WOMEN 'S HEALTH AND MENOPAUSE : - National Heart, Lung ...

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Therefore, convincing evidence of treatment benefit requires a placebo-controlled clinical trial. Women may visit the physician because they have symptoms they suspect are related to menopause or because they want information about the menopause. In either case, assessment for symptoms provides an opportunity to discuss issues that might otherwise remain unaddressed. Symptoms directly or indirectly related to the menopause transition include: • Vasomotor symptoms (hot flushes and night sweats) • Sleep-related symptoms • Mood changes • Sexual dysfunction • Problems with concentration and memory • Urogenital symptoms Symptoms can be queried by using a questionnaire or symptom checklist during the interview. Some find that asking about sexual satisfaction is facilitated by the use of a checklist. When a checklist is used, it is important to go beyond the list to assess the severity and duration of It is important to have reported symptoms and the degree to which they inter- a dialogue with the fere with the woman’s life. patient. Failure to listen For example, hot flushes that are not bothersome and discuss may explain do not require treatment. why many women prescribed HRT do not fill the prescription. 274 When asking about symptoms, the clinician should be sensitive to each woman’s: • Beliefs and attitudes about menopause, including her medical vs. nonmedical treatment preferences, anxieties, and coping style • Sociocultural and ethnic background that may affect her concerns and choices • Work situation, job satisfaction, and stress • Other life stressors, particularly with personal relationships • Social supports • Overall quality of life • Current use of nonprescription herbal, nutriceutical (a nutritional supplement designed for a specific clinical purpose), or phytoestrogen remedies. It is important to have a dialogue with the patient. Failure to listen and discuss may explain why many women prescribed HRT do not fill the prescription. 2.2 Symptom Prevention and Treatment. Vasomotor Symptoms: Hot Flushes and Night Sweats 2.2.1 Lifestyle • Wear layered clothing that can be removed or added as necessary. • There is conflicting evidence as to whether exercise improves menopause vasomotor symptoms. 2.2.2 Diet • Avoid hot spicy foods and beverages, and reduce caffeine. • Avoid alcohol beverages (excess can cause flushing). 2.2.3 Pharmacotherapy • In a systematic review of more than 40 randomized controlled clinical trials, oral and transdermal estrogen each reduced the severity of vasomotor symptoms, and estrogen was effective in doses lower than the usual 0.625 mg of equine estrogens or equivalent. • Transdermal estradiol and intranasal 17β-estradiol spray are as effective as oral estrogen in reducing hot flushes.
• Oral tibolone is as effective as other forms of HRT such as estradiol valerate or conjugated estrogens in reducing hot flushes. • Selective ER modulators can increase hot flushes. In clinical trials, approximately 20 percent of women at least 2 years after menopause less than 60 years of age and 10 percent of older women developed hot flushes on raloxifene. Vasomotor symptoms were mild and rarely led to discontinuation of therapy. • The selective serotonin reuptake inhibitors (SSRIs) venlafaxine and paroxetine have been shown to substantially reduce hot flushes in clinical trials. • Progestogens in high daily doses (medroxyprogesterone acetate 20 mg per day or megestrol acetate 40 mg per day) also reduced vasomotor symptoms. • Veralipride (100 mg per day) reduces hot flushes in patients treated with GnRH agonists. • Propranolol is no more effective than placebo for the reduction of hot flushes, whereas evidence for clonidine’s benefit is inconsistent. 2.2.4 Complementary and Alternative Therapies • Phytoestrogens have not been shown in most clinical trials to decrease vasomotor symptoms significantly better than placebo. Different results may relate to differences in women (not all of them absorb phytoestrogens equally well) or differences in the products tested. The best single dietary source of phytoestrogens is soy. The U.S. Food and Drug Administration has approved a statement that soy protein at a dose of 25 gm/day may reduce the risk of CVD, based on a modest reduction in total cholesterol level. • Dong quai has been shown in a clinical trial not to be more effective than placebo for the treatment of hot flushes. • Evening primrose oil (gamma-linolenic acid) is not more effective than placebo for the reduction of hot flushes. 2.3 Symptom Prevention and Treatment. Urogenital Symptoms • At least nine RCTs have shown that estrogen improves urogenital symptoms; this is true for oral and transdermal estrogen and for a silicone estradiol-releasing vaginal ring. Vaginal dryness and dyspareunia can be treated with a topical estrogen cream, tablet, or vaginal ring, or with nonhormone moisturizing or lubrication products. In clinical trials, topical estrogen appears to be better than systemic estrogen for relieving these symptoms, and avoids high levels of circulating estrogen. • In one clinical trial, an estradiol-releasing silicone vaginal ring was also found to reduce the incidence of urinary tract infection. • Systemic estrogen alone or with a progestin does not reduce incontinence, and in one large clinical trial, HERS, actually increased incontinence. 3. FRACTURES 3.1 Assessment When discussing osteoporosis, it is important to be sure that the provider and the patient are using the same language. Some patients confuse osteoporosis (fragile bones) with osteoarthritis (painful joints). Other women (and some doctors) mistakenly believe that a diagnosis of osteoporosis means they should not exercise. Many factors are associated with an increased fracture risk in women, which may differ by fracture site. 275
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National Heart, Lung, and Blood Ins
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CHAIRS AND EDITORS Chair and Editor
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Anne McTiernan, M.D., Ph.D. Associa
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Lenore Manderson, Ph.D. Director an
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Michael Mendelsohn, M.D. Director,
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TABLE OF CONTENTS Preface XIII 1 Ex
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PREFACE Women’s health and menopa
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CHAPTER 1: EXECUTIVE SUMMARY Nanett
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TABLE 1-1 Evidence Categories Evide
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TABLE 1-2 (continued) Possible Bene
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symptom measures, cultural factors,
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5. PHYSIOLOGICAL ROLE OF ESTROGEN A
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The atherogenic risk profile of old
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• Hormone replacement therapy: Fi
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tion of the remaining ridge in area
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9.3.1 Interventions • In many cas
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Parkinson’s disease, no overall p
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TABLE 1-3 (continued) Sexuality •
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CHAPTER 2: THE MENOPAUSE AND AGING
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oped and are less prepared to addre
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FIGURE 2-4 Diabetes Mellitus. Estim
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Sarcopenia, defined as reduced musc
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Perimenopause WHO The term “perim
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decrease about 2 years before the F
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4.3 Menstrually Defined Menopausal
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to be under stress and to hold part
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21 Brincat MP. Hormone replacement
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62 Orentreich N, Brind JL, Rizer RL
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CHAPTER 3: SYMPTOMS AND THE MENOPAU
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women who may have reached natural
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numb-tingling feelings, headaches,
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(47 percent), problems sleeping (39
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FIGURE 3-2 Proportion of Women Both
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tomized hypogonadotropic women expe
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5.1 Exercise It has been suggested
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to consume 20-150 mg/day of isoflav
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REFERENCES 1 Stewart AL, Hays RD, W
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48 Avis NE, Crawford SL, McKinlay S
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92 Albertazzi P, Pansini F, Bonacco
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Hällström wrote that the psycholo
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countries. Perhaps, as the authors
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Beyene used a systematic ethnograph
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ange of variables, such as genetic
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REFERENCES 1 Gannon L, Ekstrom B. A
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47 George T. Women in a south India
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9. Estrogen and inhibins produced b
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HRT) display tissue-selective estro
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a partial agonist. In contrast, wit
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3. UROGENITAL TRACT ERα and ERβ a
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4. BONE: DEVELOPMENT AND HOMEOSTASI
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in response to estrogen. 106,105 In
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lation of sleep, motor behavior, an
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7. HORMONE REPLACEMENT THERAPY: TRA
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REFERENCES 1 Jensen EV, Jacobsen HI
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40 Power RF, Mani SK, Codina J, Con
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83 Oursler MJ, Pederson L, Fitzpatr
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125 Gabrielsson BG, Carmignac DF, F
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169 Renier MA, Vereecken A, Buytaer
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FIGURE 6-1 Structural features of E
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ound, the conformation of the recep
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with extremely potent estrogenic ac
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Its potency as an antiestrogen was
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The observation that the degree of
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findings were remarkable because a
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Recently, the use of phage display
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20 Crawley G. Non steroidal estroge
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65 Qu Q, Zheng H, Dahllund J, et al
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in their survey of postmenopausal w
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where over half the world’s popul
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The Danish study of Koster and Gard
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Many studies of sexual interest in
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7. ASSESSING SEXUAL ACTIVITY Clinic
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None of these studies evaluated the
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estrogen-androgen group during the
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REFERENCES 1 Sarrel PM, Whitehead M
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52 Utian WH. The true clinical feat
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140
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outes of administration and differe
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FIGURE 8-2 Change in Age-Adjusted D
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fied as overweight or obese. 32 The
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TABLE 8-1 148 Guide to Risk Reducti
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TABLE 8-1 (continued) 150 Recommend
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TABLE 8-1 (continued) 152 Recommend
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Interesting differences in atherosc
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similar effects in both patients wi
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a lowering of triglycerides, 140 an
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may account for a substantial propo
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associated with an independent prot
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eases preoperatively. Quality of li
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excess risk of 6-18 per 10,000 per
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REFERENCES 1 NHLBI Morbidity and Mo
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36 Samaras K, Hayward CS, Sullivan
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79 Collins P, Rosano GM, Jiang C, L
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121 Mäkelä S, Savolainen H, Aavik
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162 Clarke S, Kelleher H, Lloyd-Jon
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201 Rahimtoola SH, Bennett AJ, Grun
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243 Varas-Lorenzo C, Garcia-Rodriqu
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7. A connection between menopausal
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3. PATHOGENESIS OF FRACTURE Fractur
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Diagnosis of osteoporosis according
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density and has a favorable effect
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How should this information be inco
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emergence of proved treatment alter
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Data on the relation between skelet
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REFERENCES 1 Osteoporosis Preventio
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42 Gluer CC. Quantitative ultrasoun
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85 Ettinger B, Pressman A, Silver P
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130 Jeffcoat MK, Lewis CE, Reddy M,
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1. INTRODUCTION Perimenopausal wome
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for breast cancer are at increased
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findings on biopsy in women with an
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thra. Patients typically describe l
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Biofeedback: Used in conjunction wi
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There has been one systematic revie
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ence in pelvic organ prolapse. The
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21 Ferenczy A. Endometrial carcinom
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65 Wyman JF, Fantl JA, McClish DK,
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222
Page 240 and 241: 1. INTRODUCTION Worldwide, breast c
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Page 244 and 245: Although HRT has been related to an
Page 246 and 247: cyclic use and 2.9 (95 percent CI 2
Page 248 and 249: TABLE 11-3 Selected Studies on Horm
Page 250 and 251: TABLE 11-3 (continued) Thus, a stro
Page 252 and 253: TABLE 11-4 236 Cohort Studies on Ho
Page 254 and 255: TABLE 11-5 238 Case-Control Studies
Page 256 and 257: TABLE 11-5 (continued) 240 Adjustme
Page 258 and 259: When the same women in NSABP were r
Page 260 and 261: REFERENCES 1 Pisani P, Parkin DM, B
Page 262 and 263: 47 Day NE. Epidemiology: the role o
Page 264 and 265: 93 Rodriguez C, Patel AV, Calle EE,
Page 266 and 267: 139 Parazzini F, La Vecchia C, Negr
Page 268 and 269: 1. INTRODUCTION Menopause is associ
Page 270 and 271: inverse relation with nonverbal mem
Page 272 and 273: ease decreased significantly with i
Page 274 and 275: of households selected to be repres
Page 276 and 277: standard antipsychotic drugs increa
Page 278 and 279: 5. FUTURE NEEDS • Explore the pos
Page 280 and 281: 19 Berman KF, Schmidt PJ, Rubinow D
Page 282 and 283: 64 Lerner A, Koss E, Debanne S, Row
Page 284 and 285: 114 Smith R, Studd JW. A pilot stud
Page 286 and 287: 162 Klein BE. Lens opacities in wom
Page 288 and 289: patients with strong personal convi
Page 292 and 293: 3.1.1 Risk Factors Many factors are
Page 294 and 295: 278 lower dosages of estrogen will
Page 296 and 297: • Diabetes: Women with diabetes b
Page 298 and 299: Lipids and lipoproteins • LDL cho
Page 300 and 301: 284 persists but is less steep in w
Page 302 and 303: 5.2.3 Pharmacotherapy Breast Cancer
Page 304 and 305: • There is no clinical trial evid
Page 306 and 307: Sirtori CR, Pazzucconi F, Colombo L
Page 308 and 309: Hansson L, Zanchetti A, Carruthers
Page 310 and 311: Dementia and Mental Health Forette
Page 312 and 313: CRP C-reactive protein CT computed
Page 314 and 315: PTCA percutaneous transluminal coro
Page 316: U.S. DEPARTMENT OF HEALTH AND HUMAN
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