The North American Menopause Society (NAMS) met in San Diego October 3 -6 2018. This organization was founded in 1989. It is a non-profit whose mission is to promote the health and quality of life of women during midlife and beyond. The membership includes clinical and basic science experts from medicine, nursing, sociology, psychology, nutrition, anthropology, epidemiology, pharmacy, and education.
Since we share the same mission, I am always excited to attend this conference. As you may imagine some of the info was over my layperson speak, however it is encouraging to note that the Menopause Specialists in the room received detailed explanation of how to test and treat the various symptoms of menopause. They were also alerted about new promising drugs and non-hormonal treatments that could help deal with some of the life altering issues. Here are some of the key takeaways from the conference:
Sexual Dysfunction & Vaginal Health:
Sexual dysfunction has many clinical sub-names that you may hear your Menopause Specialist speak about. Here are just a few of them: Female Sexual Dysfunction (FSD’s), Genitourinary Syndrome of Menopause (GSM), Hypoactive Sexual Desire Disorder (HSDD), Vulvovaginal Atrophy (VVA). The sisterhood speaks about these issues using completely different words such as: painful sex, low libido, and failure to orgasm.
Sadly, the biggest problem is that we don’t speak about these issues openly with our doctors and many doctors don’t ask us questions to help evaluate whether we are experiencing these difficult issues. Granted, sometimes we only have 15 minutes in the exam room with our doctors! This is barely enough time for us to put on that gorgeous gown (!?!?!) and get into those warm-cozy stirrups, get our pap smear and breast exam.
The important take-away is that if you are experiencing vaginal discomfort you more than likely will avoid intimacy and experience loss of libido. I always say if you would rather mop your kitchen floor than get in bed with your lover- get thee to your menopause specialist. There are a variety of options to deal successfully with these issues. Here are some to speak with your specialist about:
- Non-hormone options such as long-acting vaginal moisturizers and use of vaginal lubricants to decrease friction can reduce sexual discomfort.
There is a whole slew of moisturizers on the market. Check them out here.
If moisturizers and lubricants are not helping, time to speak to your doctor about local estrogen therapy or vaginal DHEA. Remember when it comes to the vagina, thin is out! Plump is in! FYI, NAMS continues to be upset that their efforts to get the FDA to change the “box warning” on localized hormone therapy came to no avail. Currently, they use the same box warning for localized hormone therapy and systemic therapy. NAMS will not give up!
I reached out to Dr. Rebecca Brightman who is a fellow of the American College of Obstetrics and Gynecology (ACOG) and the North American Menopause Society (NAMS) and is also a NAMS certified menopause practitioner, and an assistant clinical professor OBGYN and Reproductive Science at the Mount Sinai School of Medicine in New York City for her thoughts on this difficult menopausal symptom, she said, “I encourage my patients to be pro-active about maintaining vaginal integrity and not wait until the symptoms become too burdensome. I present my patients with various therapeutic options so that we can make a treatment plan that best addresses their needs.”
- If you are a cancer survivor your Menopause Specialist will want you to consult with your Oncologist. Sadly, lack of data and safety on women with or at high risk of breast cancer has led to avoidance in treatment which has negatively impacted the quality of life (QOL) and partnership relationships in these cancer survivors. Due to this lack of data, clinicians will try to evaluate a women’s risk of recurrence, consider if she is hormone receptor negative vs positive, and whether she is on Tamoxifen vs Aromatase Inhibitors. Then discuss her QOL. You are a partner in this conversation and should be comfortable with the protocol that you and your team decide.
- Orgasm – Guess what- the brain does speak with the vagina! The brain can, also, adapt to low interest in sex. Therefore, if you are not having sex, you can become ok with that new normal. However, your interest in sex can be activated again! I learned that when we have an orgasm, we have increased blood flow, but nothing is going on in our brain. So, for those seconds/moments we are orgasming we are not making To Do Lists. Good to know!
If you are experiencing problems orgasming currently, Flibanserin is FDA approved for this issue. It is serotonin based. They stressed that this drug takes many months to work. If you are using it, be patient!
The drug Bremelanotide(melanocortin receptor agonist) is currently being studied by the FDA. This is an injection you would take one hour before sex. This is dopamine based.
Over the counter: ArginMax was mentioned as showing some promise.
- Low Libido – If you have a penis there are over 30 drugs for this issue. If you have a vagina, we do not have an FDA approved drug yet. (Grrrrrrrrrr) However, many specialists are using testosterone off label for women and with great success. Nevertheless, if you or your partner are having libido issues it was recommended to have your Free and Total Testosterone and Sex Hormone Bind Globulin levels (SHBG) evaluated.
Currently being studied but not on the market yet:
Lybrido which is an oral testosterone. It contains testosterone and sildenafil – same ingredient that is used in Viagra.
Lybridos contains testosterone and buspirone which is a type of anxiety medication.
Sildenafil is currently used off label for women.
- Over the counter products mentioned that could help sexual dysfunction:
- Dry Vagina – Local estrogen therapy (LET) comes in an estradiol tablet, ring, or cream. Another option is vaginal DHEA – Intrarosa. Osphena – oral pill.
Laser Treatment – Clinicians use either a CO2 or YAG laser. This laser treatment is currently not FDA approved for the vagina. Many doctors are using this off label. The FDA recently sent warning letters to 7 companies that market these laser devices for vaginal rejuvenation. Good News -there is going to be a double-blind sham-controlled study coming soon. Stay tuned!
- Pelvic Floor health! Who knew??? Listen up………50% of post-menopausal women have GSM. What’s the pelvic floor have to do with it??? For more information on this read: MENOPAUSE MONDAYS Incontinence and Pelvic Floor Issues.
- Sexual Therapy – This was talked about with great hope. Apparently, there is much success in you and your partner doing some therapy. Remember Dr. Ruth? She always ended every interview with this same sentence, “Find a good sex therapist!”
- On a side note – if you or your daughter, daughter-law, or niece are prone to UTI’s…….check out this over the counter supplement – Ellura.
Longevity and Telomers:
Of course, I know what longevity means. Having just turned 65, my hope is that I lead a long healthy life. But, what in the world is a telomere? According to PubMed.com, “Telomeres are dynamic chromosome-end structures that serve as guardians of genome stability. They are known to be one of the major determinants of aging and longevity in higher mammals. Studies have demonstrated a direct correlation between telomere length and life expectancy, stress, DNA damage, and onset of aging-related diseases.”
Do we want long or short telomeres? Turns out, long telomeres as shorten telomers have been associated with age related diseases such as cancer, stroke, vascular dementia, cardiovascular disease, obesity, osteoporosis and diabetes. So, what can a gal do to lengthen them? A lot! Studies suggest that estrogen exposure increase telomerase activity in the body, the enzyme that protects and elongates the telomeres. Also, not smoking, a healthy weight (Mediterranean diet), and exercise elongate those babies! In addition, stress and environment can affect the rate of telomere shortening and health.
After this symposium, I have decided to get check out my telomere score. I am going to ask to have this test incorporated into my yearly physical, so my internist can keep track of the rate and direction of my telomere changes. This way we can adjust my nutrition, weight, exercise routing and other lifestyle modifications. As to supplementation there was no specific recommendation because there is no science yet on efficacy of telomere supplementation.
Who needs genetic testing???
Did you know that 12-14% of breast cancers are related to hereditary cancer predisposition syndromes? Approximately, 35,000 cases of breast cancer every year are attributable to hereditary risk.
The good news is that there are many new advances in cancer genetic testing.
The Speakers on this topic stressed to clinicians that patients with hereditary predisposition to breast cancer need to be identified at an early age more like 20 years old to ensure that they can benefit from better preventive protocols and care.
Here are some of the questions your doctor should ask you to screen for hereditary cancer:
- Have you or anyone in your family had cancer?
- What type and what age?
- If breast cancer, did it involve both breasts or was its triple negative?
- Is there a family history of ovarian cancer, male breast cancer, metastatic prostrate cancer of pancreatic cancer?
- Are you of Ashkenazi Jewish ethnicity?’
- Have you or anyone in your family had genetics testing for cancer?
When possible, encourage family members who are cancer survivors to get genetic testing. If they are worried about the cost, let them know that the Patient Protection and Affordable Care Act identifies BRCA testing as a preventative service. Medicare provides coverage for affected patients with qualifying personal history. Also, 97% of commercial insurers and most state Medicaid programs provide coverage for hereditary cancer testing.
If you were screened before 2013, it was recommended that you get another test as there are more snips and information available now.
I reached out to Dr. Brightman for her thoughts. Here is what she told me, “Women frequently feel that screening for BRCA 1 and 2 is enough, 10% of women at risk who are negative for BRCA 1 and 2 will be positive for another mutation that may be associated with an increased risk for hereditary cancers. While commercial kits are available to consumers, women should discuss which screening tests or panels are right for them. If their healthcare provider doesn’t offer genetic screening tests, then the patient should seek out genetic counseling services for appropriate screening.”
It is interesting to note that in 1970, there were no drugs under study for osteoporosis. Estrogen was used but there wasn’t much info helping to determine the correct dose for preventing bone loss. Today we understand that fractures are a disease and should not be regarded as part of normal aging. Huge advances have been made that help specialists understand the process of bone remodeling on both a macroscopic and cellular level.
It was recommended that doctors use goal directed treatment. Here is how it was defined in the session:
“Goal-directed treatment proposes that treatment should aim to achieve goals, such as BMD “T-score” that is at least higher than -2.5 (indicating osteoporosis) and freedom from fracture. For patients who start with a BMD T-score below -3, treatment with an oral bisphosphonate such as alendronate has a very low probability of reaching that BMD goal. Thus, patients with more severe osteoporosis and high risk of fracture, the best initial choice is a stronger agent that is more likely to improve BMD above the goal. In goal-directed treatment, follow-up focuses on progress toward achieving the goal with measurement of BMD and history of fracture – not “response” to treatment. However, response is less important than progress toward the goal. A patient may “respond” with a 2% increase in BMD but remain very far from a goal. In that case, for example, it would be warranted to switch to a more potent treatment despite the biological “response.”
Hopefully, this blog will give you some talking points with your Menopause Specialist. If you don’t have one – find one! The practitioners at this conference were given concrete tools to help them evaluate and address the issues of menopause. Therefore, I stress that you find a trained Menopause Specialist to be your partner in this menopause business.
Remember: Suffering in silence is OUT! Reaching out is IN.
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