The North American Menopause Society (NAMS) 2022 annual meeting opened with a prophetic statement from an acclaimed speaker: “ A tsunami is coming.” Being that the conference was in a landlocked location, I wasn’t literally alarmed but nevertheless intrigued. The “tsunami” was explained to be in reference to the US aging population. The rapidly changing demographic of the postmenopausal population is nothing short of astounding and carries with it immediate implications to clinical care. More specifically, the NAMS conference encouraged clinicians to learn about the menopause patient population, awareness of unique symptoms with real health consequences, and to integrate into practice recently updated treatment guidelines, particularly in areas of cardiovascular health, bone health and hormone therapy.
There is a knowledge gap in the general public and clinicians regarding menopause. According to AARP, 80% of graduating internal medicine residents did not feel competent to discuss or treat menopause. Only 20% of ob/gyn residencies offer menopause training, and half of all US ob/gyn residencies felt they needed more education on menopause medicine. Only 54% of women correctly define menopause. It is estimated that 85% of perimenopausal and menopausal women experience a wide array of symptoms that clinically impact quality of life. Sixty percent seek clinical help but 75% of women subsequently go untreated. Menopause is sometimes referred to as a vital sign of sorts, as it represents a physiologic signal of many unique physiologic /systemic processes. Estradiol is one of the body’s most amazing anti-inflammatory hormones. When estradiol declines, women suffer in a variety of tangible ways for years longer than previously thought.
Sixty-four million US women are 50 and older. Half of the US female population is age 40 and older according to the US Census Bureau (2021). By the year 2025, 1.1 billion women will be menopausal due to women living longer. The average woman can expect to spend 40% of her life in postmenopause. There are currently only 1300 NAMS certified practitioners to treat the fastest growing segment of our population. The demand for clinicians knowledgeable in the clinical care of midlife and postmenopausal represents an urgent public health crisis.
Menopausal patients desperately want to be helped. They are tired of navigating a sea of fear and misinformation ever present in popular media and at times by clinicians. After sex education, contraception information and prenatal classes, this demographic is left by society to navigate menopause without an accessible compass. Fortunately the tide is changing thanks to researchers and organizations such as NAMS. It is a privilege to help menopausal individuals traverse through chaos to a better quality of life. Presenting a menopause symptom tracker to be completed at the clinic visit is helpful for the patient to gather thoughts as well as for the clinician to make effective use of time. Such trackers can be found on the NAMS website and the Let’s Talk Menopause website. This article offers information on new clinical updates in menopause and a resource list for you and your patients. With this information also comes a genuine encouragement to clinicians with a desire to learn more about menopause.
Vasomotor Symptoms (VMS) – Causes and Treatments
VMS—aka hot flashes and night sweats—are the most well known menopause symptoms. VMS originate in the arcuate nucleus of the hypothalamus, which contains the temperature regulatory center. This center is innervated by KNDy neurons within the arcuate nucleus. Declining estrogen and increased neurokinin B (NKB) activates the neural pathway controlling heat and subsequent loss of negative feedback which results in VMS.
A lot is new with VMS treatment. Vasomotor symptoms last longer than previously thought with an average length of 7-10 years. Ten percent of postmenopausal women have lifelong hot flashes. Profuse sweating, intense upper body heat with perspiration, chills, heart palpitations, and anxiety are some features of a hot flash. VMS disrupts sleep, mood, metabolism, alertness, libido and productivity. Many women have hot flashes before menopause and are incorrectly told “ you are too young for hot flashes”. In fact, 22-68% of premenopausal women report to flashes. Hot flashes, interestingly enough, are a big financial burden with annual cost of $248-$770 per woman, as well as decreased production by 10.9-12.2%. For these reasons, VMS is an economic and societal issue. The productivity decrease by those with VMS adds to the burden of existing pay gaps that women endure when they are at the height of their careers. Anxiety and depression are also associated with VMS.
Hormone therapy (HT) is the most effective treatment for VMS. Women within the first 10 years of menopause onset, or less than age 60, in the absence of contraindications, have greater benefit than risk from HT. This is the timing hypothesis for initiating HT. In general, after 10 years of menopause or older than age 60, HT initiation (not continuation) is felt to carry more risks with less clear benefit. A new and extremely exciting update for VMS treatment, with FDA approval expected soon, is a non-hormonal NK3 receptor antagonist called Fezolinetant. This medication blocks NKB binding in the KNDy neurons to decrease neuron activity and restore thermoregulatory balance. Fezolinetant will be on the market in 2023. This medicine demonstrates a high efficacy with low side effect profile. This is very exciting particularly for the patient group with contraindications to HT. Other treatments for VMS include oxybutynin, SSRI and gabapentin as well as lifestyle changes.
New Hormone Therapy Guidelines
Perhaps one of the most important and helpful updates in the menopause arena is the “2022 NAMS Hormone Therapy Position Statement”. This document is free online. Extremely readable and practical, the position statement gives clarification, real world patient information and a thorough review of the scientific evidence.
Indications for HT include:
- VMS symptom management.
- Prevention of bone loss.
- Treatment of premature hypo-estrogen states such as prematuremenopause or premenopausal bilateral salpingo-oophorectomy.
- Genitourinary syndrome of menopause.
Key points from this 2022 statement include:
- HT is the best treatment for genitourinary syndrome of menopause and for VMS.
- HT prevents bone loss and subsequently prevents fracture.
- For women without HT contraindication, within 10 years of menopause onsetor younger than age 60, the benefits outweigh the risk of treatments.
- Risks differ depending on type of estrogen, route of administration, age of initiation and if a progesterone is needed. In summary, all hormones are not the same.
- Level 1 evidence that the risk of breast cancer related to HT use is low. Different regimens increase breast density( medroxyprogesterone acetate— used in WHI study) while others do not appear to alter breast density.
- Level 1 evidence that starting HT within 10 years of menopause onset or less than age 60 reduced or had no effect on subclinical atherosclerosis and coronary artery calcification. Observational data showed a decrease in CAD in this group.
- HT lowers the diagnosis of new onset DM. HT is not contraindicated in those with DM.
- Transdermal HT may have a lower risk of thromboembolism compared to oral HT. Observational studies show no increased risk of thromboembolic events.Transdermal HT has a neutral effect on triglycerides and is preferred in both diabetics andthose with metabolic syndrome.
- HT is needed in women with premature menopause.
- Level 2 evidence that estrogen therapy has a favorable effect on mood and some antidepressant effects in perimenopausal women.
- HT is not a substitute for antidepressants.
- Compounded HT is not regulated and therefore is in general discouraged. Certain exceptions exist such as allergies to components used in FDA approved regimens and other situations which go beyond the scope of this article.
Sleep and Menopause
Sleep concerns affect at least half of all perimenopausal and menopausal women. Screening for night sweats/vms, reviewing medications and other medical conditions are the first steps in treatment. First line treatment includes cognitive behavioral therapy and HT. Doxepin in low dose is approved for insomnia as well as other “z” drugs. The American Academy of Sleep Medicine has a wonderful sleep diary to document sleep patterns.
Cognitive behavioral therapy (CBT) can be easily accessed online, thus increasing access to care. MsFlash and other studies confirm the role of HT to reduce sleep latency and disrupted sleep. Sleep apnea has disproportional affects on menopausal women. Screening questions for snoring, hot flashes and waking up tired are helpful for guiding further evaluation such as a sleep study. Forty percent of women with sleep apnea do not have classic sleep apnea symptoms.
Mental Health in Menopause
The menopause transition is a period of vulnerability. Midlife women are at very high risk of major depression particularly during the menopause transition and early menopause. Women are more affected by depression than men with a 1.5-2.0 fold increased risk. Significant changes in estradiol increased depression while administration of estrogen decreased severity of depression during the menopause transition. In addition to estradiol administration, CBT and antidepressants are evidence-based Levels 1 and 2 therapies.
What’s New in Osteoporosis
Bone loss happens in all women due to estrogen deficiency. Half of women will sustain an osteoporosis fracture. This has serious quality of life ramifications in regards to morbidity and mortality. A few new clinical take home points however are the following:
- All women age 50 and older need a FRAX score calculated and documented as DEXA scans, which are often warranted before age 65.
- A fragility fracture is diagnostic of osteoporosis. While work up, treatment and follow up for this lifelong diagnosis is of critical importance, this process occurs in only about 15% of patients. Imagine if a person was admitted with a heart attack and no work up was done or follow up care! Considering that this is a treatable disease and a source of enormous morbidity and mortality, getting on board with new clinical guidelines will help so many.
- A consensus statement available for free online titled “The Clinician’s Guide to Prevention and Treatment of Osteoporosis” is a lifesaver for clinicians and patients. This document simplifies work-up and pathways for an often overlooked serious medical condition which disproportionally affects women.
Cardiovascular Disease (CVD) & the Menopause Patient
CVD is rising in middle aged women after years of declining rates. Myocardial infarction numbers before age 55 years rose by 27% in the past two decades. In the setting of acute MI, there are two fold greater odds of mortality in women less than 45 years old. Women with CAD have more angina and CHF, with less obstructive symptoms. All risk scores are for primary prevention and not secondary prevention. The 2021 heart disease and stroke statistics show a seven percent rise in heart disease in women ages 45-64. CVD is the leading cause of morbidity and mortality in US women. Very few studies have uniquely looked at heart disease in women. Women are more likely to die within a year after myocardial infarction(MI) than men. Women with an MI are 50% more likely to be misdiagnosed than men. Sixty-four percent of women who die of sudden heart disease have no prior symptoms.
The American Heart Association now recognizes the menopause transition as a time of increased CVD risk. The Study of Women Across the Nation (SWAN) showed that LDL-C and apoprotein B significantly increase the year before and after menopause onset. More attention is being devoted to emerging risk factor recognition for heart disease particularly in the area of obstetric history. Those with history of gestational diabetes have a 59% increased risk of MI. Women who had gestational hypertension or preeclampsia have a threefold increased risk of ischemic heart disease. Other risk factors for CVD include early or late menarche, PCOS, infertility, lack of breastfeeding, menopause, preterm delivery, IUGR, grand multiparity, early menopause, RA and Lupus. How this guides CVD screening for the individual patient has complex nuances but a coronary calcium score (CAC) may help when risk is uncertain.
The MS Heart Study has shown that VMS increase subclinical CVD. This is also noted in other ongoing longitudinal studies. The mechanism for this is unknown but currently being studied.
Menopause is more than hot flashes and vaginal dryness. When estrogen levels decrease, a woman is at increased risk for heart disease, cognitive changes as well as osteoporosis. Being aware of where to access information for clinical practice and for patients is wonderful. Please consider the following resources:
North American Menopause Society (www. menopause.org)
International Menopause Society (www.imsociety.org)
Speaking of Women’s Health (www.speakingofwomenshealth.com)
International Society for the Study of Women’s Sexual Health (www.isswsh.org)
Let’s Talk Menopause (www.letstalkmenopause.org)
Red Hot Mamas (www.redhotmamas.org)
Cuyuna Regional Medical Center (www.cuyunamed.org)
Society for Women’s Health Research (www.swhr.org)
International Society for the Study of Vulvovaginal Disease (www.issvd.org)
American College of Obstetrics and Gynecology (www.acog.org)
Madame Ovary (www.madameovary.com)
What Else Can I do?
Become a certified menopause practitioner through the North American Menopause Society. Any licensed health care practitioner can become one. The details of this process are on the NAMS website and the benefits are many. There is also an IMPART menopause online training program from the IMS. If you express an interest to be a menopause practitioner, you will have a thriving, gratifying practice. Attend a menopause conference in person or virtually. Look also to the women around you—family members, friends, work colleagues. Many have no idea about menopause and would welcome information. Starting small groups for menopause education in your clinic or in community at large is great. Developing a Menopause in the Workplace policy or guideline is a progressive way to educate and retain individuals by giving credence to their suffering with fatigue, brain fog, absenteeism, anxiety etc. We have recently done this at Cuyuna Regional Medical Center—acknowledging symptoms and providing fans, cooling packs and easily accessible pads/deoderant are just a few easy things to convey a supportive message. This is not unlike providing lactation rooms or maternity accommodations. Celebrating World Menopause Day every October invokes camaraderie and education.
Rachel Cady, MD, FACOG, NCMP, is a certified menopause practioner through NAMS and director of the CRMC menopause and healthy aging program. This program focuses on menopause, sexual health and vulvar diseases.