Managing Menopause in 2012

Recently I hosted an evening discussion for Personalized Primary Care Atlanta members on the topic of menopause. Here is a summary of our discussion:

·         Menopause is defined by no menstrual cycle for one year.

·         The average age of menopause in the US is 51.

·         90% if American women experience menopause between ages 45 and 55.

·         Prior to menopause women go through a period of transition, often referred to as perimenopause. 

·         During this time of transition women may begin by having irregular menstrual cycles with changes in cycle length and periods of heavier or lighter flow. 

·         Later in transition women may skip one or more menstrual cycles and may begin to have symptoms related to menopause.

·         Irregular menses relate to anovulatory cycles and low levels of progesterone

·         For several years prior to menopause women may have higher than normal estradiol levels and lower than normal progesterone levels.  FSH levels may also be high.

·         Following menopause FSH levels are high and estrogen and progesterone levels are low, however menopause is not defined by hormonal levels, and because of individual differences in hormone levels and also normal fluctuations in levels throughout the cycle, hormone levels can be difficult to use as parameters of change.

Common symptoms of menopause are related to a decline in estrogen levels. For most women symptoms last several years.  However, in some, symptoms may continue for up to 10 years. About 10% of women in their sixties continue to have hot flashes.

Menopause Symptoms:

·         Hot flashes (last 2-4 minutes, affect the upper body and face, occur frequently at night)

·         Insomnia (may be a manifestation of temperature regulation trouble—hot flashes)

·         Heart Palpitations

·         Forgetfulness

·         Changes in sex drive

·         Irritability

·         Vaginal dryness

·         Trouble with control of urination

·         Changes in body composition—reduced muscle mass

Menopause Risks:

Menopause increases the risk of osteoporosis. Women lose bone density quickly during the first five years following menopause.  Menopause is also associated with an increased risk of cardiovascular disease. Women develop more insulin resistance, lower HDL levels and higher LDL cholesterol.

Managing Menopause Symptoms:

Approaches to managing menopausal symptoms include hormonal therapies, off -label use of non-hormonal therapies, and natural remedies.

Hormone Replacement Therapy

·         Hormone replacement therapy is no longer recommended for menopausal women for the purpose of prevention. 

·         Hormone replacement therapy has been extensively studied in the form of conjugated equine estrogen in a dose of 0.625 mg and medroxyprogesterone at a dose of 2.5 mg in postmenopausal women with an average age of 63 in the Women’s Health Initiative trial.  This trial involved approximately 161,000 women and reported on a number of outcomes.   The Estrogen and Progesterone arm of the trial was terminated in 2002 and found that women using the two hormones had a higher risk of blood clots, heart attacks, strokes, and breast cancer.  The same women had a lower risk of colon cancer and bone fracture.

·         Women in the Estrogen alone part of the study had higher risk of strokes and blood clots, but not breast cancer and heart attacks.

·         Three years following discontinuation of the study women treated with Estrogen and Progesterone continued to have a higher risk of cancer, including lung cancer. 

·         A subgroup analysis of the study found that most of the risk conferred by hormone replacement therapy was related to the age of the treated women. Women treated from the time of menopause forward for five years did not experience significant increases in health risk. 

·         For a sense of the magnitudes of health risk I recommend looking at the handbook

Changes in Practice a Decade Later

Hormone replacement remains the most effective treatment of menopausal symptoms. However, not all women require hormone replacement to get through menopause. Currently women’s health experts prefer to use the lowest dose of hormones available to control symptoms. Today, oral estrogen is available in one half the dosage that was studied in the Women’s Health Initiative study. There are several different types of estrogen and progesterone available on the market.  All estrogens appear to carry a similar risk of blood clot.  However, it remains uncertain whether different types of estrogens and progestins confer different health risks. In the case of progestins, they do seem to vary more in their activity and side effect profiles. The adverse effects of hormone replacement are speculated to relate to dose. Current practice has shifted toward the use of transdermal estrogen and progesterone through patches—also available in low dose. Transdermal estrogen confers a lower risk of deep venous thrombosis, and it is thought by some that to be safer with respect to other health outcomes.  Vaginal estrogen is an effective means to treat the urogenital symptoms of menopause—vaginal dryness and urinary symptoms, and does not require systemic progesterone to protect the uterus as do oral and transdermal estrogen.  It is felt that if use of hormone replacement is limited to the first five years following the time of natural menopause (around age 51), the cardiovascular risks may be lower. Tapering hormonal therapy slowly after several years may produce fewer symptoms than stopping cold turkey and can help facilitate the transition to menopause for some women.  Some women may choose to live with the health risks related to hormone replacement and may continue treatment for longer than five years—reporting improved quality of life.

What are “Bioidentical Hormones?”

Bioidentical hormones typically refers to custom compounds of hormones that are also manufactured and marketed as pharmaceuticals. However, bioidentical hormones are not tested and regulated. Given the range of hormone replacement now available on the market with numerous dosing options, many women’s health experts agree that it is safer to use products that have been more thoroughly investigated and that are regulated in the U.S. through the FDA.

Non-hormonal options for treating hot flashes are available as off-label use of prescription medications and include:

·         Selective Serotonin Reuptake Inhibitors and Selective Norepinephrine Reuptake Inhibitors: paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), fluoxetine (Prozac)

·         Gabapentin (a seizure drug)

·         Clonidine (a blood pressure drug)

Natural Products

·         Plant Based Estrogens (Phytoestrogens) /Soy:  Not FDA regulated, might work in the body like a weak estrogen, might also have some health risk.

·         Black Cohosh : Also not regulated by FDA, lack of conclusive evidence that it helps, but has a fairly good safety record

 

For more information I also recommend the:

North American Menopause Society (NAMS) website and

the handbook:  Facts About Menopausal Hormone Therapy.

Or, contact me directly at drmavromatis@ppcatl.com

 

Physician Self-Disclosure: Helpful or Harmful?

How much should doctors reveal about themselves to patients? 
Whether or not “self-disclosure” is an effective communication strategy in the doctor-patient relationship has been debated.  In fact, some studies have demonstrated that doctors who talk about themselves more are rated more poorly by patients than those who are more private. This topic has been of interest to me and I have written about it in my blog:  Doctor, Patient, Friend:  Blurring the Boundaries,  and explored it further in a recent book chapter in Social Media in Medicine.   

In the case of teachers and students, communication strategies that promote “immediacy” have been found to have positive results in terms of promoting learning by creating a more open classroom environment.  Humor and self-disclosure are two strategies that promote immediacy. But, are these communication strategies effective in medicine also? I hypothesize that they are.

Recently a patient visited me to follow up after an E.R. visit. While she was in the office I recounted to her a personal tidbit that related to her day in the E.R.  While she and I were on the phone and as I was advising her the preceding Saturday afternoon, I had walked outside of a local sub-shop, Dave’s Cosmic Subs, seeking out private place to talk. On doing so, I had stepped beneath a tree into a pile of fire ants and was bitten all over my feet, which caused a degree of distraction.   For this reason I ended the phone call somewhat abruptly and later called her back. Was this self-disclosure helpful? She found it amusing, but we didn’t lose much time over the conversation.   A few days later she made mention of it again as we chuckled together about life's annoyances.

In another recent conversation with a patient who was considering various hormonal options for peri-menopausal symptoms I revealed my personal experience with using a Mirena IUD.  Several weeks later she decided this might be a good option for her as well.

Were these personal self-disclosures to my patients helpful or harmful? In the role of patient, I’ve been to see physicians who recount personal stories during an office visit that seem to take time away from my talk-time.   In a dentist's office this can provide pleasant distraction as one is held captive with her mouth open, but in a doctor's office it can be annoying to a patient when one knows that time is limited.   Nonetheless, physicians, with their expert knowledge of medicine, process medical information in the context of their own lives in ways that are sometimes helpful to patients to learn about by way of example. 

I have, on more than one occasion, shared the story: when I turned forty I was diagnosed with hypertension.  Three months after stopping oral contraceptive pills my blood pressure normalized.  I suspect that I will eventually need blood pressure medication, in light of my strong family history and current readings (130s/80s), and also despite my normal BMI and daily exercise. However, I will try to stave it off for a few more years. Are these tidbits of personal experience helpful for me to share with my patients?

As physicians increasingly engage in social media the question of appropriate self-disclosures becomes more relevant.  Should a doctor “friend” a patient on Facebook? How should a physician conduct his or herself on Twitter?  Self-disclosure is the norm for much participation in social media. The AMA has published guidelines for social media use by medical professionals.  My own theory is that physician self-disclosure can help promote intimacy and trust between doctor and patient—qualities that are increasingly lacking in the patient-physician relationship.  I might point out that in the case of social media, self- disclosures do not occur in the context of office visits, and as such are extra communications that don’t take time away from a patient’s precious appointment time.

Recently I was interested to read about a series of studies published in the Proceedings of the National Academy of Science. The studies, led by Harvard psychology researchers Diana I. Tamir and Jason P. Mitchell, made the relatively intuitive discovery: humans get a biochemical buzz from self-disclosure.  By inference, perhaps doctors who share more with their patients are happier with their patient interactions than those who are more reserved, and perhaps those positive feelings translate into a more effective health care experience.   No one knows, and more study is needed to uncover exactly what forms of physician self-disclosure are helpful to patients and what forms are more self-serving, or “narcissistic,” detracting from the patient-physician relationship.

Are Annual Physical Exams Necessary

Recently a physician reporter for the New York Times, Elisabeth Rosenthal, argued in the cover article of the Sunday Review that routine physicals are in many ways pointless, and perhaps even dangerous.  In the article, entitled “Let’s Not Get Physicals,” Dr. Rosenthal goes on to point out that many routine tests performed during physicals --EKG’s, pap smears and blood work, are unnecessary. In my opinion, Dr. Rosenthal’s front page skepticism of the utility of the annual ritual misses the key point and sets a dangerous tone.  As every good primary care physician knows, the key benefit of an annual check-up (aka “physical”) is not the litany of tests ordered, but the opportunity it provides to do a complete review of a patient’s medical history and risk factors.  The “annual physical” also provides an opportunity for healthy people to get to know their physicians and vice versa, so that when illness arises, as it always will, the physician will understand a patient’s personality and healthy baseline.  

After years of criticism by proponents of prevention Medicare recently started to cover an annual exam, which is referred to as a “Wellness Exam.”  The Medicare preventive exam, which became a covered benefit in 2011, emphasizes history-taking as opposed to testing, which in my view is appropriate.   The Affordable Care Act also regulates the provision of preventive care by health plans requiring that plans provide a core set of preventive services without requiring a co-pay, co-insurance, or deductible.

While the physician author of the New York Times piece surely understands many of her own personal risk factors for disease and also the signs and symptoms of potentially serious underlying conditions, the general public does not have this expert knowledge. Why shun a once a year, hour-long (or, as is more often the case these days, 20 minute-long) visit to a medical expert to review one’s personal health profile, risk factors and family history?  I suppose that Dr. Rosenthal’s point is to de-emphasize the testing component.  In my view, if anything many individuals could benefit from more frequent (biannual or quarterly) preventive checks to keep them on track with their health goals and risk factors—perhaps this would keep more folks out of the ER and hospital.  As to the “testing” component of the annual physical, the visit provides an opportunity for patient and physician to discuss the state of the art, information that the patient might be reading online, and the evidence for and against screening for particular conditions. Which screening tests health insurance should pay for is a separate question. The issue here may be semantic—should it be called a "physical,"  a "wellness visit," or a "preventive check-up--" but, let’s not get rid of the annual visit.