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The Challenges of Menopause and Osteoporosis at ACOG 2022

Op-Med is a collection of original articles contributed by Doximity members.

What a wonderful time to be in person, instead of virtually, at the 2022 ACOG Annual Meeting held in San Diego. There were two talks that I thought were particularly helpful to ACOG participants. I will share key takeaways from the presentations.

The first was on Perimenopause Changes and Challenges, presented by myself, Dr. JoAnn Pinkertonand Dr. Nanette Santoro.

Perimenopause, or the menopausal transition, encompasses the time of physiologic changes which mark the progression toward a woman's final menstrual period (FMP). Perimenopause lasts for a variable amount of time, with a median of four years. This phase begins with the onset of menstrual irregularities and continues until a woman reaches menopause, one year after her last menstrual period. The changing hormone milieu manifests in varying symptoms that often present complex clinical management situations. Up to 90% of women present to health care providers for advice on coping with perimenopausal symptoms. 

Understanding the physiology of the menopause transition, the fluctuating and decline in ovarian function, the resultant systemic hormonal changes, and ultimately, symptoms will help providers and patients manage this transition. The early stage of perimenopause is defined by occasional skipped cycles. The later stage is characterized by greater menstrual irregularity, with periods of amenorrhea over 60 days and finally up to 12 months. Twelve or more months of amenorrhea defines the FMP and defines menopause. This plenary will explore the physiology of the menopausal transition and associated hormonal events, review common symptoms that characterize this period, and provide evidence-based recommendations for evaluation and treatment. Challenges during this time include management of abnormal uterine bleeding, contraception options, understanding what is expected and what is abnormal, and when to intervene. The menopausal transition is the portal to the second half of life for women but can be fraught with pitfalls to be avoided or managed through understanding the underlying physiology.

The top 10 perimenopausal symptoms that women complain of include: irregular menstruation and ovulation, loss of libido, hot flashes and night sweats, insomnia, increase in abdominal or 'belly fat,' changes in the breast size and shape with increased fat accumulation, and less connective tissue support, heart palpitations, brain fog with decreased concentration and memory, mood changes and fatigue. Abnormal bleeding may be controlled with oral contraceptives used cyclically or continuously, progestogen therapy (including levonorgestrel intrauterine systems), and tranexamic acid used during the cycle. Structural abnormalities should be identified, such as polyps, leiomyomas, or the development of hyperplasia. Perimenopausal depression may respond to estrogen therapy or may need antidepressants, either used alone or in combination. Memory and concentration changes are not dementia but may improve with adequate sleep, regular exercise, and a healthy diet. Perimenopausal women need guidance during this difficult time with help navigating the physical and emotional changes. 

The second was on ACOG’s new Clinical Management Guidelines on Osteoporosis, presented by Dr. Andrea Singer with myself, Dr. JoAnn Pinkerton on the panel discussion.

Osteoporosis is a silent disease until a fracture occurs. It is a common generalized skeletal disorder with low bone mineral density (BMD), loss of bone mass, and microarchitectural deterioration leading to a decline in bone quality, which increases vulnerability to fracture. This lecture will review ACOG's evidence-based clinical recommendations for osteoporosis screening, diagnosis, and prevention, focusing on identified health disparities. Key recommendations from the ACOG practice guidelines include: screening for osteoporosis in postmenopausal patients 65 years and older with bone mineral density testing to prevent osteoporotic fractures; screening for osteoporosis with bone mineral density testing to prevent osteoporotic fractures in postmenopausal patients under age 65 are at increased risk of osteoporosis, when a formal clinical risk assessment tool is used; pharmacologic osteoporosis treatment in patients who have a high risk of fracture. Advances in the treatment of osteoporosis, including using drug holidays from bisphosphonates to possibly decrease rare adverse effects, and the development of new medications to provide targeted treatment strategies lead to the need for new ACOG guidelines. Management of postmenopausal osteoporosis includes nonpharmacologic interventions such as exercise and nutrition. Newer anabolic therapies allow options for patients diagnosed with severe osteoporosis. In contrast, antiresorptive therapies, such as bisphosphonates and denosumab, are first-line therapies for women diagnosed with osteoporosis or following anabolic therapy to maintain bone density gains and fracture protection. Guidance on best patient selection for therapy included the new paradigm for those at the highest risk of fracture.

Key information included when to refer to bone specialists. These include the development of a new fragility fracture, the presence of normal bone mineral density and a fragility fracture, recurrent fractures or progressive bone loss despite osteoporosis treatment, osteoporosis that is unusual or not responding to treatment, endocrine or metabolic causes of secondary osteoporosis (e.g., hyperthyroidism, hyperparathyroidism, hypercalciuria, or elevated prolactin) or the presence of comorbidities that complicate treatment (e.g., chronic kidney disease, low glomerular filtration rate, or malabsorption syndromes).

A key concept is that osteoporosis is a lifelong disease that warrants lifelong attention. There is no known cure for osteoporosis. It turns out that retaining the diagnosis is consistent with other chronic diseases (diabetes, hypertension, etc.) There are adverse consequences of changing diagnosis to “osteopenia” once the bone density improves, including a false sense of security, stopping medication that is still needed, potential loss of insurance coverage for medication, or a change in allowable frequency of BMD testing. Guidelines are available to guide practitioners, not to take the place of clinical judgment. Individualization of patient goals and targets for therapy should be first priority. Dr. Singer closed with the reminder that osteoporosis is a chronic disease requiring lifelong management. While we now have an extensive menu of prevention and treatment options, treatment needs to be individualized; there is no single approach for all patients. With the newer anabolic therapies, determining the appropriate and optimal sequence is essential and will be a focus of research in the future.

Dr. Pinkerton has received grants from Bayer.

Image by gmast3r / GettyImages

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