were afraid to take hormones. I became more active in the North American Menopause Society and attend the conferences yearly to hear the scientists who study women’s health in menopause discuss their data. The good news is that there is comforting information in the subsequent studies and re-analysis of the data.
First, let’s understand why the Women’s Heath Initiative was proposed. When I first began practicing in the 80’s we gave women much higher doses of HRT with the thought that it protected the bones and heart, maybe the brain, and women would look and feel better. The data from a very large study called the Nurse’s Study, indicated that the women who took hormone replacement had less heart disease.
In 1994, scientists from the NIH began the study to determine if giving HRT to post-menopausal women would decrease heart disease, as 50% of women died of cardiovascular related causes. In the study, they gave women aged 50-80 Premarin ( an estrogen derived from horses' urine) and Provera ( a synthetic progesterone) , or placebo. It was a double-blinded study so the women did not know what they were getting. Many of these women had never taken HRT in the past. The study was terminated abruptly in 2002 because they found more cases of breast cancer, strokes, heart attacks, and blood clots in women who took HRT, and less cases of fractures and colon cancers. There were more negatives than positives, and the study was terminated prematurely, which gave hormone replacement a very bad name for years to follow. Those of us who were prescribing HRT at the time realized that the methodology of the study was not in line with how we practiced: we most often gave women HRT at menopause in their 50’s, but rarely would we begin HRT in the late 60’s or 70’s, and we did not appreciate the negative effects described in the study. But, the purpose of the study was to see if giving older women
hormone would prevent them from getting heart disease.
Some researchers looked deeper into the data. When they divided the women into groups by age: 50’s, 60’s and 70’s.. they found that the data varied . Women in their 50’s, or within the first 10 years of menopause, had less mortality if they took HRT. In the 60’s the risk and benefit were equal, and in the 70’s, HRT became more risky.
The researches proposed what is called the “timing hypothesis” which states that it truly depends on how soon after menopause hormones are initiated, and it is now felt that women should be started on HRT in the first ten years since the last menstrual cycle to achieve the most benefit.
This year, data was published after a 17 year follow-up to the initial date from the WHI, and that data did not show any increase in mortality in the women in the WHI who took HRT from any cause including cancer, no matter what age the hormones were started. This data did not get the same press as the initial results.
In the arm of the WHI which involved women who took estrogen only and not progesterone, because they had had hysterectomies, the data actually demonstrated less heart disease and breast cancer than women who did not take any hormones at all.
Since the WHI, we now often prescribe transdermal estrogen, often in patches, and bioidentical progesterone instead of synthetic, so more studies need to be done with these products which are expected to have even less risk.
The data regarding the benefits of estrogen for heart and bones is quite impressive.
I believe that I am seeing many more women with worrisome bone densities in their 50’s and 60’s than I used to see when more women were taking HRT. Now, the greatest contributor to how good our bones are is our genetics. To the great extent, our bone structure is inherited, and we can make some lifestyle changes which can be of some benefit. We worry about bone density in women because fractures, especially of the hip, can be the event which changes a women’s ability to live independently, which, for many of us, is our goal as we age. And we know that 25% of women who break a hip do not survive more than a year.
94% of women who break their hip, do so because of a fall. Prevention of falls is an important goal that we talk about with our patients. How do you prevent falls: the main contributor to falls is lack of muscle strength, so, here is another reason that exercise, especially weight bearing, which can help prevent falls and fractures.
Now you might be confused, are hormones right for me? We are cautioned that hormone should not be used to prevent chronic disease, although there are benefits to prevent cardiovascular disease, osteoporosis, and some recent studies have demonstrated a decrease in dementia in women who took HRT long term.
As we worry about our risks for cancer, we must also be concerned about diabetes, heart disease, fractures, and as a physician for women, it is important for me to look at the whole patient, and make decisions regarding HRT in light of all of a patients’s symptoms, risks and family history. We always need scientific data and not fears to guide us in making appropriate choices for each individual patient.
GSM: genitourinary syndrome of menopause
Although this sounds a bit scary, gynecologists now realize that it is not only the vagina, but the vulva and bladder that suffers from the lack of estrogen. The tissues become thin and less vascular, less elastic. Many, and probably most women who are not on HRT will experience vaginal dryness after menopause, and many will experience painful intercourse, vulvar dryness and discomfort, and in regards to the bladder, will notice more urgency, frequency and urinary tract infections. Along with the thinning of the vaginal epithelium there is also weakness in the vaginal muscles, and urinary incontinence becomes quite common.
As my patients age, I find that many women no longer have vaginal penetration and find other ways to be intimate, but mourn the loss of vaginal sex as a loss for their relationship. I have found that some of my elderly patients tell me that their difficulty with bladder function has affected their ability to exercise, and sometimes even socialize because their incontinence is unpredictable and embarrassing.
So how do we manage these problems?
With the negative feelings about estrogen, many women decline to use vaginal or topical estrogen products to treat vaginal dryness and painful intercourse. So what does the data show? The level of estrogen in the bloodstream after the use of vaginal estrogens usually remains in the menopausal range. Most studies do not show an increase in cancers with normal doses of vaginal estrogen, even for women at high risk of breast cancer or those who have had breast cancer. Women currently being treated for breast cancer with aromatase inhibitors do have increased levels of estrogen with vaginal topical products and should not use them. Women who have had breast cancer do not show in increase in recurrence after the use of vaginal products. As in all decisions of this type, a women’s particular cancer, stage and treatment, must be included in decision making and in consultation with her oncologist.
What about non-hormonal treatments? Vaginal lubricants and moisturizers can be very helpful, There are many different types available. It may also be helpful to use vaginal dilators or vibrators to stretch the vaginal wall and maintain function.
A procedure that we at Foxhall have found very helpful to most patients who cannot use vaginal estrogen or find it inadequate is thevaginal laser. The laser penetrates the tissue and the laser energy causes tissue repair that increases blood vessels, collagen and elastic fibers, as well as increased layers of epithelium. These changes result in less dryness and painful intercourse for about 80-90% satisfaction rate in our patients. The FDA did put out warnings recently for various companies who have come out with lasers and radio frequency technologies that make claims that have not been substantiated in the literature. So if you decide to pursue one of these, please be certain that the data supports the benefits and the practitioner has the expertise to provide the service.
Another procedure we have found extremely helpful to our patients with incontinence and mild degrees of prolapse is called “pelvic floor muscle therapy”. Our nurse teaches patients how to best use the muscles of the pelvic floor to strengthen sphincters and improve incontinence of urine and bowels which is very common with aging.
Strengthening your pelvic floor has also helped patients with frequency, urgency, and frequent nighttime urination. Although pads are ubiquitous in the drug store , incontinence is not normal and often can be improved with exercise before medication or surgical correction needs to be considered.
So, for today, my take home message is that you do not have to live with symptoms of menopause that diminish your quality life. Don’t let anyone tell you that this is just aging and you will have to live with it. There is so much more we can do to make your life better.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
N.B. This lecture was presented on September 13, 2018, at the Woodmont Country Club as part of a benefit hosted by the Sibley Hospital Foundation to support the gynecologic cancer programs at Sibley Hospital
Decreasing hormone levels in the perimenopause and menopause can cause the physical symptoms of hot flashes, night sweats and vaginal dryness, but are also related to symptoms of anxiety and depression. Some women are very sensitive to hormonal changes manifested in PMS, pregnancy, postpartum, and during the menopausal transition.
Depressive symptoms include sadness, anxiety, fatigue, lack of energy, sleep disorders such as difficulty falling and staying asleep, and changes in appetite. More serious symptoms of hopelessness, worthlessness and suicidal ideation can occur. When depressive symptoms result in alterations of daily life and activities, it may be diagnosed as a clinical depression. The onset of clinical depression can occur at menopause.
Symptoms of menopause can include hot flashes, night sweats, sleep disturbances, weight gain, fatigue, decreased memory, and sexual dysfunction, and these symptoms can overlap with those of depression and anxiety, which is one reason why the diagnosis may be more difficult. This is often a time when women experience difficult life changes such as children leaving home, parents aging, job stresses and relationship issues which add difficult social components to the equation.
If you have suffered from depression in the past, have experienced PMS or postpartum depression, you are especially vulnerable during this time. If mood changes affect your ability to attend to normal daily activities, you should be appropriately evaluated and treated. Don’t be reluctant to recognize symptoms and ask for help.
So how do you treat depressive symptoms of menopause and clinical depression?
If diagnosed with clinical depression, certain antidepressants are effective in treating the mood disorder as well as vasomotor symptoms of hot flashes and night sweats. Gabapentin used at bedtime can alleviate night sweats and improve sleep. Cognitive behavioral therapy and psychotherapy can also be helpful in conjunction with medications.
Although hormone replacement therapy is not approved to treat mood disorders, research indicates that estrogen may be as effective as antidepressants in perimenopausal women, even if they are not experiencing hot flashes. Estrogen can benefit mood and well being in women who do not suffer depression. In postmenopausal women, estrogen is not effective in treating depression. There is less information about hormonal combinations such as estrogen and testosterone.
There is little data to support the use of complementary medical treatments such as herbal remedies or supplements to treat depression in menopause. Exercise may be helpful in alleviating depressive symptoms.
As with all medical decisions, your individual symptoms and medical history must be taken into account to decide on which treatment is best for your situation.
MenoNote, MenoNotes Task Force of the North American Menopause Society,
What does the data tell us about the effect of hormone therapy on the incidence of Alzheimer’s disease? Conflicting data has appeared in the literature for many years.
The WHI (Women’s Health Initiative) data demonstrated that women over 65 who were given oral Premarin and medroxyprogesterone acetate had cognitive decline, while the younger women did not. Perhaps, similar to cardiovascular disease, timing is important.
Data from a Finnish study which followed women for 25 years had different findings. Of the 8000 women who were followed, 227 eventually developed Alzheimer’s disease, with a mean age of 72. The analysis controlled for the following risk factors: age, alcohol use, smoking, exercise, occupation, and parity ( the number of children a women has had). The data demonstrated that if hormone therapy was taken for 5 years, there was no increased risk of developing Alzheimer’s. If hormones were taken 5-10 years, the risk ration was .89, or an 11% decrease in the incidence of Alzheimer’s, although this did not reach statistical significance.
What was significant was that women who took hormones for more than 10 years had an almost 50% reduction in Alzheimer’s disease.
Three other large randomized trials in which women took HRT for less than 7 years did not demonstrate a change in cognitive function. In contrast, the Cache County study from Utah did demonstrate a significant reduction in Alzheimer’s disease if HRT was started early in menopause and continued for at least 10 years.
Mortality date from the WHI calculated 18 years after the study was completed demonstrated a decreased risk of dementia in estrogen and progesterone uses, with a larger decrease in risk in those women who took estrogen alone.
Since the WHI, there have been changes in hormone prescribing, with more use of transdermal preparations and bio-identical progesterone. It is possible that these preparations would
provide improved results.
At this point, the North American Menopause Society does not recommend that HRT be given for the prevention of dementia until more definitive data is available. Hormones given soon after surgical menopause may improve cognitive function, and should be considered at least until the age of natural menopause.
It is not likely that long-term randomized clinical trials will be done to put this issue to rest.
What can be concluded from the data as provided is that hormone therapy started soon after menopause and continued for ten years or more may reduce the incidence of Alzheimer’s disease.
Update Menopause. OBG Management, Volume 30, Number 6, June 2018
What’s the impact of long-term use of systemic hormone therapy on Alzheimer disease risk?
Andrew Kaunitz, MD, JoAnn Pinkerton, MD, JoAnn Manson, MD
Imtiaz, et al., Post-menopausal hormone therapy and Alzheimer’s disease: a prospective cohort study, Neurology, 2017; 88 (11) pp 1062-1068
Women over the age of 40 know that it is unlikely that they will conceive spontaneously, however, gynecologists recommend that women use contraception until one year after the last menstrual period.
Although conception over 40 may be difficult, US census data demonstrated 26 births per 1000 women over the age of 40. Of these, one-third are unintended. Therefore, there is a need for contraception during this age group. Additionally, women over 40 experience a high risk of spontaneous miscarriage: 34% up to age 44, and 53% over the age of 45. Increased maternal complications include hypertension and diabetes, For the fetus, there is a high risk of chromosomal defects. Therefore, the need for effective contraception in this age group is an important consideration.
So what does the data tell us?
The CDC (Center for Disease Control) has important data regarding safety considerations and contraindications to contraceptive use.
IUD’s are considered in the top tier of recommended contraceptives. There are two types of IUD’s, those with progesterone, and those with no hormones. IUD’s are placed in the office and there are few contraindications. They are highly effective and remain in place for 5 or 10 years. They are easily reversible. Risk of infection and expulsion are quite small, and the continuation rate is higher than oral contraceptives.
The copper IUD is considered to be effective for 10-12 years. The failure rate is less than !%. It is the recommended IUD for women who have had breast cancer and should not be exposed to progesterone. Although in the first 6 months of use menstrual bleeding can be heavier, the bleeding tends to normalize in the first year of use.
Progesterone containing IUD’s have become very popular. They are effective for 3-5 years, depending the the type used. There are therapeutic benefits beside the contraceptive one. The progesterone in the IUD thins the lining of the uterus, therefore making menstrual bleeding less. The effectiveness of the decrease in bleeding is similar to an endometrial ablation, and therefore reduces the need for surgery in women with bothersome, heavy bleeding. The progesterone containing IUD can also be used in postmenopausal women on estrogen therapy to protect the endometrium.
Progesterone only contraceptive products can be used in women in whom estrogen is contraindicated. Contraindications to the use of estrogen would be tobacco use, obesity, migraines with aura, long-standing diabetes, hypertension, and a history of thromboembolism.
Options include the progesterone only oral contraceptive, the progesterone implant, and injections of depo-progesterone which are administered every 3 months. Contraindications to progesterone contraceptives are a recent history of breast cancer.
The progesterone implant is inserted in the office with local anesthesia. It is effective for at least three years, and the failure rate is less than !%. The shots of depo-progesterone are administered every three months. The longer the injections are given, the more likely that menses will stop. After stopping the injections, it can take more than 6 months for menses to resume. Users of this form of contraception were noted to have an 80% decreased risk of endometrial cancer, and a 40% deceased risk of ovarian cancer. Most studies have not demonstrated an increased risk of breast cancer.
What about combined estrogen and progesterone contraceptives? Oral contraceptives are safe in most patients, except for those with the medical problems mentioned previously. The failure rate for OC’s is stated to be 9%, but with close to perfect use, the risk is much lower. OC’s are often used in the peri-menopausal women to control irregular cycles and heavy bleeding. OC’s can also treat the symptoms or irregular hormone levels often found in the peri-menopause. These symptoms can include headaches, hot flashes, and mood changes. The risk of thromboembolism is increased with OC users, and the risk if about 8-10 per 10,000 women/years of use. The greatest risk is in the first 3 months of use.
When oral contraceptives are used in women over 40, careful considerations must be given to medical situations that might increase the risk of heart attack and stroke, since these are rare but significant side effects. OC’s should be avoided in smokers and hypertensives, and also in women who have migraines with aura.
Combined estrogen and progesterone can also be administered as a patch or intra-vaginal ring. The patch is considered to provide higher levels of estrogen and an increased risk of blood clots than a similar OC.
The benefit of reducing cancer risk is impressive and lasts for at least 15 years after discontinuation. The decreased risk of endometrial cancer is 56% after 4 years of use, and 72% after 12 years of use. Women who used OC’s more than 10 years reduced their risk of ovarian cancer by more than 50%, and the benefit lasted 20 years. A reduction of colon cancer was found to be 18%. The most reliable study done on OC effect on breast cancer risk was done by the NIH, which demonstrated no increased risk, although several other studies have demonstrated a small increased risk. Women who carry the BRCA gene did not have an increased risk of breast cancer if the formulation contained 35 mcg or less of estrogen, while the OC also decreases the risk of ovarian cancer in this high risk group.
As far as peri-menopausal symptom control, contraception has significant medical benefits.
The progesterone IUD controls heavy bleeding better than oral contraceptives, and can be used to decrease bleeding in women with fibroids, although the expulsion rate is higher. For vasomotor symptoms of hot flashes and night sweats, oral contraceptives are very effective, especially if giving continuously. Standard hormone replacement will not provide contraception.
Permanent sterilization is always an option for women after childbearing is complete. Traditional tubal ligation performed laparoscopically or after a vaginal delivery or at the time of C-section has been found to reduce the risk of ovarian cancer. Many doctors are now performing bilateral removal of the fallopian tubes, as many ovarian cancers are thought to begin the the tubes.
Another option is a metal coil placed through the uterus into the fallopian tubes.
Emergency contraception is an option after unprotected intercourse. Progesterone emergency contraceptive can be used within 72 hours of intercourse, and a copper IUD can be inserted within 5 days of intercourse. Inserting an IUD is 99% effective in preventing pregnancy if inserted within 5 days.
Use of contraception can be continued until age 55, or sooner if a blood test, FSH, demonstrates evidence of menopause. The FSH should be checked at least 14 days after discontinuation of oral contraceptives.
This article provides general considerations, but medical decisions regarding the best contraception options should be made with your personal physician who can consider your history, examination, family history, and your goals.
Menopause: The Journal of the North American Menopause Society, value 25, Number 7, July 2018. Contraception for midlife women: a review. Miller, et al.
A new video from the North American Menopause Society discussing current data regarding how hormones affect the cardiovascular system.
Dr. Marla Shapiro, Immediate Past President of NAMS interviews Dr. Maria Stuenkel, Clinical Professor of Medicine, University of California at San Diego