Medcan Women’s Health Forum

It’s The Menopause!Wilfred M Steinberg MD FRCSC

University of TorontoSt Michael’s Hospital

It’s a New World

What Does it All Mean?

What Does it All Mean?

When Does It Start? Or End?

Perimenopause…not a disease

What Changes Occur in the Menopause ?

Smith T, et al. J Soc Obstet Gynaecol Can 2001

Urogenital atrophy

Menopausal symptoms• Vasomotor symptoms• Mood disturbances

Bone loss and fractures

Cardiovascular disease

Alzheimer’s disease

Breast cancer

Colon cancer

Progression of Symptoms

Are you aware?

Cognitive Changes

Body Changes

Range of Emotions

Anyone you Know?

Menopausal Changes?

Some Weird Changes

Unappreciated Symptoms

Can I Still Get Pregnant?

Fertility Rates & Age

Who are you going to trust?

Does this resonate for you?

Be an Intelligent Consumer

Plants for menopausal Rx

Isoflavones Have estrogen-like effects, so …be aware.. Black Cohosh, Wild Yam Soy

Herbs: Traditional and Chinese

Myth #1: “Natural Hormones are Safer :

Myth #2: Compounded Bioidentical Hormones Work Better than

Brand Rx Hormones.

There is no scientific support for an advantage of these compounds over common commercially produced preparations.

 Mary M. Gallenberg, M.D Mayo Clinic

Natural Hormones-FDA H&W Approved

Newton KM, et al. Ann Intern Med 2006;145:869-79. Reproduced with permission.

Multibotanical + soy

Multibotanical

HT**

8

7

6

5

4

3

2

1

0

Baseline 3 mo 6 mo 12 mo

Vaso

mot

or S

ympt

oms

Per D

ay

* * *

Placebo

Black cohosh

What really works? 351 women

Adjusted mean number of vasomotor symptoms per day, by study group

My Favourite Natural Treatment

Non Hormonal Remedies

• Significantly reduced the number of hot flushes compared with placebo

• 66.6% reductions from baseline • Hot flush severity and number of nighttime

awakenings were significantly reducedAmerican Journal of Obstetrics & Gynecology, February 2009

Myth #3: Since Compounded Bioidentical Hormones Are Natural,

They are Safer Than Other Hormones.”

They're produced in doses and forms that differ from those in FDA-approved products BUT..with no quality assurance standards

KEEPS: Kronos Early Estrogen Prevention Study 2012

Estrogen and progestogen therapy started soon after menopause, not only relieve symptoms, but appear safe.  •No increase in blood pressure, no effects on atherosclerosis, •No increase in breast cancer or uterine cancer,•No effects on blood clots associated with stroke and myocardial infarction.

Options :Menopausal Symptoms

Lifestyle changes:.some benefit Regular exercise, diet, nonsmoking, moderate alcohol, BMI <32

Herbal remedies:..minimal benefit Dong quai, ginseng, black cohosh, soy isoflavones, red clover, Goji

j

Medical therapies:major benefits Estrogen, progestin, gabapentin, clonidine SSRI / SNRIs

7-year ET* 5 years of CCEPT use10 years of CCEPT use15 years of CCEPT useLate menopause (10-year delay)Body mass index (BMI) (10 kg increase)Alcohol consumption (2 drinks/day)Lack of regular exerciseWeight gain after menopause (20 kg or more)

*

Risks for Breast Cancer in Perspective

*Baseline no HT use 45/1,000 women 50–60 years†

Addi

tiona

l can

cers

per

1,0

00 w

omen

0

20

30

10

40

50

Healthy is the New Sexy

Healthy is the New Sexy

In postmenopausal women, the quality of the relationship and the presence of sexual problems in the partner are probably as important as are hormonal change in the maintenance of sexual interest and response.

What Else May be Going On?

•urinary incontinence,• depression, •dementia, •arthritis,•stroke and •breast cancer •Family crisis

Menopause or Depression?

•loss of or diminished sex drive•lowered sexual desire and sexual activity•loss of energy•fatigue•lethargy•tiredness•lack of concentration

Vaginal Atrophy

Thick, healthy, well-estrogenized

lining of the vagina

Thin, dry lining of vaginadue to menopause

(after estrogen loss)

superficial

parabasal

intermediate

The North American Menopause Society. Menopause. 2007;14:357-369

Most Important Sex Organ in Women

Most Important Sex Organ in Women

What happens 5 years after menopause?

Testosterone For Post Menopausal Women?

Androgel Off Label Use in Women

• AndroGel contains testosterone, a Schedule III controlled substance as defined by the Anabolic Steroids Control Act.

• AndroGel is supplied in non-aerosol, metered-dose pumps. .

• AndroGel is also supplied in unit-dose aluminum foil packets in cartons of 30

Hot Then(1959) Still Hot Now (2014)