NAMS video series 2019: Understanding the etiology and mechanism of vasomotor symptoms

The North American Menopause Society (NAMS) regularly posts comprehensive videos for clinicians about important midlife health topics. All interviews in the series are hosted by NAMS Board of Trustees Member and Past-President Dr. Marla Shapiro, a Canadian physician who led this exciting initiative. Dr. Shapiro is also a medical consultant for CTV News.

In this first video of 2019, Dr. Rebecca Thurston, Director of the Women’s Biobehavioral Health Laboratory and Professor of Psychiatry, Psychology, Epidemiology, and Clinical and Translational Science at the University of Pittsburgh throws some light on the why and how about vasomotor symptoms (VMS).

The natural history of vasomotor symptoms is still evolving. It is estimated that about 75% of women experiencing menopause will have hot flashes. A substantial number of women seen in everyday gynecological practice or specialty menopause clinic report VMS well past the age of 60 and some well into the 80s.

Hot flashes considerably reduce the quality of life and hamper the day to day activities. Prevalence of VMS is generally associated with increased risk of CVD due to endothelial dysfunction. Hence, women with VMS could be screened for CVD risk factor and offered lifestyle modifications and frequent screening for early diagnosis and prevention.

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News from NAMS 2018: Interferential current relieves dyspareunia in women with Premature ovarian insufficiency

www.mccc.edu

Women who have premature ovarian insufficiency (POI) face an array of problems including infertility, an early risk of a CVD event, vulvovaginal atrophy (VVA) and painful sexual intercourse due to insufficient estrogen levels. Dyspareunia is still reported while on HRT and limits the ability to enjoy sex and achieve orgasm.

Vaginal estriol cream is the most commonly prescribed treatment to increase lubrication and relieve the symptoms associated with estrogen deficit.

A new form of treatment with the help of Interferential current now offers hope by improving lubrication; thereby, reducing pain and increased the frequency of satisfying sexual encounters.

Researchers from the University of Campinas, commonly called Unicamp, in São Paulo, Brazil recruited women between the ages of 18 and 50 with POI and taking HRT for this small RCT. Initially, 80 women were selected out of which 35 included in the study. The women were asked to fill out a sexual function questionnaire (FSFI) and randomized to receive either Interferential current (IC) compared to topical estrogen cream (E).

IC group received electrical stimulation of the pelvic floor, in a total of 8 sessions of 20 minutes each for a month. Women in the E group used .5mg of topical estrogen per day for four weeks.

The researchers looked at improvements in lubrication and sexual function score, and relief from pain during physical intimacy. Data analysis showed that while lubrication and dyspareunia improved significantly in both the groups, there was not much improvement in the FSFI scale for women on local estrogen therapy.

However, there was a significant improvement in pre and post-intervention FSFI scores among women who received interferential current therapy (p=0.0004). These women also reported a significant improvement in sexual satisfaction and frequency of orgasm thus enabling the increase in sexual activity.

“We were encouraged with these results as they reveal a new alternative for the treatment of sexual complaints,” says Dr. Helena Giraldo, lead author of the study.

“Although this was a small study, it opens the door for further research that will help identify more options for women to help improve their overall quality of life by making their sexual experience more enjoyable,” says Dr. JoAnn Pinkerton, NAMS executive director.

The study was also presented at the 18th World Congress of Gynecological Endocrinology in Florence, Italy.

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NAMS press release 

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North American Menopause Society (NAMS) video series about important midlife health topics: common cognitive complaints

The North American Menopause Society (NAMS) has started comprehensive video series for clinicians about important midlife health topics. All the interviews in the series are hosted by NAMS Board of Trustees Member and President Dr. Marla Shapiro, a Canadian physician, who led this exciting initiative.

In this latest video, Common Cognitive Complaints, Dr. Shapiro interviews Dr. Victor Henderson, NAMS Past President, Professor of Health Research and Policy and Neurology and Neurological Sciences at Stanford University and Director of the Alzheimer's Disease Research Center in Stanford, California. Dr. Henderson explains cognitive complaints as it relates to aging and decline in estrogen as well as the cardiovascular connection. He also provides advice for when advanced testing is required.   

Here is the video about Common Cognitive Complaints around perimenopausal and menopausal years. 

USPSTF issues draft recommendations on low-dose vitamin D and calcium for fracture prevention

http://www.huffingtonpost.com/ellen-sarver-dolgen/vitamin-d-calcium-supplements_b_3543283.html

The USPSTF today issued draft recommendations for effectiveness and potential harm of prescribing Vitamin D and Calcium in community dwelling men and pre-and post-menopausal women for the primary prevention of fractures.

Aging population, low bone mass and falls all contribute to a substantial health burden of fractures. Nearly 1 in 2 women older than 50 years of age will experience a fracture during her life time.

Currently, Vitamin D and Calcium supplementation are often advised for postmenopausal women to prevent fractures.

USPSTF recommendations on efficacy of Calcium and Vitamin D in preventing fractures are based on data from a total of 41,772 women across eight 8 RCTs with mean age between 53 to 80 years while for assessing the harm it reviewed the evidence from 9 RCTs with a total of 39,659 subjects, which also included 5,991 men.

The review of evidence concluded:

USPSTF found sufficient evidence to recommend against daily supplementation of 400 IU or less of vitamin D combined with 1,000 mg or less of calcium in prevention of fractures in postmenopausal women.

Evidence is also insufficient to make recommendations for greater than 400 IU of vitamin D and greater than 1000 mg of calcium supplementation in postmenopausal women.

At this time, there is insufficient evidence to determine the balance of benefits and harms of prescribing vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in men and premenopausal women.

USPSTF found sufficient evidence that supplementation with vitamin D and calcium increases the incidence of kidney stones, although the magnitude of this harm was small.

This recommendation does not apply to persons living in institutional or nursing home care or with a history of osteoporotic fractures or those who are at increased risk for falls. It also does not apply to persons with a diagnosis of osteoporosis or vitamin D deficiency.

USPSTF recommends screening for osteoporosis in women aged 65 or older and in younger women if they have a high fracture risk. Evidence is insufficient to recommend for or against screening for vitamin D deficiency in asymptomatic adults.

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Hormone replacement, Insulin sensitivity and Diabetes: Is there a critical window of opportunity?

This article is based on a commentary Dr JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women's Hospital and   a recent paper published in Journal of Clinical Endocrinology & Metabolism by Pereira R et al which concluded that there certainly is a time period in postmenopausal women when giving estrogen would alter the development of Insulin resistance and subsequent T2DM.

Pereira and colleague conducted a very small and short term RCT consisting of 46 postmenopausal women. Half of the subjects were less than 6 years into menopause and the other half were older and nearly 10 years past menopause.

All these women were given transdermal estradiol in high dose of 150 µg/day for a week.

After that they were given Glucose disposal rate ( GDR)  test which measures the rate of glucose uptake from the blood by the peripheral tissues, such as skeletal muscle with a hyperinsulinemic-euglycemic clamp.

There is no apparent time dependent decline in GDR with age or menopausal status per se. But, it was seen that after estrogen therapy  in younger women with less than 6 years into  menopause, a improvement in GDR and insulin sensitivity was observed , whereas those women who are older and further down the lane from menopause there was deterioration in GDR test and decrease in insulin sensitivity.

In the past there are several Randomized Control trials studying the effect of hormone therapy on diabetes in menopausal women. The data from the Heart and Estrogen/progestin Replacement Study (HERS), in which 2763 postmenopausal women with documented coronary heart disease (CHD) were randomly assigned to daily estrogen plus progestin therapy or to placebo showed that those assigned to hormone therapy had a 35% lower risk of diabetes.

Similarly two trials from the Women’s Health initiative also showed benefits, although the effect was smaller when using estrogen and progesterone as when using estrogen alone.

Now does that mean that HRT should be solely started to prevent the happening of diabetes? No, because HRT is associated with its own risks of venous embolism and stroke.

The study simply gives us one more reason to be optimistic and instrumental in starting HRT in those recently postmenopausal women who have other indications for hormone therapy, such as hot flashes and other symptoms where hormone therapy would be indicated. The study also points to important metabolic benefits of hormone therapy that should be studied in greater details with much larger trials. 

References:

Pereira RI, Casey BA, Swibas TA, et al. Timing of estradiol treatment after menopause may determine benefit or harm to insulin action. J Clin Endocrinol Metab. 2015;100:4456-4462. Abstract

Margolis KL, Bonds DE, Rodabough RJ, et al.; for the Women's Health Initiative investigators. Effect of oestrogen plus progestin on the incidence of diabetes in postmenopausal women: results from the Women's Health Initiative hormone trial. Diabetologia. 2004;47:1175-1187. Abstract

Kanaya AM, Herrington D, Vittinghoff E, et al.; for the Heart and Estrogen/progestin Replacement Study investigators. Glycemic effects of postmenopausal hormone replacement therapy: the Heart and Estrogen/progestin Replacement Study. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2003;138:1-9.

http://www.ndei.org/Glossary/Glucose_disposal_rate/

http://care.diabetesjournals.org/content/30/5/1143.full