Menopause

Among postmenopausal women, breast cancers diagnosed following biennial mammography intervals are no more “unfavorable” than those diagnosed following annual intervals, according to a report published online Oct. 20 in JAMA Oncology.

“When considering recommendations regarding screening intervals, the potential benefit of diagnosing cancers at an earlier stage must be weighed against the increased potential for harms associated with more frequent screening, such as false-positive recalls and biopsies, which are 1.5 to 2 times higher in annual vs. biennial screeners,” wrote Diana L. Miglioretti, Ph.D., of the University of California, Davis, and her associates in the Breast Cancer Surveillance Consortium (BCSC).

Dr. Cecil Fox/National Cancer Institute

The optimal frequency of mammographic screening remains controversial. The American Cancer Society commissioned the BCSC to analyze the most recent information on this issue as part of its effort to update the ACS guideline for breast cancer screening for women at average risk.

BCSC registries collect patient and clinical data from community radiology facilities across the country. For this analysis, Dr. Miglioretti and her colleagues focused on 15,440 women aged 40-85 years in these registries who were diagnosed as having breast cancer from 1996 to 2012. A total of 12,070 of the women underwent annual mammographic screening and 3,370 underwent biennial mammographic screening.

Among premenopausal women, those diagnosed after biennial mammograms were more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (relative risk, 1.11). In contrast, among postmenopausal women, those diagnosed after biennial mammograms were not more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (RR, 1.03), the investigators wrote (JAMA Oncol. 2015 Oct 20. doi: 10.1001/jamaoncology.2015.3084).

In an editorial accompanying this report, Dr. Wendy Y. Chen of Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Harvard Medical School, all in Boston, wrote, “Although the authors do not endorse annual or biennial screening, they imply that biennial screening would be acceptable for postmenopausal women but inferior for premenopausal women.”

Most developed countries outside the United States – including the United Kingdom, Canada, and Australia – recommend screening every 2 or 3 years, Dr. Chen noted (JAMA Oncol. 2015 Oct 20 doi: 10.1001/jamaoncology.2015.3286).

This study and others clearly show that, with less frequent mammography, breast cancers will be larger and have a slightly more advanced stage when they are discovered, Dr. Chen wrote. But with a better understanding of tumor biology and improvements in targeted therapy, the best approach may not be simply trying to identify a smaller tumor, she added.

“Efforts should be focused on a better understanding of how screening interacts with tumor biology with a better understanding of the types of interval cancers and sojourn times and how these characteristics differ by age and/or menopausal status,” Dr. Chen wrote.

This study was supported by the American Cancer Society and the National Cancer Institute. Dr. Miglioretti reported having no relevant financial disclosures. One of the investigators reported being an unpaid advisor on General Electric Health Care’s breast medical advisory board.

Among postmenopausal women, breast cancers diagnosed following biennial mammography intervals are no more “unfavorable” than those diagnosed following annual intervals, according to a report published online Oct. 20 in JAMA Oncology.

“When considering recommendations regarding screening intervals, the potential benefit of diagnosing cancers at an earlier stage must be weighed against the increased potential for harms associated with more frequent screening, such as false-positive recalls and biopsies, which are 1.5 to 2 times higher in annual vs. biennial screeners,” wrote Diana L. Miglioretti, Ph.D., of the University of California, Davis, and her associates in the Breast Cancer Surveillance Consortium (BCSC).

Dr. Cecil Fox/National Cancer Institute

The optimal frequency of mammographic screening remains controversial. The American Cancer Society commissioned the BCSC to analyze the most recent information on this issue as part of its effort to update the ACS guideline for breast cancer screening for women at average risk.

BCSC registries collect patient and clinical data from community radiology facilities across the country. For this analysis, Dr. Miglioretti and her colleagues focused on 15,440 women aged 40-85 years in these registries who were diagnosed as having breast cancer from 1996 to 2012. A total of 12,070 of the women underwent annual mammographic screening and 3,370 underwent biennial mammographic screening.

Among premenopausal women, those diagnosed after biennial mammograms were more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (relative risk, 1.11). In contrast, among postmenopausal women, those diagnosed after biennial mammograms were not more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (RR, 1.03), the investigators wrote (JAMA Oncol. 2015 Oct 20. doi: 10.1001/jamaoncology.2015.3084).

In an editorial accompanying this report, Dr. Wendy Y. Chen of Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Harvard Medical School, all in Boston, wrote, “Although the authors do not endorse annual or biennial screening, they imply that biennial screening would be acceptable for postmenopausal women but inferior for premenopausal women.”

Most developed countries outside the United States – including the United Kingdom, Canada, and Australia – recommend screening every 2 or 3 years, Dr. Chen noted (JAMA Oncol. 2015 Oct 20 doi: 10.1001/jamaoncology.2015.3286).

This study and others clearly show that, with less frequent mammography, breast cancers will be larger and have a slightly more advanced stage when they are discovered, Dr. Chen wrote. But with a better understanding of tumor biology and improvements in targeted therapy, the best approach may not be simply trying to identify a smaller tumor, she added.

“Efforts should be focused on a better understanding of how screening interacts with tumor biology with a better understanding of the types of interval cancers and sojourn times and how these characteristics differ by age and/or menopausal status,” Dr. Chen wrote.

This study was supported by the American Cancer Society and the National Cancer Institute. Dr. Miglioretti reported having no relevant financial disclosures. One of the investigators reported being an unpaid advisor on General Electric Health Care’s breast medical advisory board.

Among postmenopausal women, breast cancers diagnosed following biennial mammography intervals are no more “unfavorable” than those diagnosed following annual intervals, according to a report published online Oct. 20 in JAMA Oncology.

“When considering recommendations regarding screening intervals, the potential benefit of diagnosing cancers at an earlier stage must be weighed against the increased potential for harms associated with more frequent screening, such as false-positive recalls and biopsies, which are 1.5 to 2 times higher in annual vs. biennial screeners,” wrote Diana L. Miglioretti, Ph.D., of the University of California, Davis, and her associates in the Breast Cancer Surveillance Consortium (BCSC).

Dr. Cecil Fox/National Cancer Institute

The optimal frequency of mammographic screening remains controversial. The American Cancer Society commissioned the BCSC to analyze the most recent information on this issue as part of its effort to update the ACS guideline for breast cancer screening for women at average risk.

BCSC registries collect patient and clinical data from community radiology facilities across the country. For this analysis, Dr. Miglioretti and her colleagues focused on 15,440 women aged 40-85 years in these registries who were diagnosed as having breast cancer from 1996 to 2012. A total of 12,070 of the women underwent annual mammographic screening and 3,370 underwent biennial mammographic screening.

Among premenopausal women, those diagnosed after biennial mammograms were more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (relative risk, 1.11). In contrast, among postmenopausal women, those diagnosed after biennial mammograms were not more likely to have tumors with unfavorable prognostic characteristics than were those diagnosed after annual mammograms (RR, 1.03), the investigators wrote (JAMA Oncol. 2015 Oct 20. doi: 10.1001/jamaoncology.2015.3084).

In an editorial accompanying this report, Dr. Wendy Y. Chen of Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Harvard Medical School, all in Boston, wrote, “Although the authors do not endorse annual or biennial screening, they imply that biennial screening would be acceptable for postmenopausal women but inferior for premenopausal women.”

Most developed countries outside the United States – including the United Kingdom, Canada, and Australia – recommend screening every 2 or 3 years, Dr. Chen noted (JAMA Oncol. 2015 Oct 20 doi: 10.1001/jamaoncology.2015.3286).

This study and others clearly show that, with less frequent mammography, breast cancers will be larger and have a slightly more advanced stage when they are discovered, Dr. Chen wrote. But with a better understanding of tumor biology and improvements in targeted therapy, the best approach may not be simply trying to identify a smaller tumor, she added.

“Efforts should be focused on a better understanding of how screening interacts with tumor biology with a better understanding of the types of interval cancers and sojourn times and how these characteristics differ by age and/or menopausal status,” Dr. Chen wrote.

This study was supported by the American Cancer Society and the National Cancer Institute. Dr. Miglioretti reported having no relevant financial disclosures. One of the investigators reported being an unpaid advisor on General Electric Health Care’s breast medical advisory board.

LAS VEGAS – Female desire and sexual function involve a complicated and interconnected cascade of hormones and neurotransmitters, each providing a potential target for modulation in cases of low desire or sexual dysfunction.

There are some pharmacologic options available now and more drugs in the pipeline, Dr. Roya Rezaee said at the NAMS 2015 annual meeting.

Dr. Rezaee, codirector of the Program for Sexual Health and Vulvovaginal Disorders at University Hospitals Case Medical Center, Cleveland, explained how each treatment acts in the chemical cascade of desire and sexual response.* Though much remains unknown, researchers have identified neurochemical pathways of desire and arousal that act on the brain stem, the hypothalamus, and the amygdala.

Among the neurotransmitters and neurohormones thought to promote female sexual function, dopamine and melanocortin are associated with attention and desire, while norepinephrine and oxytocin are more directly related to arousal. Estrogen and testosterone function as excitatory neurohormones. Serotonin, because it is associated with satiety, may be inhibitory, as are prolactin and the endogenous opioids and endocannabinoids.

In the peripheral tissues, the presence of sex hormones maintains general genital function. For example, estradiol not only promotes vaginal lubrication, but also helps maintain adequate blood flow to the vagina and clitoris. Exogenous testosterone can directly influence the amount of unbound estrogen as well as testosterone, said Dr. Rezaee. Higher testosterone levels downregulate sex hormone–binding globulin, increasing circulating levels of free estrogen and testosterone.

“For women, low testosterone does not always correlate with low desire, but testosterone administration has been shown to be efficacious for low desire,” Dr. Rezaee said. “People are still writing prescriptions for testosterone off label, because a lot of us believe in the data,” she said, adding that a 2009 Cochrane review showed a good safety profile for testosterone.

Targeting dopaminergic pathways to increase desire, an extended-release daily oral combination of trazodone and bupropion, to be marketed as Lorexys, is about to begin phase III clinical trials. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been known to have prosexual side effects, Dr. Rezaee said. Both ingredients in Lorexys are currently approved as antidepressants.

Increasing available norepinephrine may help with focus and attention, and increase subjective sexual excitement. However, the ADHD and antidepressant medications that increase norepinephrine carry significant side effects and should not be what physicians use to help their patients with low desire, Dr. Rezaee said.

“Serotonin may have a role in low desire by acting as a sexual satiety signal, and SSRIs are serotonergic agents that inhibit desire, arousal, and orgasm in the brain and in the tissue,” she said.

However, there are seven known families of serotonin receptors, and selective modulation specifically of the 5-hydroxytryptamine receptor 1A and 5-HT_2A receptors may have prosexual effects. The newly approved medication flibanserin (Addyi) is a selective agonist for 5-HT_1A and an antagonist for 5-HT_2A receptors. Flibanserin is also thought to produce upregulation in dopamine and norepinephrine in the prefrontal cortex, combating the satiety signals from serotonin and leading to increased desire.

Other medications that are 5-HT_1A agonists with potential prosexual effects include buspirone (Buspar) and trazodone (Desyrel, Oleptro).

Blockade of phosphodiesterase type 5 (PDE5) permits relaxation of smooth muscles in arterial walls and increases blood flow to erectile tissues. PDE5 inhibitors such as sildenafil (Viagra) may be of benefit to some women as well, said Dr. Rezaee, though they do not address low desire.

“Newer data support the use of PDE5 inhibitors with women who suffer from SSRI-induced orgasmic complaints of increased latency or decreased intensity, or anorgasmia,” she said. A dose of 25-50 mg of sildenafil 1 hour before sexual activity may help these patients, she advised.

Phase II trials have been completed for two other combination drugs to treat female sexual problems. Lybrido is a combination of testosterone and sildenafil, while Lybridos combines testosterone with buspirone. Both products are oral tablets, taken on demand.

Bremelanotide is a first-in-class drug in development as a melanocortin agonist. This drug, meant to be used on demand to activate an endogenous pathway that increases attention and desire, is in phase III clinical trials.

Dr. Rezaee reported having no relevant financial disclosures.

[email protected]
On Twitter @karioakes

 *Correction, 10/20/2015: An earlier version of this story misstated Dr. Rezaee's title. 

LAS VEGAS – Female desire and sexual function involve a complicated and interconnected cascade of hormones and neurotransmitters, each providing a potential target for modulation in cases of low desire or sexual dysfunction.

There are some pharmacologic options available now and more drugs in the pipeline, Dr. Roya Rezaee said at the NAMS 2015 annual meeting.

Dr. Rezaee, codirector of the Program for Sexual Health and Vulvovaginal Disorders at University Hospitals Case Medical Center, Cleveland, explained how each treatment acts in the chemical cascade of desire and sexual response.* Though much remains unknown, researchers have identified neurochemical pathways of desire and arousal that act on the brain stem, the hypothalamus, and the amygdala.

Among the neurotransmitters and neurohormones thought to promote female sexual function, dopamine and melanocortin are associated with attention and desire, while norepinephrine and oxytocin are more directly related to arousal. Estrogen and testosterone function as excitatory neurohormones. Serotonin, because it is associated with satiety, may be inhibitory, as are prolactin and the endogenous opioids and endocannabinoids.

In the peripheral tissues, the presence of sex hormones maintains general genital function. For example, estradiol not only promotes vaginal lubrication, but also helps maintain adequate blood flow to the vagina and clitoris. Exogenous testosterone can directly influence the amount of unbound estrogen as well as testosterone, said Dr. Rezaee. Higher testosterone levels downregulate sex hormone–binding globulin, increasing circulating levels of free estrogen and testosterone.

“For women, low testosterone does not always correlate with low desire, but testosterone administration has been shown to be efficacious for low desire,” Dr. Rezaee said. “People are still writing prescriptions for testosterone off label, because a lot of us believe in the data,” she said, adding that a 2009 Cochrane review showed a good safety profile for testosterone.

Targeting dopaminergic pathways to increase desire, an extended-release daily oral combination of trazodone and bupropion, to be marketed as Lorexys, is about to begin phase III clinical trials. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been known to have prosexual side effects, Dr. Rezaee said. Both ingredients in Lorexys are currently approved as antidepressants.

Increasing available norepinephrine may help with focus and attention, and increase subjective sexual excitement. However, the ADHD and antidepressant medications that increase norepinephrine carry significant side effects and should not be what physicians use to help their patients with low desire, Dr. Rezaee said.

“Serotonin may have a role in low desire by acting as a sexual satiety signal, and SSRIs are serotonergic agents that inhibit desire, arousal, and orgasm in the brain and in the tissue,” she said.

However, there are seven known families of serotonin receptors, and selective modulation specifically of the 5-hydroxytryptamine receptor 1A and 5-HT_2A receptors may have prosexual effects. The newly approved medication flibanserin (Addyi) is a selective agonist for 5-HT_1A and an antagonist for 5-HT_2A receptors. Flibanserin is also thought to produce upregulation in dopamine and norepinephrine in the prefrontal cortex, combating the satiety signals from serotonin and leading to increased desire.

Other medications that are 5-HT_1A agonists with potential prosexual effects include buspirone (Buspar) and trazodone (Desyrel, Oleptro).

Blockade of phosphodiesterase type 5 (PDE5) permits relaxation of smooth muscles in arterial walls and increases blood flow to erectile tissues. PDE5 inhibitors such as sildenafil (Viagra) may be of benefit to some women as well, said Dr. Rezaee, though they do not address low desire.

“Newer data support the use of PDE5 inhibitors with women who suffer from SSRI-induced orgasmic complaints of increased latency or decreased intensity, or anorgasmia,” she said. A dose of 25-50 mg of sildenafil 1 hour before sexual activity may help these patients, she advised.

Phase II trials have been completed for two other combination drugs to treat female sexual problems. Lybrido is a combination of testosterone and sildenafil, while Lybridos combines testosterone with buspirone. Both products are oral tablets, taken on demand.

Bremelanotide is a first-in-class drug in development as a melanocortin agonist. This drug, meant to be used on demand to activate an endogenous pathway that increases attention and desire, is in phase III clinical trials.

Dr. Rezaee reported having no relevant financial disclosures.

[email protected]
On Twitter @karioakes

 *Correction, 10/20/2015: An earlier version of this story misstated Dr. Rezaee's title. 

LAS VEGAS – Female desire and sexual function involve a complicated and interconnected cascade of hormones and neurotransmitters, each providing a potential target for modulation in cases of low desire or sexual dysfunction.

There are some pharmacologic options available now and more drugs in the pipeline, Dr. Roya Rezaee said at the NAMS 2015 annual meeting.

Dr. Rezaee, codirector of the Program for Sexual Health and Vulvovaginal Disorders at University Hospitals Case Medical Center, Cleveland, explained how each treatment acts in the chemical cascade of desire and sexual response.* Though much remains unknown, researchers have identified neurochemical pathways of desire and arousal that act on the brain stem, the hypothalamus, and the amygdala.

Among the neurotransmitters and neurohormones thought to promote female sexual function, dopamine and melanocortin are associated with attention and desire, while norepinephrine and oxytocin are more directly related to arousal. Estrogen and testosterone function as excitatory neurohormones. Serotonin, because it is associated with satiety, may be inhibitory, as are prolactin and the endogenous opioids and endocannabinoids.

In the peripheral tissues, the presence of sex hormones maintains general genital function. For example, estradiol not only promotes vaginal lubrication, but also helps maintain adequate blood flow to the vagina and clitoris. Exogenous testosterone can directly influence the amount of unbound estrogen as well as testosterone, said Dr. Rezaee. Higher testosterone levels downregulate sex hormone–binding globulin, increasing circulating levels of free estrogen and testosterone.

“For women, low testosterone does not always correlate with low desire, but testosterone administration has been shown to be efficacious for low desire,” Dr. Rezaee said. “People are still writing prescriptions for testosterone off label, because a lot of us believe in the data,” she said, adding that a 2009 Cochrane review showed a good safety profile for testosterone.

Targeting dopaminergic pathways to increase desire, an extended-release daily oral combination of trazodone and bupropion, to be marketed as Lorexys, is about to begin phase III clinical trials. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been known to have prosexual side effects, Dr. Rezaee said. Both ingredients in Lorexys are currently approved as antidepressants.

Increasing available norepinephrine may help with focus and attention, and increase subjective sexual excitement. However, the ADHD and antidepressant medications that increase norepinephrine carry significant side effects and should not be what physicians use to help their patients with low desire, Dr. Rezaee said.

“Serotonin may have a role in low desire by acting as a sexual satiety signal, and SSRIs are serotonergic agents that inhibit desire, arousal, and orgasm in the brain and in the tissue,” she said.

However, there are seven known families of serotonin receptors, and selective modulation specifically of the 5-hydroxytryptamine receptor 1A and 5-HT_2A receptors may have prosexual effects. The newly approved medication flibanserin (Addyi) is a selective agonist for 5-HT_1A and an antagonist for 5-HT_2A receptors. Flibanserin is also thought to produce upregulation in dopamine and norepinephrine in the prefrontal cortex, combating the satiety signals from serotonin and leading to increased desire.

Other medications that are 5-HT_1A agonists with potential prosexual effects include buspirone (Buspar) and trazodone (Desyrel, Oleptro).

Blockade of phosphodiesterase type 5 (PDE5) permits relaxation of smooth muscles in arterial walls and increases blood flow to erectile tissues. PDE5 inhibitors such as sildenafil (Viagra) may be of benefit to some women as well, said Dr. Rezaee, though they do not address low desire.

“Newer data support the use of PDE5 inhibitors with women who suffer from SSRI-induced orgasmic complaints of increased latency or decreased intensity, or anorgasmia,” she said. A dose of 25-50 mg of sildenafil 1 hour before sexual activity may help these patients, she advised.

Phase II trials have been completed for two other combination drugs to treat female sexual problems. Lybrido is a combination of testosterone and sildenafil, while Lybridos combines testosterone with buspirone. Both products are oral tablets, taken on demand.

Bremelanotide is a first-in-class drug in development as a melanocortin agonist. This drug, meant to be used on demand to activate an endogenous pathway that increases attention and desire, is in phase III clinical trials.

Dr. Rezaee reported having no relevant financial disclosures.

[email protected]
On Twitter @karioakes

 *Correction, 10/20/2015: An earlier version of this story misstated Dr. Rezaee's title. 

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

[email protected]

On Twitter @karioakes

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

[email protected]

On Twitter @karioakes

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

[email protected]

On Twitter @karioakes

Clinicians treating vasomotor and genitourinary symptoms of menopause should consider estrogen therapy for healthy women with moderate to severe symptoms and no contraindications to hormone therapy, according to a new clinical practice guideline issued by the Endocrine Society.

The guideline, developed by an international panel, is designed to be a comprehensive document that emphasizes individualized clinical recommendations and generally takes a conservative approach to balancing risks and benefits, said Dr. Cynthia Stuenkel, chair of the task force that developed the guideline and professor of medicine at the University of California, San Diego.

“We need to be very mindful of the individual health concerns of our patient – is the individual therapy that we choose safe for her?” noted Dr. Stuenkel during a web-hosted press conference announcing the publication of the guideline.

For women under 60 years of age or fewer than 10 years past menopause who have bothersome vasomotor symptoms (VMS) and are without contraindications, the guideline suggests initiating estrogen therapy, supplemented by a progestogen for those women who have a uterus (J Clin Endocrinol Metab. 2015. doi: 10.1210/jc.2015-2236).

The discussion regarding treatment options should be grounded by a obtaining a baseline history of and assessing risk for cardiovascular disease (CVD) and breast cancer. “Menopause is a portal to the second half of life,” so clinicians should address bone health, smoking cessation, alcohol use, and cardiovascular and cancer risks and screening in their discussion, said Dr. Stuenkel.

The panel makes specific recommendations to tailor treatment depending on risk. For example, women at intermediate to high risk of breast cancer should be steered toward nonhormonal therapies to relieve VMS. Those at moderate risk of CVD can consider transdermal estradiol, while nonhormonal therapies are recommended for the high–CVD risk group.

The genitourinary symptoms of menopause (GSM) can include not just vulvovaginal atrophy but also urinary frequency and recurrent urinary tract infections, said Dr. Stuenkel, so the panel used the broader terminology to address estrogen’s effect on both organ systems.

An initial trial of vaginal moisturizers, used at least twice weekly, supplemented by lubricants as needed before sexual activity, should be the first-line treatment for GSM. For women with persistent symptoms and no history of estrogen-dependent cancers, low-dose vaginal estrogen therapy is a logical next step and does not require accompanying progestogen treatment, according to the guideline.

For women with symptomatic GSM who have had breast or endometrial cancer whose symptoms are not sufficiently treated by nonhormonal methods, low-dose vaginal estrogen is a consideration. This option should be considered with a shared decision-making approach that involves the patient’s oncologist.

Conjugated equine estrogens plus bazedoxefine, a novel selective estrogen receptor modulator (Duavee) can treat VMS and provide protection against bone loss, said the task force. The guideline recommends against the use of custom-compounded hormonal therapy and recommends the use of Food and Drug Administration–approved formulations. Ospemifene can be considered in women with significant dyspareunia and without contraindications, which include a history of breast cancer.

In conclusion, the guideline calls for ongoing rigorous study of the optimal agents and dosing for treatment of symptoms, how best to balance symptom relief with chronic disease prevention, and the merits of long-term hormone therapy beyond the period when symptomatic relief of VMS is needed. “International registries and clinical trials are overdue to address the long-reaching implications of these important issues,” said Dr. Stuenkel and coauthors of the guideline.

Dr. Stuenkel reported no relevant financial disclosures. Three task force members, Dr. Susan Davis, Dr. JoAnn Pinkerton, and Dr. Richard Santen, reported financial ties to pharmaceutical companies. Cosponsoring organizations included the Australasian Menopause Society, the British Menopause Society, European Menopause and Andropause Society, the European Society of Endocrinology, and the International Menopause Society.

[email protected]

On Twitter @karioakes

Clinicians treating vasomotor and genitourinary symptoms of menopause should consider estrogen therapy for healthy women with moderate to severe symptoms and no contraindications to hormone therapy, according to a new clinical practice guideline issued by the Endocrine Society.

The guideline, developed by an international panel, is designed to be a comprehensive document that emphasizes individualized clinical recommendations and generally takes a conservative approach to balancing risks and benefits, said Dr. Cynthia Stuenkel, chair of the task force that developed the guideline and professor of medicine at the University of California, San Diego.

“We need to be very mindful of the individual health concerns of our patient – is the individual therapy that we choose safe for her?” noted Dr. Stuenkel during a web-hosted press conference announcing the publication of the guideline.

For women under 60 years of age or fewer than 10 years past menopause who have bothersome vasomotor symptoms (VMS) and are without contraindications, the guideline suggests initiating estrogen therapy, supplemented by a progestogen for those women who have a uterus (J Clin Endocrinol Metab. 2015. doi: 10.1210/jc.2015-2236).

The discussion regarding treatment options should be grounded by a obtaining a baseline history of and assessing risk for cardiovascular disease (CVD) and breast cancer. “Menopause is a portal to the second half of life,” so clinicians should address bone health, smoking cessation, alcohol use, and cardiovascular and cancer risks and screening in their discussion, said Dr. Stuenkel.

The panel makes specific recommendations to tailor treatment depending on risk. For example, women at intermediate to high risk of breast cancer should be steered toward nonhormonal therapies to relieve VMS. Those at moderate risk of CVD can consider transdermal estradiol, while nonhormonal therapies are recommended for the high–CVD risk group.

The genitourinary symptoms of menopause (GSM) can include not just vulvovaginal atrophy but also urinary frequency and recurrent urinary tract infections, said Dr. Stuenkel, so the panel used the broader terminology to address estrogen’s effect on both organ systems.

An initial trial of vaginal moisturizers, used at least twice weekly, supplemented by lubricants as needed before sexual activity, should be the first-line treatment for GSM. For women with persistent symptoms and no history of estrogen-dependent cancers, low-dose vaginal estrogen therapy is a logical next step and does not require accompanying progestogen treatment, according to the guideline.

For women with symptomatic GSM who have had breast or endometrial cancer whose symptoms are not sufficiently treated by nonhormonal methods, low-dose vaginal estrogen is a consideration. This option should be considered with a shared decision-making approach that involves the patient’s oncologist.

Conjugated equine estrogens plus bazedoxefine, a novel selective estrogen receptor modulator (Duavee) can treat VMS and provide protection against bone loss, said the task force. The guideline recommends against the use of custom-compounded hormonal therapy and recommends the use of Food and Drug Administration–approved formulations. Ospemifene can be considered in women with significant dyspareunia and without contraindications, which include a history of breast cancer.

In conclusion, the guideline calls for ongoing rigorous study of the optimal agents and dosing for treatment of symptoms, how best to balance symptom relief with chronic disease prevention, and the merits of long-term hormone therapy beyond the period when symptomatic relief of VMS is needed. “International registries and clinical trials are overdue to address the long-reaching implications of these important issues,” said Dr. Stuenkel and coauthors of the guideline.

Dr. Stuenkel reported no relevant financial disclosures. Three task force members, Dr. Susan Davis, Dr. JoAnn Pinkerton, and Dr. Richard Santen, reported financial ties to pharmaceutical companies. Cosponsoring organizations included the Australasian Menopause Society, the British Menopause Society, European Menopause and Andropause Society, the European Society of Endocrinology, and the International Menopause Society.

[email protected]

On Twitter @karioakes

Clinicians treating vasomotor and genitourinary symptoms of menopause should consider estrogen therapy for healthy women with moderate to severe symptoms and no contraindications to hormone therapy, according to a new clinical practice guideline issued by the Endocrine Society.

The guideline, developed by an international panel, is designed to be a comprehensive document that emphasizes individualized clinical recommendations and generally takes a conservative approach to balancing risks and benefits, said Dr. Cynthia Stuenkel, chair of the task force that developed the guideline and professor of medicine at the University of California, San Diego.

“We need to be very mindful of the individual health concerns of our patient – is the individual therapy that we choose safe for her?” noted Dr. Stuenkel during a web-hosted press conference announcing the publication of the guideline.

For women under 60 years of age or fewer than 10 years past menopause who have bothersome vasomotor symptoms (VMS) and are without contraindications, the guideline suggests initiating estrogen therapy, supplemented by a progestogen for those women who have a uterus (J Clin Endocrinol Metab. 2015. doi: 10.1210/jc.2015-2236).

The discussion regarding treatment options should be grounded by a obtaining a baseline history of and assessing risk for cardiovascular disease (CVD) and breast cancer. “Menopause is a portal to the second half of life,” so clinicians should address bone health, smoking cessation, alcohol use, and cardiovascular and cancer risks and screening in their discussion, said Dr. Stuenkel.

The panel makes specific recommendations to tailor treatment depending on risk. For example, women at intermediate to high risk of breast cancer should be steered toward nonhormonal therapies to relieve VMS. Those at moderate risk of CVD can consider transdermal estradiol, while nonhormonal therapies are recommended for the high–CVD risk group.

The genitourinary symptoms of menopause (GSM) can include not just vulvovaginal atrophy but also urinary frequency and recurrent urinary tract infections, said Dr. Stuenkel, so the panel used the broader terminology to address estrogen’s effect on both organ systems.

An initial trial of vaginal moisturizers, used at least twice weekly, supplemented by lubricants as needed before sexual activity, should be the first-line treatment for GSM. For women with persistent symptoms and no history of estrogen-dependent cancers, low-dose vaginal estrogen therapy is a logical next step and does not require accompanying progestogen treatment, according to the guideline.

For women with symptomatic GSM who have had breast or endometrial cancer whose symptoms are not sufficiently treated by nonhormonal methods, low-dose vaginal estrogen is a consideration. This option should be considered with a shared decision-making approach that involves the patient’s oncologist.

Conjugated equine estrogens plus bazedoxefine, a novel selective estrogen receptor modulator (Duavee) can treat VMS and provide protection against bone loss, said the task force. The guideline recommends against the use of custom-compounded hormonal therapy and recommends the use of Food and Drug Administration–approved formulations. Ospemifene can be considered in women with significant dyspareunia and without contraindications, which include a history of breast cancer.

In conclusion, the guideline calls for ongoing rigorous study of the optimal agents and dosing for treatment of symptoms, how best to balance symptom relief with chronic disease prevention, and the merits of long-term hormone therapy beyond the period when symptomatic relief of VMS is needed. “International registries and clinical trials are overdue to address the long-reaching implications of these important issues,” said Dr. Stuenkel and coauthors of the guideline.

Dr. Stuenkel reported no relevant financial disclosures. Three task force members, Dr. Susan Davis, Dr. JoAnn Pinkerton, and Dr. Richard Santen, reported financial ties to pharmaceutical companies. Cosponsoring organizations included the Australasian Menopause Society, the British Menopause Society, European Menopause and Andropause Society, the European Society of Endocrinology, and the International Menopause Society.

[email protected]

On Twitter @karioakes

LAS VEGAS – Physicians looking for more options for alleviating dyspareunia in postmenopausal women should consider vaginal dilators, specialized vibrators, and pelvic floor physical therapy, according to Susan Kellogg Spadt, Ph.D.

These approaches can prevent or overcome some of the changes in the pelvic anatomy that can occur with menopause or with prolonged periods without sexual activity, Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said at the NAMS 2015 Annual Meeting.

Along with the topical atrophy that can occur with the low estrogen state of menopause, hypertonus and foreshortening of the pelvic floor muscles can occur in some postmenopausal women. Multiparous women may experience significant muscle laxity. Some women, especially those who may have gone without intercourse for prolonged periods, may also have vaginal stenosis. These can all present barriers to sexual health for women in midlife, she said.

Pelvic floor physical therapy, said Dr. Kellogg Spadt, is critical to help with all of these physical changes. Clinicians can find physical therapists certified in women’s health through the website of the American Physical Therapy Association (www.apta.org).

With the guidance of a physical therapist, women can learn about home use of a series of graduated vaginal dilators. Beginning with a smaller size, patients typically insert a dilator several times a week (up to daily) for 5-10 minutes, changing size every 2-3 weeks. During the changeover week, patients can start with the smaller size for 5 minutes and then change to the larger dilator for the second half of the session. This consistent, but gradual, approach is well tolerated and produces good results, she said.

Physical therapists may also use a pelvic wand, such as the Therawand, for women who have hypertonus of the pelvic musculature. This S-shaped acrylic wand is inserted into the vagina and provides direct internal pressure on the pubococcygeus and puborectalis muscles, facilitating trigger point release. Pelvic wands can be used in physical therapy sessions, but patients can also learn how to use the devices at home, Dr. Kellogg Spadt said.

Vibrators are another tool in addressing dyspareunia. The Intensity exerciser/vibrator is intended for therapeutic use as well as sexual pleasure. The device is powered by four AA batteries and is known to produce very intense orgasms with powerful pelvic muscle contractions. This might be deleterious and even painful for patients with an already tight pelvic floor, but it can be helpful for women with muscle laxity, Dr. Kellogg Spadt said. It can also be an important part of sex therapy for some women, “bringing orgasms to the orgasmless,” she said.

Another device option is Fiera, a small hands-free device that provides a low level of vibration to the clitoris and anterior vulva. It’s not designed to produce an orgasm, but to assist with arousal, so tissues are lubricated and engorged by the time the woman is ready to engage in partner sex play, she said.

Dr. Kellogg Stadt reported being a consultant to or on the advisory board of Neogyn and Nuelle, which markets Fiera. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – Physicians looking for more options for alleviating dyspareunia in postmenopausal women should consider vaginal dilators, specialized vibrators, and pelvic floor physical therapy, according to Susan Kellogg Spadt, Ph.D.

These approaches can prevent or overcome some of the changes in the pelvic anatomy that can occur with menopause or with prolonged periods without sexual activity, Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said at the NAMS 2015 Annual Meeting.

Along with the topical atrophy that can occur with the low estrogen state of menopause, hypertonus and foreshortening of the pelvic floor muscles can occur in some postmenopausal women. Multiparous women may experience significant muscle laxity. Some women, especially those who may have gone without intercourse for prolonged periods, may also have vaginal stenosis. These can all present barriers to sexual health for women in midlife, she said.

Pelvic floor physical therapy, said Dr. Kellogg Spadt, is critical to help with all of these physical changes. Clinicians can find physical therapists certified in women’s health through the website of the American Physical Therapy Association (www.apta.org).

With the guidance of a physical therapist, women can learn about home use of a series of graduated vaginal dilators. Beginning with a smaller size, patients typically insert a dilator several times a week (up to daily) for 5-10 minutes, changing size every 2-3 weeks. During the changeover week, patients can start with the smaller size for 5 minutes and then change to the larger dilator for the second half of the session. This consistent, but gradual, approach is well tolerated and produces good results, she said.

Physical therapists may also use a pelvic wand, such as the Therawand, for women who have hypertonus of the pelvic musculature. This S-shaped acrylic wand is inserted into the vagina and provides direct internal pressure on the pubococcygeus and puborectalis muscles, facilitating trigger point release. Pelvic wands can be used in physical therapy sessions, but patients can also learn how to use the devices at home, Dr. Kellogg Spadt said.

Vibrators are another tool in addressing dyspareunia. The Intensity exerciser/vibrator is intended for therapeutic use as well as sexual pleasure. The device is powered by four AA batteries and is known to produce very intense orgasms with powerful pelvic muscle contractions. This might be deleterious and even painful for patients with an already tight pelvic floor, but it can be helpful for women with muscle laxity, Dr. Kellogg Spadt said. It can also be an important part of sex therapy for some women, “bringing orgasms to the orgasmless,” she said.

Another device option is Fiera, a small hands-free device that provides a low level of vibration to the clitoris and anterior vulva. It’s not designed to produce an orgasm, but to assist with arousal, so tissues are lubricated and engorged by the time the woman is ready to engage in partner sex play, she said.

Dr. Kellogg Stadt reported being a consultant to or on the advisory board of Neogyn and Nuelle, which markets Fiera. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – Physicians looking for more options for alleviating dyspareunia in postmenopausal women should consider vaginal dilators, specialized vibrators, and pelvic floor physical therapy, according to Susan Kellogg Spadt, Ph.D.

These approaches can prevent or overcome some of the changes in the pelvic anatomy that can occur with menopause or with prolonged periods without sexual activity, Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said at the NAMS 2015 Annual Meeting.

Along with the topical atrophy that can occur with the low estrogen state of menopause, hypertonus and foreshortening of the pelvic floor muscles can occur in some postmenopausal women. Multiparous women may experience significant muscle laxity. Some women, especially those who may have gone without intercourse for prolonged periods, may also have vaginal stenosis. These can all present barriers to sexual health for women in midlife, she said.

Pelvic floor physical therapy, said Dr. Kellogg Spadt, is critical to help with all of these physical changes. Clinicians can find physical therapists certified in women’s health through the website of the American Physical Therapy Association (www.apta.org).

With the guidance of a physical therapist, women can learn about home use of a series of graduated vaginal dilators. Beginning with a smaller size, patients typically insert a dilator several times a week (up to daily) for 5-10 minutes, changing size every 2-3 weeks. During the changeover week, patients can start with the smaller size for 5 minutes and then change to the larger dilator for the second half of the session. This consistent, but gradual, approach is well tolerated and produces good results, she said.

Physical therapists may also use a pelvic wand, such as the Therawand, for women who have hypertonus of the pelvic musculature. This S-shaped acrylic wand is inserted into the vagina and provides direct internal pressure on the pubococcygeus and puborectalis muscles, facilitating trigger point release. Pelvic wands can be used in physical therapy sessions, but patients can also learn how to use the devices at home, Dr. Kellogg Spadt said.

Vibrators are another tool in addressing dyspareunia. The Intensity exerciser/vibrator is intended for therapeutic use as well as sexual pleasure. The device is powered by four AA batteries and is known to produce very intense orgasms with powerful pelvic muscle contractions. This might be deleterious and even painful for patients with an already tight pelvic floor, but it can be helpful for women with muscle laxity, Dr. Kellogg Spadt said. It can also be an important part of sex therapy for some women, “bringing orgasms to the orgasmless,” she said.

Another device option is Fiera, a small hands-free device that provides a low level of vibration to the clitoris and anterior vulva. It’s not designed to produce an orgasm, but to assist with arousal, so tissues are lubricated and engorged by the time the woman is ready to engage in partner sex play, she said.

Dr. Kellogg Stadt reported being a consultant to or on the advisory board of Neogyn and Nuelle, which markets Fiera. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – For postmenopausal women who don’t want a hormonal topical treatment, there are plenty of other nonhormonal options to ease the symptoms of vulvovaginal atrophy, according to Susan Kellogg Spadt, Ph.D.

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said many of these topical products are available over the counter.

Lubricants – a good first-line choice to decrease pain and increase pleasure during intercourse – are primarily designed to minimize friction and irritation around the clitoral area, the labia, and the introitus and vagina. They are meant to be applied immediately before sex play, on an as-needed basis, Dr. Kellogg Spadt said at the annual meeting of the North American Menopause Society.

“The take-home message: Apply to both partner’s genitals,” she said.

However, some of these products have been associated with significant contact dermatitis, often because of additives such as camphor or menthol that are intended to provide a warming or tingling sensation. When women experience contact dermatitis from these or other causes in the vulvovaginal region, Dr. Kellogg Spadt said, clinicians should recommend that they avoid overzealous hygiene and treat the tissues gently. They can use a neutral emollient such as Aquaphor and use sleep aids or antihistamines for sedation and comfort at night as needed for a few days.

Lubricants are hyperosmotic, hypo-osmotic, or iso-osmotic. Hypo-osmotic lubricants such as FemGlide and Slippery Stuff can reduce mucus production. Hyperosmotic lubricants such as Replens lubricant, KY, and Astroglide can be irritating for some users, though some of these products have devoted long-time users who have never had difficulty, said Dr. Kellogg Spadt. Pre-seed is an iso-osmotic lubricant designed especially for couples who are trying to conceive.

Vaginal moisturizers have a different mode of action. These products use bioadhesive polymers that attach to mucin and the epithelial cells on the vaginal wall. These products can carry up to 60 times their weight in water, and will leave the water in place on the vulvovaginal epithelial surface until the product is eventually sloughed off, Dr. Kellogg Spadt said.

Vaginal moisturizers are meant to be used regularly – not necessarily every day, but at least two or three times weekly. They do not need reapplication before intercourse. Though studies on the efficacy of these products have generally been lacking, Replens is a vaginal moisturizer that, in one study, was found to improve vulvovaginal health with findings of normalized vaginal cytology and a return to premenopausal vaginal pH (Fertil Steril. 1994 Jan;61[1]:178-80.).

These changes in the vaginal environment, said Dr. Kellogg Spadt, won’t treat yeast or bacterial vaginal infections, but they may help prevent recurrent infections.

Some vaginal moisturizers use hyaluronic acid, and one in particular, Hyalogyn, is 100% hyaluronic acid. This product has been found to be as efficacious as local estrogen in a randomized clinical trial (J Sex Med. 2013 Jun;10[6]:1575-84).

Juvagyn is a hybrid lubricant-moisturizer with hyaluronic acid that can be applied with a fingertip. This allows more selective application to the external structures, where much of the discomfort of intercourse can occur, Dr. Kellogg Spadt said. Most other products use an intravaginal applicator to deliver a premeasured amount.

Another option is Neogyn, which is marketed as an external vulvar soothing cream and is also meant to be applied to the introitus and external vulvar tissue. It has been shown to reduce vulvar pain significantly, she said.

For patients who still have pain despite these measures and desire to have intercourse, over-the-counter lidocaine gel can be used. Patients should be warned that the lidocaine – 1% topical gel is available over the counter – will burn on application before numbing. It should be washed off after intercourse, she said.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Nuelle and of Neogyn, which also markets Juvagyn. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – For postmenopausal women who don’t want a hormonal topical treatment, there are plenty of other nonhormonal options to ease the symptoms of vulvovaginal atrophy, according to Susan Kellogg Spadt, Ph.D.

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said many of these topical products are available over the counter.

Lubricants – a good first-line choice to decrease pain and increase pleasure during intercourse – are primarily designed to minimize friction and irritation around the clitoral area, the labia, and the introitus and vagina. They are meant to be applied immediately before sex play, on an as-needed basis, Dr. Kellogg Spadt said at the annual meeting of the North American Menopause Society.

“The take-home message: Apply to both partner’s genitals,” she said.

However, some of these products have been associated with significant contact dermatitis, often because of additives such as camphor or menthol that are intended to provide a warming or tingling sensation. When women experience contact dermatitis from these or other causes in the vulvovaginal region, Dr. Kellogg Spadt said, clinicians should recommend that they avoid overzealous hygiene and treat the tissues gently. They can use a neutral emollient such as Aquaphor and use sleep aids or antihistamines for sedation and comfort at night as needed for a few days.

Lubricants are hyperosmotic, hypo-osmotic, or iso-osmotic. Hypo-osmotic lubricants such as FemGlide and Slippery Stuff can reduce mucus production. Hyperosmotic lubricants such as Replens lubricant, KY, and Astroglide can be irritating for some users, though some of these products have devoted long-time users who have never had difficulty, said Dr. Kellogg Spadt. Pre-seed is an iso-osmotic lubricant designed especially for couples who are trying to conceive.

Vaginal moisturizers have a different mode of action. These products use bioadhesive polymers that attach to mucin and the epithelial cells on the vaginal wall. These products can carry up to 60 times their weight in water, and will leave the water in place on the vulvovaginal epithelial surface until the product is eventually sloughed off, Dr. Kellogg Spadt said.

Vaginal moisturizers are meant to be used regularly – not necessarily every day, but at least two or three times weekly. They do not need reapplication before intercourse. Though studies on the efficacy of these products have generally been lacking, Replens is a vaginal moisturizer that, in one study, was found to improve vulvovaginal health with findings of normalized vaginal cytology and a return to premenopausal vaginal pH (Fertil Steril. 1994 Jan;61[1]:178-80.).

These changes in the vaginal environment, said Dr. Kellogg Spadt, won’t treat yeast or bacterial vaginal infections, but they may help prevent recurrent infections.

Some vaginal moisturizers use hyaluronic acid, and one in particular, Hyalogyn, is 100% hyaluronic acid. This product has been found to be as efficacious as local estrogen in a randomized clinical trial (J Sex Med. 2013 Jun;10[6]:1575-84).

Juvagyn is a hybrid lubricant-moisturizer with hyaluronic acid that can be applied with a fingertip. This allows more selective application to the external structures, where much of the discomfort of intercourse can occur, Dr. Kellogg Spadt said. Most other products use an intravaginal applicator to deliver a premeasured amount.

Another option is Neogyn, which is marketed as an external vulvar soothing cream and is also meant to be applied to the introitus and external vulvar tissue. It has been shown to reduce vulvar pain significantly, she said.

For patients who still have pain despite these measures and desire to have intercourse, over-the-counter lidocaine gel can be used. Patients should be warned that the lidocaine – 1% topical gel is available over the counter – will burn on application before numbing. It should be washed off after intercourse, she said.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Nuelle and of Neogyn, which also markets Juvagyn. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – For postmenopausal women who don’t want a hormonal topical treatment, there are plenty of other nonhormonal options to ease the symptoms of vulvovaginal atrophy, according to Susan Kellogg Spadt, Ph.D.

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, said many of these topical products are available over the counter.

Lubricants – a good first-line choice to decrease pain and increase pleasure during intercourse – are primarily designed to minimize friction and irritation around the clitoral area, the labia, and the introitus and vagina. They are meant to be applied immediately before sex play, on an as-needed basis, Dr. Kellogg Spadt said at the annual meeting of the North American Menopause Society.

“The take-home message: Apply to both partner’s genitals,” she said.

However, some of these products have been associated with significant contact dermatitis, often because of additives such as camphor or menthol that are intended to provide a warming or tingling sensation. When women experience contact dermatitis from these or other causes in the vulvovaginal region, Dr. Kellogg Spadt said, clinicians should recommend that they avoid overzealous hygiene and treat the tissues gently. They can use a neutral emollient such as Aquaphor and use sleep aids or antihistamines for sedation and comfort at night as needed for a few days.

Lubricants are hyperosmotic, hypo-osmotic, or iso-osmotic. Hypo-osmotic lubricants such as FemGlide and Slippery Stuff can reduce mucus production. Hyperosmotic lubricants such as Replens lubricant, KY, and Astroglide can be irritating for some users, though some of these products have devoted long-time users who have never had difficulty, said Dr. Kellogg Spadt. Pre-seed is an iso-osmotic lubricant designed especially for couples who are trying to conceive.

Vaginal moisturizers have a different mode of action. These products use bioadhesive polymers that attach to mucin and the epithelial cells on the vaginal wall. These products can carry up to 60 times their weight in water, and will leave the water in place on the vulvovaginal epithelial surface until the product is eventually sloughed off, Dr. Kellogg Spadt said.

Vaginal moisturizers are meant to be used regularly – not necessarily every day, but at least two or three times weekly. They do not need reapplication before intercourse. Though studies on the efficacy of these products have generally been lacking, Replens is a vaginal moisturizer that, in one study, was found to improve vulvovaginal health with findings of normalized vaginal cytology and a return to premenopausal vaginal pH (Fertil Steril. 1994 Jan;61[1]:178-80.).

These changes in the vaginal environment, said Dr. Kellogg Spadt, won’t treat yeast or bacterial vaginal infections, but they may help prevent recurrent infections.

Some vaginal moisturizers use hyaluronic acid, and one in particular, Hyalogyn, is 100% hyaluronic acid. This product has been found to be as efficacious as local estrogen in a randomized clinical trial (J Sex Med. 2013 Jun;10[6]:1575-84).

Juvagyn is a hybrid lubricant-moisturizer with hyaluronic acid that can be applied with a fingertip. This allows more selective application to the external structures, where much of the discomfort of intercourse can occur, Dr. Kellogg Spadt said. Most other products use an intravaginal applicator to deliver a premeasured amount.

Another option is Neogyn, which is marketed as an external vulvar soothing cream and is also meant to be applied to the introitus and external vulvar tissue. It has been shown to reduce vulvar pain significantly, she said.

For patients who still have pain despite these measures and desire to have intercourse, over-the-counter lidocaine gel can be used. Patients should be warned that the lidocaine – 1% topical gel is available over the counter – will burn on application before numbing. It should be washed off after intercourse, she said.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Nuelle and of Neogyn, which also markets Juvagyn. She is also on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

This audiocast was recorded at the North American Menopause Society Annual Meeting held September 30 to October 3, 2015, in Las Vegas, Nevada

For more on this topic, read Dr. Kaunitz's August 2015 Cases in Menopause article, Is menopausal hormone therapy safe when your patient carries a BRCA mutation?

This audiocast was recorded at the North American Menopause Society Annual Meeting held September 30 to October 3, 2015, in Las Vegas, Nevada

For more on this topic, read Dr. Kaunitz's August 2015 Cases in Menopause article, Is menopausal hormone therapy safe when your patient carries a BRCA mutation?

This audiocast was recorded at the North American Menopause Society Annual Meeting held September 30 to October 3, 2015, in Las Vegas, Nevada

For more on this topic, read Dr. Kaunitz's August 2015 Cases in Menopause article, Is menopausal hormone therapy safe when your patient carries a BRCA mutation?

LAS VEGAS – Sleeplessness is both common and distressing for women in midlife, according to a new analysis of data from a large observational study.

One-third of women at all stages of the menopausal transition reported sleep disturbance that met the clinical criteria for insomnia, regardless of many markers of health and socioeconomic status, Colleen L. Ciano, Ph.D., reported at the NAMS 2015 annual meeting.

©Karen Winton/iStockphoto.com

Acute insomnia is prevalent in adults, and women are known to suffer more than men from chronic insomnia. Perimenopausal women, in particular, may have increased sleep disturbances.

Dr. Ciano, a postdoctoral fellow at the University of Pennsylvania, Philadelphia, and her colleagues used data from the large, longitudinal Study of Women’s Health Across the Nation (SWAN) to ascertain insomnia’s prevalence in perimenopausal and surgically menopausal women. Using SWAN study data, she also attempted to tease out factors that might increase a woman’s risk for chronic insomnia.

SWAN, said Dr. Ciano, was designed to examine the health of midlife women, gathering data from 3,302 women with a mean age of 45.9 years. Ten years of study data are now available from an ethnically diverse sample of women participating at seven sites across the United States.

Four questions from the SWAN questionnaire were identified for analysis as dependent variables. The questions related to trouble falling asleep, nighttime wakings, early-morning wakings, and a subjective rating of sleep quality over 2 weeks. Women were stratified into early or late menopause, or surgical menopause.

More than one-third of women at all stages of the midlife transition, or who were in surgical menopause, reported diagnosable insomnia. On the whole, insomnia increased for women over the study period. Waking after sleep onset also increased for perimenopausal women as they moved through menopause, from 26% to 36%. Sleep quality, as a bifurcated measure of sleep quality derived from a four-point scale, also dropped over the study period.

During the SWAN data collection period, the number of perimenopausal women who met at least one of the American Academy of Sleep Medicine criteria for insomnia rose from just over 30% to just over 40%, while the number of women who reported no insomnia symptoms fell steeply, dropping from just under 70% to approximately 50%.

When Dr. Ciano analyzed the prevalence of insomnia by perimenopausal stage, she found more insomnia in late-perimenopausal women (prevalence 31%-48%), compared with those in early menopause (31%-59%).

Women in late perimenopause had an odds ratio of 1.3 of reporting any symptom of insomnia, compared with those in early menopause, according to Dr. Ciano.

Women who were heavier, older, or depressed, as well as those having night sweats, were all more likely to suffer from insomnia on multivariable analysis (all P=0.002 or less). Factors that did not influence insomnia included marital status, tobacco or alcohol use, race/ethnicity, socioeconomic status, and many comorbidities including diabetes, hypertension, and cardiovascular disease.

Dr. Ciano advised clinicians to pay attention to these findings and initiate insomnia screenings. Routine evaluation of perimenopausal women should include careful questioning and an assessment of sleep patterns and problems. This is especially important since obesity, diabetes, and cardiovascular disease are all prevalent chronic illnesses that can be impacted by insomnia, she said.

Future studies should include physiologic measures and objective sleep data, which could be correlated with subjective reports, said Dr. Ciano. Sleep diaries can be an adjunct to observational and objective data, and can be correlated with such objective measures as endogenous hormone levels and objective vasomotor symptom monitoring.

Dr. Ciano’s research was supported by the National Institute for Nursing Research, Pennsylvana State University, and the Beta Sigma chapter of Sigma Theta Tau. She reported having no relevant financial disclosures.

[email protected]

On Twitter @karioakes

LAS VEGAS – Sleeplessness is both common and distressing for women in midlife, according to a new analysis of data from a large observational study.

One-third of women at all stages of the menopausal transition reported sleep disturbance that met the clinical criteria for insomnia, regardless of many markers of health and socioeconomic status, Colleen L. Ciano, Ph.D., reported at the NAMS 2015 annual meeting.

©Karen Winton/iStockphoto.com

Acute insomnia is prevalent in adults, and women are known to suffer more than men from chronic insomnia. Perimenopausal women, in particular, may have increased sleep disturbances.

Dr. Ciano, a postdoctoral fellow at the University of Pennsylvania, Philadelphia, and her colleagues used data from the large, longitudinal Study of Women’s Health Across the Nation (SWAN) to ascertain insomnia’s prevalence in perimenopausal and surgically menopausal women. Using SWAN study data, she also attempted to tease out factors that might increase a woman’s risk for chronic insomnia.

SWAN, said Dr. Ciano, was designed to examine the health of midlife women, gathering data from 3,302 women with a mean age of 45.9 years. Ten years of study data are now available from an ethnically diverse sample of women participating at seven sites across the United States.

Four questions from the SWAN questionnaire were identified for analysis as dependent variables. The questions related to trouble falling asleep, nighttime wakings, early-morning wakings, and a subjective rating of sleep quality over 2 weeks. Women were stratified into early or late menopause, or surgical menopause.

More than one-third of women at all stages of the midlife transition, or who were in surgical menopause, reported diagnosable insomnia. On the whole, insomnia increased for women over the study period. Waking after sleep onset also increased for perimenopausal women as they moved through menopause, from 26% to 36%. Sleep quality, as a bifurcated measure of sleep quality derived from a four-point scale, also dropped over the study period.

During the SWAN data collection period, the number of perimenopausal women who met at least one of the American Academy of Sleep Medicine criteria for insomnia rose from just over 30% to just over 40%, while the number of women who reported no insomnia symptoms fell steeply, dropping from just under 70% to approximately 50%.

When Dr. Ciano analyzed the prevalence of insomnia by perimenopausal stage, she found more insomnia in late-perimenopausal women (prevalence 31%-48%), compared with those in early menopause (31%-59%).

Women in late perimenopause had an odds ratio of 1.3 of reporting any symptom of insomnia, compared with those in early menopause, according to Dr. Ciano.

Women who were heavier, older, or depressed, as well as those having night sweats, were all more likely to suffer from insomnia on multivariable analysis (all P=0.002 or less). Factors that did not influence insomnia included marital status, tobacco or alcohol use, race/ethnicity, socioeconomic status, and many comorbidities including diabetes, hypertension, and cardiovascular disease.

Dr. Ciano advised clinicians to pay attention to these findings and initiate insomnia screenings. Routine evaluation of perimenopausal women should include careful questioning and an assessment of sleep patterns and problems. This is especially important since obesity, diabetes, and cardiovascular disease are all prevalent chronic illnesses that can be impacted by insomnia, she said.

Future studies should include physiologic measures and objective sleep data, which could be correlated with subjective reports, said Dr. Ciano. Sleep diaries can be an adjunct to observational and objective data, and can be correlated with such objective measures as endogenous hormone levels and objective vasomotor symptom monitoring.

Dr. Ciano’s research was supported by the National Institute for Nursing Research, Pennsylvana State University, and the Beta Sigma chapter of Sigma Theta Tau. She reported having no relevant financial disclosures.

[email protected]

On Twitter @karioakes

LAS VEGAS – Sleeplessness is both common and distressing for women in midlife, according to a new analysis of data from a large observational study.

One-third of women at all stages of the menopausal transition reported sleep disturbance that met the clinical criteria for insomnia, regardless of many markers of health and socioeconomic status, Colleen L. Ciano, Ph.D., reported at the NAMS 2015 annual meeting.

©Karen Winton/iStockphoto.com

Acute insomnia is prevalent in adults, and women are known to suffer more than men from chronic insomnia. Perimenopausal women, in particular, may have increased sleep disturbances.

Dr. Ciano, a postdoctoral fellow at the University of Pennsylvania, Philadelphia, and her colleagues used data from the large, longitudinal Study of Women’s Health Across the Nation (SWAN) to ascertain insomnia’s prevalence in perimenopausal and surgically menopausal women. Using SWAN study data, she also attempted to tease out factors that might increase a woman’s risk for chronic insomnia.

SWAN, said Dr. Ciano, was designed to examine the health of midlife women, gathering data from 3,302 women with a mean age of 45.9 years. Ten years of study data are now available from an ethnically diverse sample of women participating at seven sites across the United States.

Four questions from the SWAN questionnaire were identified for analysis as dependent variables. The questions related to trouble falling asleep, nighttime wakings, early-morning wakings, and a subjective rating of sleep quality over 2 weeks. Women were stratified into early or late menopause, or surgical menopause.

More than one-third of women at all stages of the midlife transition, or who were in surgical menopause, reported diagnosable insomnia. On the whole, insomnia increased for women over the study period. Waking after sleep onset also increased for perimenopausal women as they moved through menopause, from 26% to 36%. Sleep quality, as a bifurcated measure of sleep quality derived from a four-point scale, also dropped over the study period.

During the SWAN data collection period, the number of perimenopausal women who met at least one of the American Academy of Sleep Medicine criteria for insomnia rose from just over 30% to just over 40%, while the number of women who reported no insomnia symptoms fell steeply, dropping from just under 70% to approximately 50%.

When Dr. Ciano analyzed the prevalence of insomnia by perimenopausal stage, she found more insomnia in late-perimenopausal women (prevalence 31%-48%), compared with those in early menopause (31%-59%).

Women in late perimenopause had an odds ratio of 1.3 of reporting any symptom of insomnia, compared with those in early menopause, according to Dr. Ciano.

Women who were heavier, older, or depressed, as well as those having night sweats, were all more likely to suffer from insomnia on multivariable analysis (all P=0.002 or less). Factors that did not influence insomnia included marital status, tobacco or alcohol use, race/ethnicity, socioeconomic status, and many comorbidities including diabetes, hypertension, and cardiovascular disease.

Dr. Ciano advised clinicians to pay attention to these findings and initiate insomnia screenings. Routine evaluation of perimenopausal women should include careful questioning and an assessment of sleep patterns and problems. This is especially important since obesity, diabetes, and cardiovascular disease are all prevalent chronic illnesses that can be impacted by insomnia, she said.

Future studies should include physiologic measures and objective sleep data, which could be correlated with subjective reports, said Dr. Ciano. Sleep diaries can be an adjunct to observational and objective data, and can be correlated with such objective measures as endogenous hormone levels and objective vasomotor symptom monitoring.

Dr. Ciano’s research was supported by the National Institute for Nursing Research, Pennsylvana State University, and the Beta Sigma chapter of Sigma Theta Tau. She reported having no relevant financial disclosures.

[email protected]

On Twitter @karioakes

LAS VEGAS – The first step is to ask. A menopausal woman may be struggling with a female sexual disorder (FSD), but unless her clinician asks, the patient may never volunteer information about her sexual health.

Susan Kellogg Spadt, Ph.D., offered that advice, along with a toolkit of tips, treatments, and pearls for physicians and others caring for the menopausal woman’s sexual health.

Clever Cupcakes/Flickr/CC BY-SA 2.0/No changes

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, addressed FSD in the context of the complicated psychosocial landscape of midlife.

Women at this stage of life may be experiencing life stress as children move out, retirement looms, and aging parents require time and attention. Also, as women age, they are more likely to require medications that can negatively affect sexual health. Body image issues, depression, anxiety, and discrepancy with partner desire levels can all be prevalent in women aged 45-64 years, the group most likely to experience distress from sexual problems, she said at the NAMS 2015 annual meeting.

This is important in the context of a relationship, said Dr. Kellogg Spadt. She pointed out that “when sex is good, it adds a little bit – like icing on the cupcake – to a good relationship.” But when sex is bad or nonexistent, she said, it plays an inordinately negative role, reducing the quality of the relationship by 50%-70% in some studies.

Dr. Kellogg Spadt said a good opening approach should confirm the ubiquity of sexual problems in midlife and normalize concerns. Clinicians can ask: “With menopause, many women have changes in their sexual response. These concerns are very common. Tell me – are you feeling well and complete in your sex life?”

If questioning reveals unsatisfying or nonexistent sex, many problems can be addressed in the office. First, careful questioning and an exam can tease out the extent to which dyspareunia and vaginal dryness may be limiting sexual pleasure. In that case, lubricants, moisturizers, and topical estrogen can be considered.

Office sessions with physical therapists certified in pelvic issues, combined with home use of dilators, can help overcome physical contributors to an uncomfortable sexual experience, she said.

Clinicians can also provide brief office-based counseling using the “PLISSIT” model, which. gives permission for the patient to speak openly about sexual issues; provides limited information to educate the patient about her anatomy and resources available; offers specific suggestions, for example, positioning tips or moisturizer recommendations; and offers intensive therapy, when indicated, such as referring for adjunctive psychotherapy.

Dr. Kellogg Stadt concluded with her top clinical pearls for sexual health in menopausal women:

• Add moisture daily. Using a water-based, bioadhesive lubricant several times a week regardless of sexual frequency can significantly ease comfort and satisfaction with sex and make it easier to have an orgasm.

• Nourish. A Mediterranean diet has been shown to promote sexual function, and regular exercise improves mood and overall health.

• Talk. Partners can use “I” language to talk about sex honestly and in a nonaccusatory way. Clinicians can help provide the vocabulary and communication tips to facilitate this.

• Prioritize pleasure. Intimate time together won’t just happen; even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex.

• Think. Reading or watching erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important.

• Stimulate. After menopause, some women need more intense stimulation to reach orgasm, so vibrators can be incorporated into sex play. Women who are uncomfortable with this can use the “doctor’s orders” approach with their partners.

• Try. Just opening up and talking about sex problems shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Neogyn and Nuelle, and on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – The first step is to ask. A menopausal woman may be struggling with a female sexual disorder (FSD), but unless her clinician asks, the patient may never volunteer information about her sexual health.

Susan Kellogg Spadt, Ph.D., offered that advice, along with a toolkit of tips, treatments, and pearls for physicians and others caring for the menopausal woman’s sexual health.

Clever Cupcakes/Flickr/CC BY-SA 2.0/No changes

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, addressed FSD in the context of the complicated psychosocial landscape of midlife.

Women at this stage of life may be experiencing life stress as children move out, retirement looms, and aging parents require time and attention. Also, as women age, they are more likely to require medications that can negatively affect sexual health. Body image issues, depression, anxiety, and discrepancy with partner desire levels can all be prevalent in women aged 45-64 years, the group most likely to experience distress from sexual problems, she said at the NAMS 2015 annual meeting.

This is important in the context of a relationship, said Dr. Kellogg Spadt. She pointed out that “when sex is good, it adds a little bit – like icing on the cupcake – to a good relationship.” But when sex is bad or nonexistent, she said, it plays an inordinately negative role, reducing the quality of the relationship by 50%-70% in some studies.

Dr. Kellogg Spadt said a good opening approach should confirm the ubiquity of sexual problems in midlife and normalize concerns. Clinicians can ask: “With menopause, many women have changes in their sexual response. These concerns are very common. Tell me – are you feeling well and complete in your sex life?”

If questioning reveals unsatisfying or nonexistent sex, many problems can be addressed in the office. First, careful questioning and an exam can tease out the extent to which dyspareunia and vaginal dryness may be limiting sexual pleasure. In that case, lubricants, moisturizers, and topical estrogen can be considered.

Office sessions with physical therapists certified in pelvic issues, combined with home use of dilators, can help overcome physical contributors to an uncomfortable sexual experience, she said.

Clinicians can also provide brief office-based counseling using the “PLISSIT” model, which. gives permission for the patient to speak openly about sexual issues; provides limited information to educate the patient about her anatomy and resources available; offers specific suggestions, for example, positioning tips or moisturizer recommendations; and offers intensive therapy, when indicated, such as referring for adjunctive psychotherapy.

Dr. Kellogg Stadt concluded with her top clinical pearls for sexual health in menopausal women:

• Add moisture daily. Using a water-based, bioadhesive lubricant several times a week regardless of sexual frequency can significantly ease comfort and satisfaction with sex and make it easier to have an orgasm.

• Nourish. A Mediterranean diet has been shown to promote sexual function, and regular exercise improves mood and overall health.

• Talk. Partners can use “I” language to talk about sex honestly and in a nonaccusatory way. Clinicians can help provide the vocabulary and communication tips to facilitate this.

• Prioritize pleasure. Intimate time together won’t just happen; even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex.

• Think. Reading or watching erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important.

• Stimulate. After menopause, some women need more intense stimulation to reach orgasm, so vibrators can be incorporated into sex play. Women who are uncomfortable with this can use the “doctor’s orders” approach with their partners.

• Try. Just opening up and talking about sex problems shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Neogyn and Nuelle, and on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

LAS VEGAS – The first step is to ask. A menopausal woman may be struggling with a female sexual disorder (FSD), but unless her clinician asks, the patient may never volunteer information about her sexual health.

Susan Kellogg Spadt, Ph.D., offered that advice, along with a toolkit of tips, treatments, and pearls for physicians and others caring for the menopausal woman’s sexual health.

Clever Cupcakes/Flickr/CC BY-SA 2.0/No changes

Dr. Kellogg Spadt, a certified sexual counselor and professor of obstetrics and gynecology at Drexel University, Philadelphia, addressed FSD in the context of the complicated psychosocial landscape of midlife.

Women at this stage of life may be experiencing life stress as children move out, retirement looms, and aging parents require time and attention. Also, as women age, they are more likely to require medications that can negatively affect sexual health. Body image issues, depression, anxiety, and discrepancy with partner desire levels can all be prevalent in women aged 45-64 years, the group most likely to experience distress from sexual problems, she said at the NAMS 2015 annual meeting.

This is important in the context of a relationship, said Dr. Kellogg Spadt. She pointed out that “when sex is good, it adds a little bit – like icing on the cupcake – to a good relationship.” But when sex is bad or nonexistent, she said, it plays an inordinately negative role, reducing the quality of the relationship by 50%-70% in some studies.

Dr. Kellogg Spadt said a good opening approach should confirm the ubiquity of sexual problems in midlife and normalize concerns. Clinicians can ask: “With menopause, many women have changes in their sexual response. These concerns are very common. Tell me – are you feeling well and complete in your sex life?”

If questioning reveals unsatisfying or nonexistent sex, many problems can be addressed in the office. First, careful questioning and an exam can tease out the extent to which dyspareunia and vaginal dryness may be limiting sexual pleasure. In that case, lubricants, moisturizers, and topical estrogen can be considered.

Office sessions with physical therapists certified in pelvic issues, combined with home use of dilators, can help overcome physical contributors to an uncomfortable sexual experience, she said.

Clinicians can also provide brief office-based counseling using the “PLISSIT” model, which. gives permission for the patient to speak openly about sexual issues; provides limited information to educate the patient about her anatomy and resources available; offers specific suggestions, for example, positioning tips or moisturizer recommendations; and offers intensive therapy, when indicated, such as referring for adjunctive psychotherapy.

Dr. Kellogg Stadt concluded with her top clinical pearls for sexual health in menopausal women:

• Add moisture daily. Using a water-based, bioadhesive lubricant several times a week regardless of sexual frequency can significantly ease comfort and satisfaction with sex and make it easier to have an orgasm.

• Nourish. A Mediterranean diet has been shown to promote sexual function, and regular exercise improves mood and overall health.

• Talk. Partners can use “I” language to talk about sex honestly and in a nonaccusatory way. Clinicians can help provide the vocabulary and communication tips to facilitate this.

• Prioritize pleasure. Intimate time together won’t just happen; even a 20-minute block of time, scheduled weekly, for touching and intimate conversation can clear the way to better sex.

• Think. Reading or watching erotica, being mindful of erotic thoughts as they occur, and focusing on sensation rather than distractions during arousal are all important.

• Stimulate. After menopause, some women need more intense stimulation to reach orgasm, so vibrators can be incorporated into sex play. Women who are uncomfortable with this can use the “doctor’s orders” approach with their partners.

• Try. Just opening up and talking about sex problems shows that a woman is committed to her partner, and taking action shows her level of care and concern for the relationship.

Dr. Kellogg Stadt reported being a consultant or on the advisory board of Neogyn and Nuelle, and on the speakers bureau of Novo Nordisk and Shionogi.

[email protected]

On Twitter @karioakes

Clinicians work to maximize the quality of life and longevity of every patient. For women with moderate to severe menopausal symptoms, oral estrogen therapy can improve quality of life, but at the cost of significant adverse effects. The Women’s Health Initiative
 (WHI) reported that for postmenopausal women with a uterus, 
conjugated estrogen plus medroxyprogesterone acetate (CEE+MPA) hormone therapy (HT) versus placebo 
significantly increased the risk of 
cardiovascular events (relative risk 
[RR], 1.13), breast cancer (RR, 1.24), 
stroke (RR, 1.37), deep vein thrombosis (RR, 1.87), and pulmonary 
embolism (RR, 1.98).¹ In postmeno
pausal women without a uterus, CEE 
HT did not increase the risk of breast 
cancer (RR, 0.79), compared with 
placebo, but it did significantly in
crease the risk of cardiovascular 
events (RR, 1.11), stroke (RR, 1.35), 
deep vein thrombosis (RR, 1.48), and 
pulmonary embolism (RR, 1.35).¹

Clinicians prescribing estrogen must individualize therapy according
 to its benefits and risks. An important issue that has received insufficient at
tention is, “What is the effect of HT 
on mortality in recently menopausal women?” Here, I examine this issue.

HT reduces mortality in 
recently menopausal women

Pooling the results of the WHI CEE+MPA and CEE-only trials 
reveals that there were 70 deaths in the HT-treated groups and 98 deaths in the placebo groups among women aged 50 to 59 years.¹ With 4,706 and 4,259 women alive at the conclusion of the study in the HT and placebo groups, respectively, the women in the placebo group had significantly more deaths than the women in the HT-treated groups (Fisher exact test, P = .0194, χ² test with Yates correction, P = .0226).

Using pooled data from the WHI, the RR of death in the HT versus placebo group was estimated at 0.70 (95% confidence interval [CI], 0.51−0.96), representing approximately 5 fewer deaths per 
1,000 women per 5 years of therapy.² In women aged 60 to 69 years and 70 to 79 years there were no significant differences in death rates between the HT- and placebo-treated women.

My interpretation of these results is that HT likely is associated with a reduced risk of death in recently menopausal women, but not in 
women distant from menopause onset.

Cochrane review of 
HT and mortality

Consistent with the WHI findings, authors of a recent Cochrane 
meta-analysis of 19 randomized trials including 40,410 menopausal women reported that HT significantly increased the risk of stroke (RR, 1.24; 95% CI, 1.10−1.41), venous thromboembolism (RR, 1.92; 95% CI, 1.36−2.69), and pulmonary emboli (RR, 1.81; 95% CI, 1.32−2.48).³ However, among women treated with oral HT within 10 years after the start of menopause, there was a reduced risk of coronary heart disease (RR, 0.52; 95% CI, 0.29−0.96). Using data from 5 clinical trials, the Cochrane meta-analysis researchers reported that, compared with placebo, HT reduced mortality (RR, 0.70; 95% CI, 0.52−0.95).³

Results of the Cochrane meta-analysis are consistent with those of a previous meta-analysis of 
19 randomized trials involving 16,000 women. In this analysis, investigators found a reduced risk of death in recently menopausal women treated with hormone therapy (RR, 0.73; 95% CI, 0.52−0.96).⁴

Early menopause, 
HT, and mortality

Authors of multiple large epidemiologic studies have reported that early menopause is associated with an increased risk of death if HT is not initiated.⁵⁻⁷ For example, results of a study of women in Olmsted County, Minnesota, conducted from 1950 to 1987, indicated that, for women younger than age 45 years who underwent bilateral oophorectomy, the risk of death was increased among those who did not initiate HT, compared with women who did not undergo oophorectomy (hazard ratio [HR], 1.84; 95% CI, 1.27−2.68; 
P = .001).⁷

By contrast, women younger than 45 years who underwent bilateral oophorectomy and initiated estrogen therapy did not have an increased risk of death compared with women who did not undergo oophorectomy (HR, 0.65; 95% CI, 0.30−1.41; P = .28).⁷ An excess number of cardiovascular events appeared to account for the increased mortality among women with early surgical menopause who did not initiate HT.

The “timing hypothesis” proposes that the initiation of HT soon after the onset of menopause is associated with beneficial cardiovascular effects, but initiation more than 10 years after the onset of menopause is not associated with beneficial cardiovascular effects. The timing hypothesis is supported by the finding that, in recently menopausal women, HT is associated with reduced carotid intima-media thickness (CIMT), compared with placebo.⁸ Greater CIMT thickness is associated with an increased risk of cardiovascular events.

In my experience, few primary care clinicians are aware of these data. Often, these clinicians over-emphasize the risks and withhold HT in this vulnerable group of women.

HT: Minimizing the risks 
of stroke, deep vein thrombosis, pulmonary embolism, and 
breast cancer

Results of multiple studies have shown that certain HT regimens increase the risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Is it possible to prescribe HT in a way that reduces these risks?

Results of observational studies indicate that, compared with oral estrogen therapy, transdermal HT is associated with a lower risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer 
(TABLE).⁹⁻¹⁵

Reducing the risk of stroke caused by HT is an important goal. In a study of 15,710 women who had stroke and 59,958 control women aged 50 to 79 years, transdermal estradiol at a dose of 50 µg or less daily was not associated with an increased risk of stroke, compared with HT nonuse (rate ratio, 0.81; 95% CI, 0.62−1.05).⁹ Compared with HT nonuse, the use of oral estrogen (rate ratio, 1.28; 95% CI, 1.15−1.42) or transdermal estradiol 50 µg or greater daily (rate ratio, 1.89; 95% CI, 1.15−3.11) was associated with an increased risk of stroke.⁹

Reducing the risks of deep venous thromboembolism (VTE) and pulmonary embolism caused by HT is an important goal. In a meta-analysis of the risk of VTE with HT, compared with nonusers, oral estrogen therapy was associated with a significantly increased risk of VTE (odds ratio [OR], 2.5; 95% CI, 1.9−3.4). Compared with nonuse, transdermal estrogen therapy was not associated with an increased risk of VTE (OR, 1.2; 95% CI, 0.9−1.7).¹¹ In a study comparing oral versus transdermal estradiol, transdermal estradiol was associated with a reduced risk of pulmonary embolism (0.46 [95% CI, 0.22−0.97]).¹³

Reducing the risk of breast cancer caused by HT is an important goal. Results of one study showed that the combination of oral estrogen plus synthetic progestin was associated with an increased risk of breast cancer, compared with nonuse (RR, 1.5; 95% CI, 1.1−1.9). By contrast, the combination of transdermal estradiol plus micronized progesterone was not associated with an increased risk of breast cancer, compared with nonuse (RR, 0.9; 95% CI, 0.7−1.2).¹⁵

INSTANT POLL
Many health insurers use pharmacy benefit managers to control the cost of prescription medicines. These managers often develop formulary algorithms that favor the use of oral estrogen and medroxyprogesterone acetate over transdermal estradiol and micronized progesterone. When you prescribe transdermal estradiol and micronized progesterone, have your patients had difficulty filling the prescription?

Tell us! Send your Letter to the Editor!

The bottom line

In recently menopausal women with moderate to severe hot flashes, HT improves quality of life and appears to decrease mortality. However, HT with oral estrogen plus synthetic progestin is associated with an increased risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Compared with oral estrogen, transdermal estradiol treatment is associated with a lower risk of stroke, deep vein thrombosis, and pulmonary embolism. Compared with oral estrogen plus a synthetic progestin, transdermal estradiol plus micronized progesterone is associated with a lower risk of breast cancer. The benefits of HT are likely maximized by initiating therapy in the perimenopause transition or early in the postmenopause, and the risks are minimized by using transdermal estradiol.¹⁶⁻¹⁸

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Clinicians work to maximize the quality of life and longevity of every patient. For women with moderate to severe menopausal symptoms, oral estrogen therapy can improve quality of life, but at the cost of significant adverse effects. The Women’s Health Initiative
 (WHI) reported that for postmenopausal women with a uterus, 
conjugated estrogen plus medroxyprogesterone acetate (CEE+MPA) hormone therapy (HT) versus placebo 
significantly increased the risk of 
cardiovascular events (relative risk 
[RR], 1.13), breast cancer (RR, 1.24), 
stroke (RR, 1.37), deep vein thrombosis (RR, 1.87), and pulmonary 
embolism (RR, 1.98).¹ In postmeno
pausal women without a uterus, CEE 
HT did not increase the risk of breast 
cancer (RR, 0.79), compared with 
placebo, but it did significantly in
crease the risk of cardiovascular 
events (RR, 1.11), stroke (RR, 1.35), 
deep vein thrombosis (RR, 1.48), and 
pulmonary embolism (RR, 1.35).¹

Clinicians prescribing estrogen must individualize therapy according
 to its benefits and risks. An important issue that has received insufficient at
tention is, “What is the effect of HT 
on mortality in recently menopausal women?” Here, I examine this issue.

HT reduces mortality in 
recently menopausal women

Pooling the results of the WHI CEE+MPA and CEE-only trials 
reveals that there were 70 deaths in the HT-treated groups and 98 deaths in the placebo groups among women aged 50 to 59 years.¹ With 4,706 and 4,259 women alive at the conclusion of the study in the HT and placebo groups, respectively, the women in the placebo group had significantly more deaths than the women in the HT-treated groups (Fisher exact test, P = .0194, χ² test with Yates correction, P = .0226).

Using pooled data from the WHI, the RR of death in the HT versus placebo group was estimated at 0.70 (95% confidence interval [CI], 0.51−0.96), representing approximately 5 fewer deaths per 
1,000 women per 5 years of therapy.² In women aged 60 to 69 years and 70 to 79 years there were no significant differences in death rates between the HT- and placebo-treated women.

My interpretation of these results is that HT likely is associated with a reduced risk of death in recently menopausal women, but not in 
women distant from menopause onset.

Cochrane review of 
HT and mortality

Consistent with the WHI findings, authors of a recent Cochrane 
meta-analysis of 19 randomized trials including 40,410 menopausal women reported that HT significantly increased the risk of stroke (RR, 1.24; 95% CI, 1.10−1.41), venous thromboembolism (RR, 1.92; 95% CI, 1.36−2.69), and pulmonary emboli (RR, 1.81; 95% CI, 1.32−2.48).³ However, among women treated with oral HT within 10 years after the start of menopause, there was a reduced risk of coronary heart disease (RR, 0.52; 95% CI, 0.29−0.96). Using data from 5 clinical trials, the Cochrane meta-analysis researchers reported that, compared with placebo, HT reduced mortality (RR, 0.70; 95% CI, 0.52−0.95).³

Results of the Cochrane meta-analysis are consistent with those of a previous meta-analysis of 
19 randomized trials involving 16,000 women. In this analysis, investigators found a reduced risk of death in recently menopausal women treated with hormone therapy (RR, 0.73; 95% CI, 0.52−0.96).⁴

Early menopause, 
HT, and mortality

Authors of multiple large epidemiologic studies have reported that early menopause is associated with an increased risk of death if HT is not initiated.⁵⁻⁷ For example, results of a study of women in Olmsted County, Minnesota, conducted from 1950 to 1987, indicated that, for women younger than age 45 years who underwent bilateral oophorectomy, the risk of death was increased among those who did not initiate HT, compared with women who did not undergo oophorectomy (hazard ratio [HR], 1.84; 95% CI, 1.27−2.68; 
P = .001).⁷

By contrast, women younger than 45 years who underwent bilateral oophorectomy and initiated estrogen therapy did not have an increased risk of death compared with women who did not undergo oophorectomy (HR, 0.65; 95% CI, 0.30−1.41; P = .28).⁷ An excess number of cardiovascular events appeared to account for the increased mortality among women with early surgical menopause who did not initiate HT.

The “timing hypothesis” proposes that the initiation of HT soon after the onset of menopause is associated with beneficial cardiovascular effects, but initiation more than 10 years after the onset of menopause is not associated with beneficial cardiovascular effects. The timing hypothesis is supported by the finding that, in recently menopausal women, HT is associated with reduced carotid intima-media thickness (CIMT), compared with placebo.⁸ Greater CIMT thickness is associated with an increased risk of cardiovascular events.

In my experience, few primary care clinicians are aware of these data. Often, these clinicians over-emphasize the risks and withhold HT in this vulnerable group of women.

HT: Minimizing the risks 
of stroke, deep vein thrombosis, pulmonary embolism, and 
breast cancer

Results of multiple studies have shown that certain HT regimens increase the risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Is it possible to prescribe HT in a way that reduces these risks?

Results of observational studies indicate that, compared with oral estrogen therapy, transdermal HT is associated with a lower risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer 
(TABLE).⁹⁻¹⁵

Reducing the risk of stroke caused by HT is an important goal. In a study of 15,710 women who had stroke and 59,958 control women aged 50 to 79 years, transdermal estradiol at a dose of 50 µg or less daily was not associated with an increased risk of stroke, compared with HT nonuse (rate ratio, 0.81; 95% CI, 0.62−1.05).⁹ Compared with HT nonuse, the use of oral estrogen (rate ratio, 1.28; 95% CI, 1.15−1.42) or transdermal estradiol 50 µg or greater daily (rate ratio, 1.89; 95% CI, 1.15−3.11) was associated with an increased risk of stroke.⁹

Reducing the risks of deep venous thromboembolism (VTE) and pulmonary embolism caused by HT is an important goal. In a meta-analysis of the risk of VTE with HT, compared with nonusers, oral estrogen therapy was associated with a significantly increased risk of VTE (odds ratio [OR], 2.5; 95% CI, 1.9−3.4). Compared with nonuse, transdermal estrogen therapy was not associated with an increased risk of VTE (OR, 1.2; 95% CI, 0.9−1.7).¹¹ In a study comparing oral versus transdermal estradiol, transdermal estradiol was associated with a reduced risk of pulmonary embolism (0.46 [95% CI, 0.22−0.97]).¹³

Reducing the risk of breast cancer caused by HT is an important goal. Results of one study showed that the combination of oral estrogen plus synthetic progestin was associated with an increased risk of breast cancer, compared with nonuse (RR, 1.5; 95% CI, 1.1−1.9). By contrast, the combination of transdermal estradiol plus micronized progesterone was not associated with an increased risk of breast cancer, compared with nonuse (RR, 0.9; 95% CI, 0.7−1.2).¹⁵

INSTANT POLL
Many health insurers use pharmacy benefit managers to control the cost of prescription medicines. These managers often develop formulary algorithms that favor the use of oral estrogen and medroxyprogesterone acetate over transdermal estradiol and micronized progesterone. When you prescribe transdermal estradiol and micronized progesterone, have your patients had difficulty filling the prescription?

Tell us! Send your Letter to the Editor!

The bottom line

In recently menopausal women with moderate to severe hot flashes, HT improves quality of life and appears to decrease mortality. However, HT with oral estrogen plus synthetic progestin is associated with an increased risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Compared with oral estrogen, transdermal estradiol treatment is associated with a lower risk of stroke, deep vein thrombosis, and pulmonary embolism. Compared with oral estrogen plus a synthetic progestin, transdermal estradiol plus micronized progesterone is associated with a lower risk of breast cancer. The benefits of HT are likely maximized by initiating therapy in the perimenopause transition or early in the postmenopause, and the risks are minimized by using transdermal estradiol.¹⁶⁻¹⁸

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Clinicians work to maximize the quality of life and longevity of every patient. For women with moderate to severe menopausal symptoms, oral estrogen therapy can improve quality of life, but at the cost of significant adverse effects. The Women’s Health Initiative
 (WHI) reported that for postmenopausal women with a uterus, 
conjugated estrogen plus medroxyprogesterone acetate (CEE+MPA) hormone therapy (HT) versus placebo 
significantly increased the risk of 
cardiovascular events (relative risk 
[RR], 1.13), breast cancer (RR, 1.24), 
stroke (RR, 1.37), deep vein thrombosis (RR, 1.87), and pulmonary 
embolism (RR, 1.98).¹ In postmeno
pausal women without a uterus, CEE 
HT did not increase the risk of breast 
cancer (RR, 0.79), compared with 
placebo, but it did significantly in
crease the risk of cardiovascular 
events (RR, 1.11), stroke (RR, 1.35), 
deep vein thrombosis (RR, 1.48), and 
pulmonary embolism (RR, 1.35).¹

Clinicians prescribing estrogen must individualize therapy according
 to its benefits and risks. An important issue that has received insufficient at
tention is, “What is the effect of HT 
on mortality in recently menopausal women?” Here, I examine this issue.

HT reduces mortality in 
recently menopausal women

Pooling the results of the WHI CEE+MPA and CEE-only trials 
reveals that there were 70 deaths in the HT-treated groups and 98 deaths in the placebo groups among women aged 50 to 59 years.¹ With 4,706 and 4,259 women alive at the conclusion of the study in the HT and placebo groups, respectively, the women in the placebo group had significantly more deaths than the women in the HT-treated groups (Fisher exact test, P = .0194, χ² test with Yates correction, P = .0226).

Using pooled data from the WHI, the RR of death in the HT versus placebo group was estimated at 0.70 (95% confidence interval [CI], 0.51−0.96), representing approximately 5 fewer deaths per 
1,000 women per 5 years of therapy.² In women aged 60 to 69 years and 70 to 79 years there were no significant differences in death rates between the HT- and placebo-treated women.

My interpretation of these results is that HT likely is associated with a reduced risk of death in recently menopausal women, but not in 
women distant from menopause onset.

Cochrane review of 
HT and mortality

Consistent with the WHI findings, authors of a recent Cochrane 
meta-analysis of 19 randomized trials including 40,410 menopausal women reported that HT significantly increased the risk of stroke (RR, 1.24; 95% CI, 1.10−1.41), venous thromboembolism (RR, 1.92; 95% CI, 1.36−2.69), and pulmonary emboli (RR, 1.81; 95% CI, 1.32−2.48).³ However, among women treated with oral HT within 10 years after the start of menopause, there was a reduced risk of coronary heart disease (RR, 0.52; 95% CI, 0.29−0.96). Using data from 5 clinical trials, the Cochrane meta-analysis researchers reported that, compared with placebo, HT reduced mortality (RR, 0.70; 95% CI, 0.52−0.95).³

Results of the Cochrane meta-analysis are consistent with those of a previous meta-analysis of 
19 randomized trials involving 16,000 women. In this analysis, investigators found a reduced risk of death in recently menopausal women treated with hormone therapy (RR, 0.73; 95% CI, 0.52−0.96).⁴

Early menopause, 
HT, and mortality

Authors of multiple large epidemiologic studies have reported that early menopause is associated with an increased risk of death if HT is not initiated.⁵⁻⁷ For example, results of a study of women in Olmsted County, Minnesota, conducted from 1950 to 1987, indicated that, for women younger than age 45 years who underwent bilateral oophorectomy, the risk of death was increased among those who did not initiate HT, compared with women who did not undergo oophorectomy (hazard ratio [HR], 1.84; 95% CI, 1.27−2.68; 
P = .001).⁷

By contrast, women younger than 45 years who underwent bilateral oophorectomy and initiated estrogen therapy did not have an increased risk of death compared with women who did not undergo oophorectomy (HR, 0.65; 95% CI, 0.30−1.41; P = .28).⁷ An excess number of cardiovascular events appeared to account for the increased mortality among women with early surgical menopause who did not initiate HT.

The “timing hypothesis” proposes that the initiation of HT soon after the onset of menopause is associated with beneficial cardiovascular effects, but initiation more than 10 years after the onset of menopause is not associated with beneficial cardiovascular effects. The timing hypothesis is supported by the finding that, in recently menopausal women, HT is associated with reduced carotid intima-media thickness (CIMT), compared with placebo.⁸ Greater CIMT thickness is associated with an increased risk of cardiovascular events.

In my experience, few primary care clinicians are aware of these data. Often, these clinicians over-emphasize the risks and withhold HT in this vulnerable group of women.

HT: Minimizing the risks 
of stroke, deep vein thrombosis, pulmonary embolism, and 
breast cancer

Results of multiple studies have shown that certain HT regimens increase the risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Is it possible to prescribe HT in a way that reduces these risks?

Results of observational studies indicate that, compared with oral estrogen therapy, transdermal HT is associated with a lower risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer 
(TABLE).⁹⁻¹⁵

Reducing the risk of stroke caused by HT is an important goal. In a study of 15,710 women who had stroke and 59,958 control women aged 50 to 79 years, transdermal estradiol at a dose of 50 µg or less daily was not associated with an increased risk of stroke, compared with HT nonuse (rate ratio, 0.81; 95% CI, 0.62−1.05).⁹ Compared with HT nonuse, the use of oral estrogen (rate ratio, 1.28; 95% CI, 1.15−1.42) or transdermal estradiol 50 µg or greater daily (rate ratio, 1.89; 95% CI, 1.15−3.11) was associated with an increased risk of stroke.⁹

Reducing the risks of deep venous thromboembolism (VTE) and pulmonary embolism caused by HT is an important goal. In a meta-analysis of the risk of VTE with HT, compared with nonusers, oral estrogen therapy was associated with a significantly increased risk of VTE (odds ratio [OR], 2.5; 95% CI, 1.9−3.4). Compared with nonuse, transdermal estrogen therapy was not associated with an increased risk of VTE (OR, 1.2; 95% CI, 0.9−1.7).¹¹ In a study comparing oral versus transdermal estradiol, transdermal estradiol was associated with a reduced risk of pulmonary embolism (0.46 [95% CI, 0.22−0.97]).¹³

Reducing the risk of breast cancer caused by HT is an important goal. Results of one study showed that the combination of oral estrogen plus synthetic progestin was associated with an increased risk of breast cancer, compared with nonuse (RR, 1.5; 95% CI, 1.1−1.9). By contrast, the combination of transdermal estradiol plus micronized progesterone was not associated with an increased risk of breast cancer, compared with nonuse (RR, 0.9; 95% CI, 0.7−1.2).¹⁵

INSTANT POLL
Many health insurers use pharmacy benefit managers to control the cost of prescription medicines. These managers often develop formulary algorithms that favor the use of oral estrogen and medroxyprogesterone acetate over transdermal estradiol and micronized progesterone. When you prescribe transdermal estradiol and micronized progesterone, have your patients had difficulty filling the prescription?

Tell us! Send your Letter to the Editor!

The bottom line

In recently menopausal women with moderate to severe hot flashes, HT improves quality of life and appears to decrease mortality. However, HT with oral estrogen plus synthetic progestin is associated with an increased risk of stroke, deep vein thrombosis, pulmonary embolism, and breast cancer. Compared with oral estrogen, transdermal estradiol treatment is associated with a lower risk of stroke, deep vein thrombosis, and pulmonary embolism. Compared with oral estrogen plus a synthetic progestin, transdermal estradiol plus micronized progesterone is associated with a lower risk of breast cancer. The benefits of HT are likely maximized by initiating therapy in the perimenopause transition or early in the postmenopause, and the risks are minimized by using transdermal estradiol.¹⁶⁻¹⁸

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.