Transcript Struggles with the Thermostat & Other things “mature women

Struggles with the Thermostat & Other
things “mature women” need to know
Jennifer K. McDonald DO
Sexual Function
Classification
Hypoactive Sexual
Desire
Sexual Arousal Disorder
Orgasmic Disorder
Sexual Pain Disorder
Vaginismus (Vaginal spasms)
Dyspaurenia (Painful intercourse)


Cardiovascular
Disease in Women
Mortality From Heart Disease
US Women
Deaths/100,000
7000
6000
Heart disease
Breast cancer
5000
Hip fractures
4000
3000
2000
1000
0
0
25
35 45
55
Age
65
75 85
95
Facts



1 in 2 women will die from cardiovascular disease
Estrogen exerts beneficial effects on CV
system through
 Direct effect on the vasculature
 Indirect effect on lipid metabolism
In healthy menopausal women the use of ERT/HRT has
demonstrated cardiovascular benefit in numerous
observational studies
Total Cholesterol Levels After Menopause
Menopause
Percent
110
100
90
-24
8
-18
8
Maturitas 12(1990)321-331.
9
-12
-6
0
Months
9
9
10
10
10
6
10
10
10
HDL Cholesterol Levels After Menopause
Menopause
Percent
110
100
90
-18
-24
8
Maturitas 12(1990)321-331.
8
9
-12
9
-6
Months
9
10
0
10
10
6
10
10
10
LDL Cholesterol Levels After Menopause
Menopause
Percent
110
100
90
-24
-18
-12
-6
0
6
Months
8
Maturitas 12(1990)321-331.
8
9
9
9
10
10
10
10
10
10
What’s normal cholesterol?
JNC Blood Pressure Classification
SBP (mm Hg)
DBP (mm Hg)
Normal
< 120
< 80
Prehypertension
120 - 139
80 - 89
Stage 1
140 - 159
90 - 99
Stage 2
> 160
> 100
Framingham 10 Year Risk
Electronic 10 year risk calculators
available at:
www.nhlbi.nih.gov/guidelines/cholesterol
Menopause
Decline in ovarian function
 Permanent cessation of menses
Average age in the United States 51.4 years
of age


5 Ways to know you have Estrogen issues
1.
Everyone around you has an attitude problem
2. Your husband is suddenly agreeing to everything you say
3. The dryer has shrunk every last pair of your jeans
4. You’re sure the thermostat in your home is always completely wrong
5. You’re using your cellular phone to dial every bumper sticker that
says “How’s my driving call
1-800 …“
Perimenopausal Transition
Average age of onset ………………………
46
Average onset for 95% of women …… 39 to 51
Average duration ………………………… 5 years
Duration for 95% of women …………
years
2 to 8
Perimenopause is a transition not an event
Symptoms of Perimenopause








Hot flashes
Vaginal dryness
Breast Tenderness
Mood disturbances
Sleep disturbances
Urinary tract
infections/incontinence
Menstrual changes
Sexual dysfunction
Other Physiologic Changes





Slowing of metabolism
Weight gain
Changes in lipids
Increase in heart disease
Osteoporosis
•90% experience changes in menstrual
pattern
•90% report symptoms of vasomotor
instability
•75% lack of energy
•68% forgetfulness
Hormone Soup
Estrone (E1)
Estradiol (E2)
Estriol (E3)
Progesterone
Testosterone
“Natural” Hormones
Synthetic Hormones
Bioidentical Hormones
Hormone Replacement
Therapy (HRT)


Treats the symptoms of menopause
(hot flashes, etc.)

Prevention of heart disease?
WHI/NHS

Prevention and treatment of
osteoporosis

May help prevent dementia

May prevent strokes
Lower mortality rates in women who
take estrogen
Side Effects of HRT

Blood clots (especially in
smokers)
 Gallbladder disease
 Vaginal bleeding
 Breast tenderness
HRT & Breast Cancer
Risk factors for breast cancer and hormone
therapy do not have an additive effect

In WHI three deaths from breast cancer
occurred in the HRT group and two in the
placebo group
Hormone users who developed breast cancer had
a decreased risk of mortality from their disease

Lower stage, lower grade, and less aggressive
tumors

Decreased rate of recurrent disease


Problems with the WHI
Average age 63 years of age (30% > 70yo)
Women with significant menopausal symptoms
were excluded

Dropout rate high
Estrogen only group 58%
Combined Therapy 42%
Only one estrogen/estrogen-progestin product
examined



Problems with the WHI
35% being treated for hypertension

35% overweight

34% morbidly obese

13% on cholesterol meds already

4% had diabetes
16% strong family history of breast cancer


WHI Estrogen Only Breast
Cancer Cases
Year
Estrogen
Placebo
1
9
7
2
11
20
3
13
15
4
18
22
5
10
24
6
16
18
7
6
12
8
6
6
Overall
Deaths
94
4
124
8
WHI Estrogen Only
CHD Cases
Year
Estrogen
Placebo
1
26
23
2
27
23
3
22
25
4
21
27
5
30
24
6
31
26
7
13
28
8
6
17
Overall
Deaths
177
93
199
95
WHI Combined Therapy
CHD Cases
Year
1*
2
3
4
5
6 or more
Estrogen-Progestin
42
38
19
32
29
28
Placebo
23
28
15
25
19
37
Overall
Deaths
188
39
147
34
* Statistically significant
WHI
Complementary Therapies
Most lack scientific proof of
efficacy
 Large placebo effect
 Large financial incentive for
marketers
 “Dietary supplements”- no
regulation by FDA
 May be helpful for women who
do not choose HRT or as
adjunctive therapy

Multivitamins
Vitamin E

400-1200 IU daily

Reduces vasomotor symptoms

Reduces risk of coronary artery disease
Vitamin D

400 IU with calcium significantly reduced fracture risk

Postmenopausal women require 1500 mg/day calcium
Magnesium

Crucial for prevention of osteoporosis

Best if maintained in ratio with calcium 2:1
Phytogestrogens
Effects
1. Reduction of menopausal symptoms & prevention
of osteoporosis: data are conflicting.
2. FDA has approved food substances containing soy
protein to reduce the risk of heart disease
Adverse effects
No adverse effects
Risks
No randomized studies. So, it is not possible to
draw absolute conclusions without large long-term
RCT.
Alternatives
Acupuncture


Reduction in vasomotor symptoms
Benefits continued for 3 weeks beyond
treatment
Black Cohosh



Vasomotor symptoms
Improved bleeding profile
No randomized trials
Leaking is not a normal part
of aging !!
Boat in dock analogy
Boat- pelvic organs
 Water- levator muscles
 Moorings- Endopelvic fascial
ligaments
Problem is with the water or moorings
or both
 Result is sinking of the boat
 Really the boat itself is fine


Incontinence

1 in 3 female age 55 or more complain
of incontinence.
 1 in 10 women will have surgery for
prolapse or incontinence in her
lifetime
 One third will need further surgery
Types of Incontinence
 Genuine stress incontinence (GSI)
 Detrusor instability (DI)
 Mixed (GSI and DI)
 Overflow
Osteoporosis
Bone Mass
Peak Bone Mass
• Age
• Gender
• Genetic factors
• Hormonal status
• Exercise
• Calcium intake
Osteoporosis prevalence
Affects 200 million women worldwide
• 1/3 of women aged 60 to 70
• 2/3 of women aged 80 or older
• One out of two white women will suffer
an osteoporotic fracture in their
lifetime
Impact
Hip fracture results in 10-20% excess
mortality within 1 year of fracture
25% of hip fracture patients require
long term nursing home care
Only 40% regain pre-fracture level of
independence
Fracture Distribution
15 %
19 %
19 %
46 %
Other
Vertebral
Hip
Wrist
Incidence of
osteoporotic fractures in women
Annual
incidence per
1000 women
40
Vertebrae
30
Hip
20
Wrist
10
50
60
70
Age (Years)
80
Risk Factors
Non-modifiable
Potentially modifiable
Personal history of fracture as
an adult
Fracture in a first degree
relative
Caucasian/Asian
Advanced age
Female sex
Dementia
Poor health/frailty
Steroid therapy > 3 months
Current cigarette smoking
Low body weight (<127#)
Estrogen deficiency
Low calcium intake (lifelong)
Alcohol intake (> 2/day)
Impaired eyesight despite
correction
Recurrent falls
Inadequate physical activity
Poor health/frailty
DEXA Scan
T Score
Comparison to premenopausal mean peak
reference value
Who should get a DEXA scan?



Women > 65 regardless of risk factors
Post-menopausal women <65 with one or
more risk factors in addition to being
white, PM, and female
Post-menopausal women who present with
fractures