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Improving the Lives of Menopausal Patients in More Ways Than One

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The North American Menopause Society 2018 Annual Meeting was focused on Innovation, Evidence, and Individualization: Moving Menopause Management Forward.

It was an exciting meeting full of updates on the care of menopausal women.

The keynote address was given by Dr. Elissa Epel, Professor in Psychiatry at UCSF was entitled “Healthy Longevity and Telomeres: What Does Sex Have To Do With It?” She is co-author of “The Telomere Effect” with Nobel laureate Elizabeth Blackburn. Their book on living longer, healthier lives is on NY Best Sellers list.

She delivered an engaging, comprehensive presentation on what telomeres are and the implications of changing their length. Telomeres are the protective caps at the end of each chromosome. Over time, due to each cell division, the telomere ends become shorter. An enzyme, telomerase reverse transcriptase, replenishes them. Aging and other insults to the body diminish telomere length.

She highlighted some genetic advantage of women in biological aging, which may explain our longer lives compared to men. Females have longer telomeres from birth, an additional 240 bp equal to about 8 years. Females have a slower epigenetic clock aging and more mitochondrial resistance, the pathway of cellular aging. Inflammation accelerates the aging process. Stress, obesity (which is inflammatory), poor nutrition all act to reduce our body’s defenses shortens the telomeres. Obesity reduces lifespan by 3 years and morbid obesity reduces lifespan by 6.5–13.7 years.

On the other hand, estrogen is anti-inflammatory and protects the telomere and mitochondria. Strategies to living a longer, healthier life included reducing stress, exercise, more sleep, eat healthy and having healthy social connections all lengthen the telomeres.

The #MeToo Movement is definitely a current issue. Dr. Rebecca Thurston presented her research on long-term adverse effects of sexual assault and harassment. She gave compelling evidence that a history of sexual harassment was associated with higher BP stage 1 or 2 hypertension and poor sleep consistent with clinical insomnia. Sexual assault history was associated with significantly higher odds of having clinically elevated depressive symptoms, anxiety and poor sleep. Both have a potentially significant impact on long-term health and well-being.

Trauma-Informed Counseling — Dr. Allison Johnson gave a very impactful and practical presentation on trauma-informed counseling. Given Dr. Thurston’s finding, it is more important, that we make providers aware, so providers have a heightened awareness to improve identification of patients and counseling is recommended, offered and available for women experiencing trauma. Her example of how the brain normally stores information in an organized way “like we would organize drawers.” Trauma scrambles the way our brain stores information. It’s not packed away neatly. There may be triggers stored in drawers with pleasant experiences resulting in triggers anxiety and depression when you expected fun. It is important to get help as soon as possible, and it is never too late.

Obesity — New this year was a session on obesity by Drs. Holly Wyatt and Ruth Freeman. More than 35% of Americans are obese. 100 million American adults are living with diabetes or prediabetes according to the CDC. Without significant changes, as many as 30% of people with prediabetes will go on to develop type 2 diabetes. Obesity is one of the biggest drivers of preventable chronic diseases and healthcare costs in the United States. In 2017, $327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity was spent on diabetes and obesity-related conditions.

The hormonal changes of menopause make you more likely to gain weight around your abdomen than around your hips and thighs, which is bad as it aligns with CVD. Hormonal changes alone aren’t necessarily the cause of menopausal weight gain it is usually related to aging, as well as lifestyle and genetic factors.

As healthcare providers, we must all engage in moving our patients to healthier lifestyles. Dr. Holly Hyatt differentiated between weight loss versus weight maintenance. Lifestyle management is the critical first step, even when pharmacological and surgical methods have to be employed if we don’t address enduring lifestyle changes to avoid yo-yo back weight loss. We recognize it is not easy. Weight loss is short-term goals, but maintenance is long term…the marathon!!! There are common characteristics in individuals that are able to maintain weight loss:

1) Eating breakfast every day- 78%

2) High levels of volitional physical activity- 90%, 1 hour a day

3) Reduced fat intake- 24% of calories from fat

4) Self-monitoring of dietary intake, activity and weight

5) Consumption of low or no calorie sweeteners

6) Limiting TV viewing — 62% watched

In other areas, we have some exciting new therapeutic options:

In genitourinary syndrome of menopause (GSM), aside from the non-hormonal options — lubricants and moisturizers, local estrogen — we have added vaginal DHEA — the FDA-approved Intrarosa for GSM.

On the horizon are vaginal energy devices, such as laser and radiofrequency. The data is promising, but we need longer-term safety data to ensure safety. These energy devices, like various lasers (CO2, Erbium Yag), and radiofrequency devices are NOT FDA approved. Currently, in the US it is widely marketed for off-label use for the genitourinary syndrome of menopause or “vaginal rejuvenation.” ACOG and other organizations discourage this term. There are ongoing clinical trials showing improvement in vaginal mucosa thickness, but we need more safety data and long-term follow up. In the current day use, there is no mechanism to report adverse outcomes such as vaginal burns, scarring, chronic pain and pain with sex. Consumer caution is advised until more safety and long-term data is available.

For VMS, we have a combined 17 B estradiol and micronized progesterone in one pill soon to be released. It will be a great addition for women wanting a natural option that are using the non-FDA compounding hormones currently.

Dr. Susan Reed presented on a potential new non-hormonal option for treatment of VMS using the KNDy receptor pathway, which may be approved soon. KNDy neurons are co-localized with > 95% of ER, PR, AR in the arcuate nucleus. Hyperactivation of KNDy neurons causes hot flashes. KNDy receptor releases neuropeptides…Kisspeptin, neurokinin, NKB actives KNDy Dynorphin inactivates KNDy. Look for new VMS therapeutic approach in this area.

Heredity Breast Cancer Screening — Dr. Holly Pederson’s take home was hereditary cancer is under-recognized The “Angelina Effect” has raised awareness of hereditary breast cancer and now there is a legal risk of not screening or counseling. There are more genes identified that increases risk other than BRCA1/2 and there are variances of unknown significance that shows up in screens. When in doubt refer to a genetic counselor. Many companies performing tests offer genetic counseling online.

There was just so much more!!! We will see you in Chicago for NAMS 2019.

Dr. Gloria Richard-Davis, MD, MBA, NCMP, FACOG is Professor & Division Director of Reproductive Endocrinology & Infertility at University of Arkansas Medical Sciences. She served as Chair of NAMS Scientific Committee for the 2018 annual meeting.

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