July/August 2014

Demystifying Menopause — What Providers Should Know
By Juliann Schaeffer
Today’s Geriatric Medicine
Vol. 7 No. 4 P. 12

Fewer than one in five recently polled obstetrics and gynecology residents received formal training in menopause medicine. Other physicians feel similarly ill equipped to adequately treat menopause symptoms.

Menopause, the natural biological process by which menses officially end (and which every woman who’s lucky enough to reach midlife eventually will endure), also is a process that brings with it a barrage of mildly uncomfortable to severely disruptive symptoms for most women.

Yet according to a small survey conducted by Johns Hopkins Medicine in 2013, not all physicians are well equipped to offer their female patients treatment advice to alleviate these unwelcome symptoms. Following a poll of American obstetrics and gynecology residents, survey results indicated that fewer than one in five received formal training in menopause medicine, though the majority (seven in 10) desired such training.

Experts interviewed for this article say that for both geriatricians and primary care providers, there’s a range of treatment options available that can offer perimenopausal and postmenopausal patients the relief they’ve been seeking from menopause symptoms. But it appears that just as it’s important to know which treatments to recommend (and which to avoid), to help female patients find optimal relief, it’s even more crucial for clinicians to be proactive and bring up the topic of menopausal symptoms themselves, as many women simply won’t, experts say.

What’s Normal?
While the strict definition of menopause is simple—the natural cessation of menstruation—the reality of menopause symptoms is anything but, says Margery L. S. Gass, MD, NCMP, executive director of the North American Menopause Society and a clinical professor at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University.

According to Gass, providers should know that there’s a wide range of what’s considered normal when it comes to menopause, and that pertains to when it occurs as well as what symptoms accompany it. While the average age of menopause in the United States is 51, patients can experience menopause-related symptoms as early as their late 30s or as late as their mid-50s. “I think this is very important for clinicians and women to appreciate,” Gass says. “The range of normal is often quoted as being 41 to 55, so that’s a much wider range than for puberty.”

Because of the broad age range, menopause catches many female patients off guard, Gass says, noting the importance of health care providers recognizing the signs leading up to it, which can include changes in the menstruation pattern.

Treating the Most Common Symptoms
Factors that figure into the menopause equation, such as the age at onset, also are highly variable. And while some women will stop their menses without any prior indication of irregularity and without any associated symptoms, the majority aren’t as fortunate. Hot flashes and vaginal atrophy are by far the most common symptoms of menopause, with both caused by a drop in estrogen levels.

In addition to knowing what treatments work best for these common symptoms, there are additional symptoms and ailments that can present with menopause, according to experts, and providers would be wise to take note.

Early Menopause
James A. Simon, MD, CCD, NCMP, FACOG, a Washington, D.C.-based women’s health physician and a past president of the North American Menopause Society, says the most common menopause symptoms can be categorized based on when they typically occur. According to Simon, 80% of women will experience hot flashes or night sweats (which are hot flashes that happen at night) that typically occur in early menopause. “Hot flashes are very common and range from mild—just feeling warm—to severe—feeling hot, having sweats, and having whatever that woman was doing being interrupted,” he says.

For most of her patients, particularly those with mild hot flashes, Gass likes to suggest behavior or lifestyle changes before exploring the possibility of other treatments. “For hot flashes, I talk to women about behavior modification in terms of avoiding situations where you know the environment is going to get warmer,” she says. “This includes things like not using down comforters, which will trap the heat while you’re sleeping. There are many practical things women can try if they’d like to do that first.”

For patients whose symptoms aren’t resolved with behavior modifications, Simon says there are a number of treatments for such vasomotor symptoms. However, experts here agreed that hormonal treatments, whether estrogen alone or a combination of estrogen and progestin or progesterone, are the most effective treatments and are safe for most women. “Hormone therapy comes in a lot of different types of delivery systems,” Gass says. “There can be pills, patches, gels, creams, or a vaginal ring, so there are many ways to deliver the product.”

“We also have nonhormonal treatments that are effective for hot flashes and night sweats, and we even have one that was recently approved by the FDA for hot flashes,” Simon says, referring to Brisdelle, a very low dose of the antidepressant paroxetine.

Simon says several other medications currently are used off label to treat hot flashes and night sweats. Although he says they can be effective, most haven’t been systematically tested. “Generally speaking, I don’t think we should be recommending products that really have not been tested to be effective and safe,” Gass cautions. “That’s why, as a society, we recommend patients and clinicians use FDA-approved hormone therapy products as opposed to compounded products that are made on an individual basis and haven’t been tested.”

Middle Menopause
The other most common symptom of menopause, according to Simon, typically occurs a few years after menopause, and therefore most often presents in women in their late 50s and older. That set of symptoms relates to vulvar and vaginal atrophy and can include vaginal dryness, pain with sexual intercourse, and a general lack of vaginal lubrication. “At this time, the hormones in the body are largely gone, and they’ve been gone for long enough that the tissues themselves have lost their elasticity and their ability to lubricate, and women have symptoms of atrophy, both related and unrelated to sexual activity,” Simon says.

There are a number of treatments for vulvar and vaginal atrophy symptoms, and once again, Gass says behavior modification can be enough for some women. “For example, to treat vaginal dryness, one can start with a vaginal lubricant for intercourse or just a vaginal moisturizer,” she says. “Those have no hormone products in them, so that’s a simple way to start.”

When that doesn’t resolve symptoms, Simon says hormonal treatments tend to be the most effective here, too. Treatments are typically topical and come in various forms, including creams, gels, or caplets.

But there are nonhormonal treatments that can be effective as well, according to Simon. “This year we have a new nonhormonal treatment for vulvar or vaginal atrophy, Osphena [ospemifene], and it’s been recently approved by the FDA,” he says. “It’s not a hormone, and it’s not a local treatment. And it works principally on the vaginal and vulvar tissues to make them estrogenized, even though it’s not estrogen.”

If a woman has only vaginal symptoms, Gass recommends treating with a low-dose vaginal estrogen product to try to treat the problem locally.

In addition to the direct distress vaginal atrophy can cause menopausal patients, Simon says providers also should be on alert regarding another issue that may arise because of these symptoms: urinary tract infections (UTIs). “Women who don’t have adequate lubrication in their vaginas also don’t have an adequate amount of acid in their vaginas, and as a result, they are much more likely to have UTIs,” Simon explains, noting that hormonal and nonhormonal lubricants cannot resolve or even prevent this problem. “The vagina is meant to be acid, and both the estrogens and Osphena acidify the vagina in addition to making it more lubricated, but the acidification in the vagina is likely to decrease a woman’s risk of getting a urinary tract infection, which is an extremely common problem in middle age and aging women.”

Later Menopause
Simon says providers should be aware that later menopause is associated with problems in other organ systems as well, although they may not be specifically related to menopause itself but to the estrogen deficiency that accompanies it. Two problems providers should be on the lookout for, he says, are issues related to osteoporosis and bone loss as well as cardiovascular disease. “Both of these—bone loss, osteoporosis, and fracture and an increase in cholesterol and cardiovascular disease—start quite close to menopause but don’t become clinically evident until much later,” he says.

Because it takes much longer for a patient to develop actual disease that presents with more outward symptoms, Simon recommends providers measure any potential changes in postmenopausal patients via a bone densitometer test in the case of osteoporosis or a blood test to track cholesterol and lipid changes.

Even when a patient may not exhibit any direct menopausal symptoms, Simon says estrogen hormone replacement therapy (HRT) could provide benefits. For example, for a woman who has no symptoms, is 52 years old, and has just had a bone density test indicating that her bone density is low but she has no fractures and doesn’t have osteoporosis, a family history may still warrant cause for concern. “Even if there’s no clinical reason to treat her because she’s having no hot flashes or vaginal dryness, she might say both her mother and her father had hip fractures at relatively young ages,” Simon says. “Maybe they were totally bent over with a dowager’s hump by the age of 55. In this case, you might make the judgment with her that while she has no symptoms currently, we have the ability to prevent those two outcomes that happened to her parents by being aggressive and getting a jump on it with HRT.”

Because a woman’s menopause trajectory is very much individual, other symptoms may also present, though Gass says it’s less clear how such symptoms relate to estrogen deficiency. Two for which providers should remain vigilant are a moodiness similar to PMS and a vulnerability for depression, which Gass notes is more common in women who’ve previously experienced a depressive episode.

A Note About HRT
According to Gass, one reason for a lack of training related to menopause can be traced back to the 2002 Women’s Health Initiative study, which found that taking HRT actually increased women’s risk of cardiovascular disease and breast cancer.

After these findings were widely publicized, Gass says many clinicians began avoiding hormone treatments because of the complexity of interpreting side effects in their patients. In addition, many of those clinicians may not have noted the less publicized research that’s been conducted and analyzed since then, much of which has shown that HRT actually is safe for most patients. “When the data were analyzed according to age group, it did appear that women in their 50s had far fewer side effects than women in their 60s and 70s who were in the study,” Gass says, “so it’s now widely accepted that most women can use hormone therapy for a while, if they’d like to.”

Gass says she’d like to see more up-to-date information about HRT in training programs today, and both she and the North American Menopause Society are working toward that end.

In general, Gass says HRT is a good fit for most healthy postmenopausal women who recently have experienced menopause. “And that’s very appropriate because that’s generally when women notice symptoms the most and when they find the most discomfort and disruption from hot flashes,” she says. “So if a woman is healthy, she should be at very low risk for having any complications from hormone therapy.”

According to Gass, potential complications are similar to hormonal contraception and include blood clots in the legs and lungs, “so women who have a history of blood clots may not be good candidates,” she says. “Women who’ve had a history of breast cancer are probably not good candidates for hormone therapy.”

“But if a woman does not have any contraindications to estrogen, I think it’s safe to give women estrogen, with the following caveats,” says Jean Rene Anderson, MD, director of the division of gynecologic specialties and a professor of gynecology and obstetrics at Johns Hopkins Medicine. “We usually give a much lower dose than we used to 10 to 15 years ago; we give it for a shorter period of time because these symptoms generally will resolve with time; and if a woman still has her uterus and she’s given systemic estrogen [by a pill or patch], then she needs progesterone as well.”

Some women, and even physicians, still are leery of HRT in many instances, but Anderson says the physician landscape with respect to hormone therapy has changed, and discussing the issues with patients can often help them make the best decision for themselves. “Twenty years ago, physicians gave HRT out like water, and we thought it was good for virtually everything,” Anderson says. “And then the Women’s Health study findings caused the pendulum to swing, probably too far the other way. I think that a lot of women and their providers became very frightened of using HRT.

“I think what happened since is that we’ve gotten a little more perspective,” she continues. “There have been more studies done, the doses we now use are probably half or less of the dose that used to be used. We’ve become more cognizant of the benefits, and the risks may have been a little overemphasized as to their magnitude in some cases. The important thing is to have a discussion with women about the pros and cons, as physicians should do regarding any treatment.”
Gass agrees that HRT is the most effective therapy for menopausal symptoms and says it’s very safe for the majority of women. “The most important concept from a treatment standpoint is to appreciate that some women do have very bothersome and disruptive symptoms from menopause, and the risks are small enough that we should feel comfortable prescribing hormone therapy to most healthy women at menopause who need help with their symptoms,” she says.

Broach the Subject
As important as knowing what works best for menopausal symptoms, and potentially more so, is broaching the subject with women because it’s quite likely they could be suffering in silence. “There’s an abundance of scientific information that says women don’t bring [menopause symptoms] up,” Simon says.

Whether due to personal vanity, a lack of familiarity, or a reluctance to discuss issues “down there,” Simon says women often will wait until their symptoms are more than they can bear before they bring up the subject with their physicians. And at that point, he says it can take much longer to treat or reverse the problems.

Simon says women would be much better off if physicians made it a point at every routine examination to ask middle-aged patients about a litany of menopausal symptoms, whether it’s part of a general physical examination or a gynecological examination. “That includes asking about hot flashes, night sweats, disturbed sleep, vaginal dryness, lack of vaginal lubrication, pain with sex, recurring or frequent UTIs, any broken bones, and changes in height,” he says.

Anderson agrees that on the issue of menopause, the onus is on providers to tease out patient problems and concerns. “Providers should be asking their patients who are perimenopausal or menopausal about what symptoms they may have because women may be embarrassed or for whatever reason may not bring it up,” she says. “Providers need to be proactive on this issue.”

With so many symptoms related to sexual intercourse (eg, vaginal dryness, pain with sex), it’s common for conversations about menopause never to actually focus on the topic of sex itself. According to Simon, for providers to overlook this integral point would be a missed opportunity. “All of the processes about aging come with changes that make it much more difficult for older couples to engage in pleasurable sexual contact,” he says. “And we often forget that older men and women do have sex. We like to think of women and men our parents’ age as having no sexual activity, but the answer is they do. And in order to have pleasurable sexual activity, many times these problems need to be prevented or treated. And that’s critical to a healthy life together as a couple.”

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania.