Dr. Kay Nay Kwok - Torrance Memorial Medical Center

Postmenopausal Therapy Vaginal Dryness Cancer Screening Kay May Kwok, M.D., F.A.C.O.G. Obstetrics, Gynecology, & Infer4lity A Flash From the Past…and a Promising Future The EvoluFon of Treatment OpFons for Menopause 2
Menopause Treatments Through the Years 3
A Historical Look at Treatment !   Since the 1940s, millions of women have received hormone ! 
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therapy (HT) HT was viewed as natural, giving the body back something it had become deficient in (estrogen) HT was and sFll is proven to relieve vasomotor menopausal symptoms: hot flashes and night sweats Prior to WHI, HT was thought to prevent heart disease, osteoporosis, and cancer, as well as improve a woman s quality of life Two medicaFons were commonly given: ! 
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Premarin®: an estrogen Prempro®: a combinaFon of estrogen and progesFn Premarin® and Prempro® are registered trademarks of Wyeth Pharmaceuticals, Inc.
What s a Woman to Do? !   In 2002, news reports from a study of hormone therapy began to appear !   Women were in for a roller-­‐coaster ride of conflicFng informaFon… 5
Hormone Therapy in the Media 2002
U.S. Stops Study on
Hormone Therapy
by Rita Rubin, USA TODAY
2003
Hormone Therapy Undergoes
Rise and Fall
by Stephen Smith, THE BOSTON GLOBE
2004
New Hormone Therapy Risks Study:
Additional Risks for Women on
Estrogen-Alone Therapy
by Rome Neal, CBS NEWS, THE EARLY SHOW
2005
Hormone Therapy Tied to
More Severe Strokes
by Miranda Hitti, FOX NEWS
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2006
On 2nd Thought, Estrogen
Can Help: Safe Window Found for
Hormone Therapy
by Judy Peres, CHICAGO TRIBUNE
2007
A Boost for Hormone
Therapy
by Alice Park, TIME
2008
Hormone Therapy Safe,
Effective for Women
Entering Menopause
FORBES.COM
2009
Hot Flash: Hormone Therapy is
Back
by Naomi Barr, OPRAH.COM
Findings From the WHI 7
The Women s Health IniFaFve (WHI) A landmark research initiative that started in 1991; over 27,000
women enrolled in the Hormone Therapy Trial.
!   Set out to evaluate what effect menopausal hormone therapy would have ! 
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on heart disease prevenFon, breast and colorectal cancer, bone loss, and other outcomes Did not evaluate effecFveness of hormone therapy as treatment for menopausal symptoms Treatment included placebo, estrogen alone (Premarin®), or estrogen + progesFn (Prempro®) once daily for a planned 8 years Women receiving estrogen alone were found to be at an increased risk for stroke and blood clot Women receiving estrogen + progesFn experienced an increased risk for breast cancer, heart disease, stroke, and blood clots Study caused healthcare community to rethink hormone therapy Led to posiFve changes in treatment opFons and pracFces A`er the WHI Boxed Warning: Applies to all estrogen therapies that treat hot flashes and vaginal symptoms, regardless of type, delivery, and dose !   Increased risk of cancer of the uterus !   Increased risk of heart aaacks, strokes, breast cancer, and blood clots !   Increased risk of demenFa !   Talk regularly with your healthcare professional about whether you sFll need treatment 9
A`er the WHI !   Estrogen is an effecFve treatment for hot flashes, night sweats, vaginal dryness, and prevenFon of osteoporosis !   It s important to weigh the benefits and risks !   With all the variables that must be considered—personal and family histories, lifestyle—individualizing treatment is criFcal !   The FDA has approved newer therapies, including bioidenFcals, that offer lower doses to treat specific menopausal symptoms 10
Know Your OpFons Treatment Comes in Many Different Forms 11
Educate Yourself, Empower Yourself
Find out what s right for you, your lifestyle, your body, and your symptoms 12
Lifestyle Changes !   Avoid triggers !   Stay as cool as possible !   Exercise !   PracFce relaxaFon techniques 13
Hormone Therapy !   PrescripFon hormone therapies—estrogen alone or in combinaFon with progesFn—are the only proven and approved treatments for hot flash/night sweat relief. There are many opFons, including: ! 
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BioidenFcal and FDA-­‐approved estrogens Custom-­‐compounded hormones (not FDA-­‐approved) 14
What Is BioidenFcal Estrogen? !   Chemically idenFcal to the estrogen produced by women naturally (primarily in the ovaries) before menopause !   Commonly derived from plant sources !   Some bioidenFcal prescripFons are well-­‐known FDA-­‐approved brands !   Look for an accompanying package insert or prescribing informaFon to ensure the product is FDA-­‐approved FDA-approved
estradiol
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Compounding
estradiol
Custom-­‐Compounded Hormones !   Some custom-­‐compounded formulaFons—made using chemical recipes —are also called bioidenFcal !   Custom-­‐compounded hormones offer the benefit of individually tailored doses and mixing of different hormones !   Custom-­‐compounded formulaFons are not FDA-­‐approved and have not been tested for purity, potency, efficacy, or safety !   However, some acFve ingredients may be available in some FDA-­‐approved products 16
Current FDA-­‐Approved Delivery OpFons Hormone treatment comes in several different formulaFons: !   Oral tablets (AcFvella®, Angeliq®, CenesFn®, Enjuvia™, Estrace®, Femhrt®, Femtrace®, Menest®, Ortho-­‐Est®, Prefest®, Premarin®, Premphase®, Prempro®) !   Vaginal prepara=ons (Estrace® Vaginal Cream, Estring®, Femring®, Premarin® Vaginal Cream, Vagifem®) !   Transdermal prepara=ons ! 
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Gels (Divigel®, Elestrin™, EstroGel®) LoFon (Estrasorb®) Spray (Evamist™) Patches (Alora®, Climara®, Climara Pro®, Combipatch®, Esclim®, Estraderm®, Menostar®, Vivelle-­‐Dot®) A Word About Oral and Vaginal MedicaFon Delivery !   Oral estrogen must first pass through your liver before it exposes your enFre body to medicaFon !   Vaginal preparaFons may act locally or throughout your body by entering your system through the vaginal membrane ! 
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Vaginal preparaFons that act locally are not indicated for hot flashes If estrogen is prescribed for vaginal symptoms only, local preparaFons should be considered The Benefits of Delivery Through the Skin (Transdermal) !   Allows estrogen to be absorbed through the skin and enter the bloodstream directly !   Bypasses the digesFve system !   Avoids first-­‐pass metabolism by the liver, allowing for lower doses of drug ! 
The possibility of fewer side effects !   Fewer fluctuaFons in hormone concentraFons in the blood than seen with oral drugs, resulFng in relaFvely level concentraFons !   Convenient 19
Natural Remedies !   Commonly used supplements include !   Soy, isoflavones (other plant estrogens) !   Black cohosh !   ScienFfic evidence is o`en not reviewed by the FDA !   Not Fghtly regulated !   Relief may be due in part to a placebo effect !   Not risk-­‐free 20
Finding What s Right for You Are You a Candidate for Estrogen Therapy? 21
Who SHOULD Consider Hormone Therapy? Hormone therapy may be considered for women who: !   Are experiencing moderate to severe hot flashes ! 
These include night sweats, which can cause frequent waking and other sleep disturbances !   Have vaginal dryness or irritaFon !   Need to prevent postmenopausal osteoporosis and are at significant risk of osteoporosis* *Careful consideraFon should be given to nonestrogen therapies. 22
Common Estrogen Side Effects These are side effects that are commonly reported: !   Uterine bleeding (starFng or returning) !   Breast tenderness or pain (increased density and someFmes enlargement) !   Nausea !   Abdominal bloaFng !   Fluid retenFon in extremiFes !   Changes in the shape of the cornea of the eye (someFmes leading to contact lens intolerance) !   Headache (someFmes migraine) !   Dizziness !   Hair loss 23
Who Should NOT Consider Hormone Therapy? Hormone therapy should not be used for women who may be pregnant or who have: !   Unusual vaginal or uterine bleeding !   Had certain cancers, including cancer of the breast or uterus !   Had a stroke or heart aaack in the last year !   Had blood clots !   Had liver problems 24
Summary !   Perimenopause and menopause are natural phases of your life !   The physical and psychological changes may have a real impact !   Work with your healthcare professional to understand your opFons and make the best choice for you and your lifestyle 25
AddiFonal InformaFon !   The American College of Obstetricians and Gynecologists: www.acog.org !   Food and Drug AdministraFon, FDA Office of Women s Health, ! 
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Menopause and Hormone Therapy InformaFon: www.FDA.gov/womens/menopause/default.htm NaFonal InsFtute on Aging, NaFonal InsFtutes of Health: www.nia.nih.gov NaFonal Women s Health Resource Center: www.healthywomen.org The North American Menopause Society: www.menopause.org The Office on Women s Health, US Department of Health and Human Services: www.4women.gov/owh The US government Web site, MedlinePlus: hap://medlineplus.gov Vaginal Dryness Vaginal Dryness !   Vaginal atrophy = Atrophic vaginiFs – a common chronic condiFon that affects the vagina and surrounding Fssues !   Common in postmenopausal women and if both ovaries have been removed !   Characterized by symptoms: ! 
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vaginal dryness pain and bleeding with intercourse vaginal irritaFon or soreness itching in and around the vagina painful urinaFon !   Several effecFve treatments for vaginal dryness Vaginal Dryness Causes !   Estrogen maintains thickness of vaginal lining and sFmulates vaginal secreFons !   Atrophy occurs when ovaries produce decreased estrogen !   Times when less estrogen is made include: ! 
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At the Fme of menopause A`er surgical removal of the ovaries, chemotherapy, or radiaFon therapy of the pelvis for cancer A`er having a baby, parFcularly if you breasoeed While using certain medicaFons, such as danazol, Provera® or DepoProvera®, Lupron® !   Women who smoke cigareaes have an increased risk of an earlier menopause transiFon as compared to non-­‐smokers Vaginal Dryness Treatment !   There are two treatment opFons for women with vaginal dryness ! 
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moisturizers/lubricants vaginal estrogen !   All vaginal dryness treatments work temporarily !   The vaginal dryness will return when the treatment is stopped unless the ovaries make more estrogen Vaginal Lubricants !   Reduce fricFon and discomfort from dryness during sexual intercourse !   Lubricant applied inside the vagina or on the penis just before having sex !   Products designed as vaginal lubricants (Astroglide®) are more effecFve than those not designed for this purpose (petroleum jelly – Vaseline®) !   Oil-­‐based lubricants (petroleum jelly, baby oil, or mineral oil) !   may damage latex condoms and/or diaphragms and make them less effecFve in prevenFng pregnancy or sexually transmiaed infecFons !   can be used with polyurethane condoms !   Water or silicone based lubricants can be used with latex condoms and diaphragms !   Natural lubricants (olive, avocado or peanut oil) Vaginal Moisturizers !   Vaginal moisturizes (Replens®, Moist Again™, Vagisil®, K-­‐Y® Silk-­‐E®, and Feminease®) are formulated to allow water to be retained in the vaginal Fssues !   Applied into the vagina 3 Fmes weekly to allow a conFnued moisturizing effect !   Should not be used just before intercourse, can be irritaFng !   Hand and body loFons should not be used since can be irritaFng to vaginal Fssues Vaginal Estrogen !   Most effecFve treatment opFon for women with vaginal dryness !   Must be prescribed by a healthcare provider !   Very low doses of vaginal estrogen can be used when it is put into the vagina to treat vaginal dryness !   Small amount of estrogen is absorbed into the bloodstream, but only about 100 Fmes less than when using estrogen pills Much lower risk of side effects (blood clots, breast cancer, and heart aaack) compared with other estrogen-­‐containing products (birth control pills, menopausal hormone therapy) Vaginal Estrogen !   Estrogen cream (Premarin®, Estrace® cream) !   inserted into the vagina every day for 2-­‐3 weeks, then 1-­‐2 Fmes per week !   Estrogen tablet (Vagifem®) ! 
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inserted inside the vagina via a disposable applicator taken every day for 2 weeks and then 2 Fmes per week !   Estrogen ring (Estring®) ! 
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flexible plasFc ring worn inside the vagina all the Fme replaced every 3 months does not need to be removed during sex or bathing cannot be felt by most women or their sexual partners Is Vaginal Estrogen Safe? !   How long can I use it? !   Safe and can probably be used indefinitely !   Is it safe for women with a history of breast cancer? ! 
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Vaginal estrogen in women with prior breast cancer is unclear Small amount of estrogen can be absorbed into bloodstream If you have a history of breast cancer, talk to your healthcare provider or your oncologist about the potenFal risks and benefits of vaginal estrogen Sexual AcFvity !   Vaginal estrogen improves vaginal dryness quickly, usually within a few weeks !   You may conFnue to have sex as you treat vaginal dryness because sex itself can help to keep the vaginal Fssues healthy !   Sexual acFvity (including masturbaFon) may help the vaginal Fssues by keeping them so` and stretchable and prevenFng the Fssues from shrinking !   If sex conFnues to be painful despite treatment for vaginal dryness, talk to your healthcare provider Gynecologic Cancer Screening Cervical Cancer !   Cervical cancer screening (tes=ng) should begin at age 21 !   Women between ages 21 and 29 should have a Pap test every 2 years !   Women aged 30 years and older should have a Pap test plus an HPV test ! 
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(called co-­‐tesFng ) every 2 years !   A`er 3 normal Pap tests in a row, Pap every 3 years Women aged 65-­‐70 can stop having Pap tests a`er 3 normal in a row within the past 10 years A woman whose uterus and cervix have been removed for reasons not related to cervical cancer or pre-­‐cancer does not need Pap tests A woman who has been vaccinated against HPV should sFll follow the screening recommendaFons for her age group Some women – because of their history – may need to have a different screening schedule for cervical cancer Human Papillomavirus (HPV) !   Spread skin-­‐to-­‐skin contact, sexual contact !   No signs or symptoms of infecFon !   Very common !   Low risk HPV→ genital warts, High risk HPV→ cervical cancer !   Immune system usually clears HPV before causes cancer !   Pap plus HPV test screen for cervical cancer !   Protect from HPV by: ! 
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HPV vaccine Limit number of sexual partners Use condoms to reduce risk of infecFon Endometrial (Uterine) Cancer !   Endometrial cancer is most common type of gynecologic cancer in the US !   All menopausal women should be told about the risks and symptoms of ! 
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endometrial cancer Symptoms: abnormal bleeding, sporng, vaginal discharge, bleeding or sporng a`er menopause No screening tests to detect EM cancer in women with no symptoms Several methods may be used to detect whether EM cancer is present: !   Endometrial biopsy !   Vaginal Ultrasound !   Hysteroscopy !   DilaFon and cureaage (D&C) EM cancer can be diagnosed only by examining Fssue from the uterus Ovarian Cancer !   Ovarian cancer is the leading cause of death from gynecologic malignancy in the US !   There is no good screening test for ovarian cancer !   Screening tests for high risk women: ! 
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CA-­‐125 Pelvic Ultrasound Combined CA-­‐125 and Pelvic Ultrasound Breast Cancer !   Yearly mammograms are recommended starFng at age 40 ! 
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and conFnuing for as long as a woman is in good health Clinical breast exam (CBE) every 1-­‐3 years for women in their 20s and 30s and every year for women 40 and over Women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. Breast self-­‐exam (BSE) is an opFon for women starFng in their 20s Some women – because of their family history, a geneFc tendency, or certain other factors – should be screened with MRI in addiFon to mammograms Talk with your doctor about your history and whether you should have addiFonal tests at an earlier age Breast DiagnosFc Center