Managing menopausal symptoms and associated clinical issues in breast cancer survivors

Objective: Review evidence to guide management of menopausal signs and symptoms in women after breast cancer and make recommendations accordingly. Evidence: Randomized controlled clinical trials, observational studies, evidence-based guidelines, and expert opinion from professional societies. Background: Symptoms and clinical problems associated with estrogen depletion—sleep disorders, vulvovaginal atrophy (VVA), vasomotor symptoms (VMS), mood changes, depressive symptoms, cardiovascular disease, osteopenia, and osteoporosis—confront the estimated 9.3 million breast cancer survivors globally. Recommendations: Following breast cancer, women should not generally be treated with menopausal hormone therapy or tibolone but should optimize lifestyle. Women with moderate to severe symptoms may benefit from mind–brain behavior or nonhormone, pharmacologic therapy. The selective serotonin/noradrenaline reuptake inhibitors and gabapentenoid agents improve VMS and quality of life. For osteoporosis, nonhormonal agents are available. Treatment of VVA remains an area of unmet need. Low-dose vaginal estrogen is absorbed in small amounts with blood levels remaining within the normal postmenopausal range but could potentially stimulate occult breast cancer cells, and although poorly studied, is not generally advised, particularly for those on aromatase inhibitors. Intravaginal dehydroepiandrosterone and oral ospemiphene have been approved to treat dyspareunia, but safety after breast cancer has not been established. Vaginal laser therapy is being used for VVA but efficacy from sham-controlled studies is lacking. Therapies undergoing development include lasofoxifene, neurokinin B inhibitors, stellate ganglion blockade, vaginal testosterone, and estetrol. Conclusions: Nonhormone options and therapies are available for treatment of estrogen depletion symptoms and clinical problems after a diagnosis of breast cancer. Individualization of treatment is essential

Treatment of symptoms of the menopause: an endocrine society clinical practice guideline

Objective: The objective of this document is to generate a practice guideline for the management and treatment of symptoms of the menopause. Participants: The Treatment of Symptoms of the Menopause Task Force included six experts, a methodologist, and a medical writer, all appointed by The Endocrine Society. Evidence: The Task Force developed this evidenced-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned three systematic reviews of published data and considered several other existing meta-analyses and trials. Consensus Process: Multiple e-mail communications, conference calls, and one face-to-face meeting determined consensus. Committees of The Endocrine Society, representatives from endorsing societies, and members of The Endocrine Society reviewed and commented on the drafts of the guidelines. The Australasian Menopause Society, the British Menopause Society, European Menopause and Andropause Society, the European Society of Endocrinology, and the International Menopause Society (co-sponsors of the guideline) reviewed and commented on the draft. Conclusions: Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms and other symptoms of the climacteric. Benefits may exceed risks for the majority of symptomatic postmenopausal women who are under age 60 or under 10 years since the onset of menopause. Health care professionals should individualize therapy based on clinical factors and patient preference. They should screen women before initiating MHT for cardiovascular and breast cancer risk and recommend the most appropriate therapy depending on risk/benefit considerations. Current evidence does not justify the use of MHT to prevent coronary heart disease, breast cancer, or dementia. Other options are available for those with vasomotor symptoms who prefer not to use MHT or who have contraindications because these patients should not use MHT. Low-dose vaginal estrogen and ospemifene provide effective therapy for the genitourinary syndrome of menopause, and vaginal moisturizers and lubricants are available for those not choosing hormonal therapy. All postmenopausal women should embrace appropriate lifestyle measures

Hormone Therapy for Postmenopausal Women: A Brief History of Time

All women who live long enough with ovaries intact will experience the menopause transition. This nearly universal, natural physiological event transcends mere biology, however. In our culture, the menopause also connotes a marker of aging. Margaret Meade considered menopause as the portal to a season of postmenopausal zest. Others, such as the infamous gynecologist Robert Wilson, approached menopause as an endocrine deficiency disorder with only negative sequelae in a woman\u27s appearance, sexuality, and health. In an effort to relieve women\u27s symptoms and to ward off the vagaries of aging, hormone therapy entered midstream medicine over fifty years ago. In an effort to confirm the utility of hormone therapy as a preventive strategy to reduce chronic disorders associated with aging, the National Institutes of Health funded the largest, longest, clinical trial ever conducted in women. In the decade since the initial announcement of the Women\u27s Health Initiative trial findings in 2002, both women and clinicians have been challenged to reconsider the use of hormone therapy for treating the most common symptoms of the menopause. Determination of risks and benefits, careful candidate selection, and consideration of different doses, regimens, preparations, modes of administration, and durations of therapy have significantly altered the current approach to hormone therapy. Expanded nonhormonal options for symptom relief provide alternative choices for women who are not appropriate candidates for, or who are averse to, estrogen therapy. Above all, ensuring that tailored therapy is available to meet the individual needs of each individual woman remains the first priority

Menopause Practitioner Perspective on the American Society of Bone and Mineral Research Task Force Report on Atypical Femoral Fracture.

CLINICAL SCENARIO: One of your patients, a 59-year-old postmenopausal Asian woman (menopause, age 52), took hormone therapy for about one year for her menopause symptoms. When she was 54, her mother (age 80) suffered a hip fracture, and she requested a bone density test at her next gynecology visit. The t-score results were spine, -1.1; total hip, -1.8; and femoral neck, -2.1, all in the osteopenic range. After some discussion, she was started on alendronate 70 mg once a week, together with calcium and vitamin D. Follow-up dual-energy x-ray absorptiometry testing after 2 and 5 years of therapy showed increases in bone mineral density, resulting in t-score improvements of about 0.3 to 0.5 units (spine was now normal; femoral neck was -1.8). The Fracture Risk Assessment Tool estimated her 10-year risk of hip fracture to be 0.4% and her 10-year risk of any of 4 major osteoporotic fractures to be 7.5%. During her most recent gynecology visit, she expressed concern about unusual femoral fractures being linked to long-term use of alendronate. She asks if there is reason for her to stop using this drug

Лікування симптомів менопаузи. Клінічне практичне керівництво ендокринологічного товариства США, 2015

The objective of this document is to generate a practice guideline for the management and treatment of symptoms of the menopause.The Treatment of Symptoms of the Menopause Task Force included six experts, a methodologist, and a medical writer, all appointed by The Endocrine Society.The Task Force developed this evidenced-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned three systematic reviews of published data and considered several other existing meta-analyses and trials.Multiple e-mail communications, conference calls, and one face-to-face meeting determined consensus. Committees of The Endocrine Society, representatives from endorsing societies, and members of The Endocrine Society reviewed and commented on the drafts of the guidelines. The Australasian Menopause Society, the British Menopause Society, European Menopause and Andropause Society, the European Society of Endocrinology, and the International Menopause Society (co-sponsors of the guideline) reviewed and commented on the draft.Conclusions: menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms and other symptoms of the climacteric. Benefits may exceed risks for the majority of symptomatic postmenopausal women who are under age 60 or under 10 years since the onset of menopause. Health care professionals should individualize therapy based on clinical factors and patient preference. They should screen women before initiating MHT for cardiovascular and breast cancer risk and recommend the most appropriate therapy depending on risk/benefit considerations. Current evidence does not justify the use of MHT to prevent coronary heart disease, breast cancer, or dementia.Other options are available for those with vasomotor symptoms who prefer not to use MHT or who have contraindications because these patients should not use MHT. Low-dose vaginal estrogen and ospemifene provide effective therapy for the genitourinary syndrome of menopause, and vaginal moisturizers and lubricants are available for those not choosing hormonal therapy. All postmenopausal women should embrace appropriate lifestyle measures.Цель этого документа заключается в создании практического руководства по тактике ведения и лечения симптомов менопаузы.В Рабочую группу по лечению симптомов менопаузы вошли шесть экспертов, методист и медицинский редактор, которые были назначены Эндокринологическим обществом США.Рабочая группа разработала данное основанное на доказательных данных руководство с использованием шкалы градации доказательных данных GRADE (Grading of Recommendations, Assessment, Development and Evaluation) для описания силы рекомендаций и качества доказательств, подготовив три систематических обзора опубликованных данных и рассмотрев несколько других существующих на сегодня мета-анализов и исследований.Консенсус процесса основывался на коммуникации с помощью электронной почты, конференц-звонках и непосредственной встрече участников. Комитеты Эндокринологического общества, представители смежных обществ и члены Эндокринологического общества США рассмотрели и прокомментировали проект данного руководства. Черновой вариант документа также был рецензирован Обществами менопаузы Австралии и Великобритании, Европейским обществом менопаузы и андропаузы, Европейским обществом эндокринологии и Международным обществом менопаузы (соавторы руководства).Выводы: менопаузальная гормональная терапия (MГT) является наиболее эффективным способом лечения вазомоторных симптомов и других симптомов климактерия. Польза превышает риски для большинства симптоматических женщин в постменопаузе, возраст которых составляет менее 60 лет, или если с момента наступления менопаузы прошло не больше 10 лет. Врачам следует индивидуализировать терапию, исходя из клинических факторов и предпочтений пациентки. Перед началом MГT нужно провести скрининг женщины для оценки сердечно-сосудистого риска и риска рака молочной железы и рекомендовать наиболее подходящий способ терапии в зависимости от соотношения риск/польза.Имеющиеся на сегодня данные не оправдывают использование MГT с целью профилактики ишемической болезни сердца, рака молочной железы и деменции.Для женщин, страдающих вазомоторными симптомами, которые предпочитают не использовать MГT, или при наличии противопоказаний к ней доступны другие способы терапии. Низкие дозы загинального эстрогена и оспемифен представляют эффективную терапию урогенитального синдрома менопаузы, а вагинальные увлажнители и лубриканты подходят тем, кто не хочет применять гормональную терапию. Все женщины в постменопаузе должны принимать надлежащие меры по изменению образа жизни.Мета цього документа полягає у створенні практичного керівництва з тактики ведення і лікування симптомів менопаузи.До Робочої групи з лікування симптомів менопаузи увійшли шість експертів, методист і медичний редактор, які були призначені Ендокринологічним товариством США.Робоча група розробила це засноване на доказових даних керівництво з використанням шкали градації доказових даних GRADE (Grading of Recommendations, Assessment, Development and Evaluation) для опису сили рекомендацій і якості доказів, підготувавши три систематичних огляди опублікованих даних і розглянувши кілька інших існуючих на сьогодні мета-аналізів і досліджень.Консенсус процесу ґрунтувався на комунікації за допомогою електронної пошти, конференц-дзвінків та безпосередній зустрічі учасників. Комітети Ендокринологічного товариства, представники суміжних товариств та члени Ендокринологічного товариства США розглянули і прокоментували проект даного керівництва. Чорновий варіант документа також був рецензований Товариствами менопаузи Австралії та Великобританії, Європейським товариством менопаузи і андропаузи, Європейським товариством ендокринології та Міжнародним товариством менопаузи (співавтори керівництва).Висновки: менопаузальна гормональна терапія (MГT) є найбільш ефективним способом лікування вазомоторних симптомів та інших симптомів клімактерію. Її користь перевищує ризики для більшості симптоматичних жінок у постменопаузі, вік яких становить менше за 60 років, або якщо з моменту настання менопаузи минуло не більше 10 років. Лікарям слід індивідуалізувати терапію, виходячи з клінічних факторів і переваг для пацієнтки. Перед початком MГT потрібно провести скринінг жінки для оцінки серцево-судинного ризику і ризику раку молочної залози та рекомендувати найбільш оптимальний спосіб терапії залежно від співвідношення ризик/користь.Наявні на сьогодні дані не виправдовують використання MГT з метою профілактики ішемічної хвороби серця, раку молочної залози і деменції.Для жінок, які страждають на вазомоторні симптоми та не бажають використовувати MГT, або при наявності протипоказань до неї в арсеналі лікаря доступні інші способи терапії. Низькі дози вагінального естрогену і оспеміфен являють собою ефективну терапію урогенітального синдрому менопаузи, а вагінальні зволожувачі і лубриканти підходять тим, хто не хоче застосовувати гормональну терапію. Всі жінки в пост менопаузі повинні вживати належні заходи щодо зміни способу життя

Menopause Management Knowledge in Post-graduate Family Medicine, Internal Medicine and Obstetrics & Gynecology Residents: A CrossSectional Survey

Objective: We aimed to evaluate training in menopause management in post-graduate residents across different training programs. Design: A cross-sectional, anonymous survey was emailed to trainees at all post- graduate levels in family medicine (FM), internal medicine (IM), and obstetrics and gynecology (OB/GYN) at residency programs across the U.S. The survey evaluated attitudes potentially influencing menopausal hormone therapy (HT) prescribing, knowledge about HT, availability and type of training in menopause medicine, and demographic information. Results: 20 U.S. programs participated, providing 183 at least partially completed surveys (703 residents contacted; 26% response rate). Most trainees were between 26 – 30 years of age (77%), female (66%), and believed it was important or very important to be trained to manage menopause (94%). Statistically significant differences were seen between disciplines regarding menopause competency questions. OB/GYN and FM were more likely than IM residents to answer various knowledge questions correctly. For example, 53 % of OB/GYN, and 56% of FM would appropriately prescribe HT until age 50 to a prematurely menopausal woman, while only 23% of IM answered this question correctly (