Beck - Menopause
-
Upload
aris-maruto -
Category
Documents
-
view
245 -
download
2
description
Transcript of Beck - Menopause
Menopause
Paul Beck, MD, FACOG, FACS
What is Menopause
Loss of ovarian activity – loss of menses Loss of estrogen-significant impact Life span in menopause – 1/3 to ½
MenopauseDemographics
42 million women over age 50 52 million by 2010 8.8 million women age 50 to 54 Average age at menopause 51.4 years
(range – 45 to 55 years)
Epidemiology
Born Life Span
Years in Menopa
use
1850 45 0
1900 50 0
1950 70 19
1960 73 22
1970 75 24
1980 79 28
1990 80 30
2000 80 30+
0
10
20
30
40
50
60
70
80
1850 1850 1950 1970 1990
Life Span
Yrs. In Men
3-D Column 3
Primary Symptoms of Menopause
Cycle changes Oligoamenorrhea – amenorrhea Vasomotor Vaginal dryness
Secondary Symptoms of Menopause
Urinary – stress/urge incontinence Frequency – burning ( cystitis) Psychophysiologic changes Musculoskeletal pains Decrease concentration Decreased libido
Actions of Estrogen
Development of ovaries, tubes, uterus and vagina
Secondary sexual characteristics HPO axis interaction Proliferative changes in the endometrium Increases fat deposition and vascular
profusion of skin
Actions of Progesterone
Specific Interacts with hypothalmus and pituitary
to regulate menstrual cycle Produces secretory changes in the
endometrium Increases viscosity of cervical mucus Prepares breast for lactation during
pregnancy
Consequences and Impact of Estrogen Loss
Hot flashes Sleep disturbance Urogenital Atrophy Osteoporosis Skin Dryness Aging
Managment
Hormone therapy Alternative therapy Grin and bear it
Estrogen/Progesterone TherapyPotential Risks and Concerns
Women’s health initiative study Breast cancer Cardio vascular disease Venous thrombosis Endometrial cancer Compliance/therapy
WHI Objective
Assess benefits and risks of the most commonly used E/P combination in the US
16,608 women randomized 8, 506 – E+P (.625 CEE + 2.5 MP) 8, 102 – placebo Planned duration 8.5 years Post menopausal women age 50 – 79 years
WHI Main Outcome Measures
Primary outcome
coronary heart disease (CHD): non-fatal
myocardial infarction and CHD death Primary adverse outcome
invasive breast cancer Secondary outcomes
stoke
pulmonary embolism
endometrial cancer
cholorectal cancer
hip fracture
death due to other causes
WHI Continued
No substantive difference between groups at baseline
Mean age 63.2 for E+P group Mean age 63.3 for placebo group 2/3 between 60 and 79 years
WHI Status
E+P study stopped early – 531 2002, mean 5.2 years
Reason – increase in invasive breast cancer exceeded the safety boundary for harm
Evidence for some increase in CHD, stroke and pulmonary embolism
Outweighed evidence fracture decrease Unopposed estrogen study continued
Women’s Health InitiativeClinical Outcomes
Outcome Placebo HRT Additional
(fewer) Cases
Hazard
Ratio
CHD 30 37 +7 1.29
Stroke 21 29 +8 1.41
Pulmonary Embolism
8 16 +8 2.13
Breast Cancer 30 38 +8 1.26
Hip Fracture 15 10 -5 0.66Colon Cancer 16 10 -6 0.63
WHI Time Trends
CHD began to develop soon after randomization (first year)
Breast Cancer – comparable through first four years then curve for estrogen began to rise more rapidly then placebo
5.2 years sharper increase- more pronounced
Women’s Heath Initiative Primary Conclusion
“The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regiment should not be initiated or continued for primary prevention of CHD.”
Writing Group for the Women’s Health Initiative Investigators
JAMA 2002;288:321-333
WHI Implications/Limitations
Absolute risks –small-previously described
E/PT for treatment of menopausal symptoms not evaluated
Only one drug used not comparable for other E/PTs
WHI Preliminary Findings for Estrogen Alone – As Reported by the NIH
Outcomes Changes Vs Placebo after nearly 7 years
CHD No increased or decreased overall risk
Breast Cancer No increased risk
Stroke Increased risk
Hip Fractures Decreased risk
Probable Dementia and Mild Cognitive Impairment
Trend Toward Increased Risk
Summary (WHI Trials)
E/P E/Only
Breast CA Significant increased risk
Did not detect increased risk
Coronary heart disease events
Significant increased risk
Did not detect increased risk
Hip fractures Decreased risk Decreased risk
Colon cancer Decreased risk Decreased risk
Stroke Increased risk Increased risk
Alternative MeasuresVasomotor Symptoms
Progesterone/oral and transdermal works/adverse affect on lipid profile
Micronized natural plant progesterone – no adverse effect on lipid profile – no trials regarding vasomotor symptoms
Exercise –beneficial (selection bias) Soy – significant reduction in hot flashes-
requires large amounts – lowers LDL
Vasomotor Symptoms(continued)
Black Cohosh: significant improvement Dong Quai: no improvement when used alone Evening Primrose Oil: no more effective than placebo Antidepressants: SSRIs – 50% improvement St. John’s Wort: use in mild depression beneficial – for
menopausal symptoms – questionable efficacy Other Herbal Supplements/Homeopathy: flaxseed oil, fish
oil, omega 3, red clover, ginseng, rice bran oil, wild yam, calcium, gotukola, licorice root, sage, sarsaparilla, passion flower, ginkgo biloba and valerian root – no evidence
MenopausePreventing Cardiovascular Disease
Soy: claim based on lipid lowering effects Vitamin C, E, and B Carotene: no good
evidence Fish Oil: Omega-3 fatty acids and N-3
polyunsaturated fatty acids – effective for secondary prevention of cardiac events – no large trials as a means of primary prevention in postmenopausal women who are at risk
Red Clover: does not improve plasma lipids- no long term studies
MenopausePreventing Bone Loss
Soy: (i.e., isoflavone) - small studies on postmenopausal women show increase in lumbar spine BMD – no difference in hip
Hip Fracture: no studies documenting reduction
Magnesium: deficiency may contribute to decreased BMD
Summary Black Cohosh: good for vasomotor
symptoms Soy: good for VMS –bone – lowers lipid
levels Exercise: good for VMS Fish Oil: good for secondary prevention
of cardiac events, not VMS Magnesium: good for bone density – no
evidence of prevention of hip fractures