Menopause- Hormones, Lifestyle, and Optimizing Aging

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KEY POINTS

*The average age of menopause is 51.5 years in the United States. Twenty percent of women have essentially no symptoms, and 20% of women have severe symptoms. One percent of women are menopausal by age 40, and 5% by age 45.

*Classic symptoms include hot flashes (usually early on) and vulvovaginal atrophic symptoms, classically later on. Many women and providers do not recognize atypical symptoms, such as diffuse achiness.

*Hormonal therapy is the most effective intervention for symptomatic relief. Considerable controversy over estrogen usage has occurred over the past 17 years, with major rethinking on the topic over the past 2 years.

*Nonhormonal therapies and topical hormonal therapies are also available for women with symptoms who cannot take or prefer to avoid systemic hormone therapies.










PERSPECTIVE AND FUTURE DIRECTIONS

Many women will go through the menopause transition with minimal complaints. Some will suffer significantly, and many women will experience issues that neither they nor their care providers will associate with menopause. Even for those who escape significant symptomatology, much basic physiology is affected by the loss of estrogen. Hopefully the guidance presented in this article will help educate providers and their patients.

The American Geriatrics Society has recently published the Beers Criteria for potentially inappropriate medication use in older adults, in which they state that “systemic estrogen is a high-risk medication because of its carcinogenic potential and lack of cardiovascular protective effects.”26 Sadly, many insurers will then decline to pay for the cost of hormone therapy for their patients older than 65 based on this statement,26 which then places an undue burden on many women in their later years. However, ACOG has directly addressed this issue in its Committee Opinion 565, issued in 2013 and reaffirmed in 2018. Specifically, ACOG “recommends against routine discontinuation of systemic estrogen at age 65 years,” and instead recommends that “as with younger women, use of HT [hormone therapy] and ET [estrogen therapy] should be individualized based on each woman’s risk benefit ratio and clinical presentation.”27 We strongly recommend that the ACOG guidelines be very actively disseminated to insurers, through multiple media and with political pressure, if necessary, to ensure as best as possible, that women have ready access to hormone therapy and estrogen therapy if and when these therapies are required.

In the spirit of optimizing aging, a critically important recommendation for women is not strictly medical: it is the development of a long-term relationship with a fixed provider or group. With the proliferation of health-related propaganda on the Internet, quality-of-life issues need to be discussed with a longstanding and trusted provider.

We can never cease to reinforce the importance of a healthy lifestyle, with proper exercise and nutrition, independent of any pharmacologic advancements. To augment this point somewhat, many recent studies also have established the utility of some strength training as part of one’s workout or exercise regimen, for improvement in both long-term cognitive capability and adverse event protection.

As we indicated earlier, the present extent of menopausal education to providers in training is quite inadequate. Accordingly, the development of educational tools and modules is acutely needed, as is enhanced training. Moreover, a delineation of the symptomatology and efficacy of treatment modalities among racial, ethnic, and sexual orientation subgroups is sorely needed, and quite timely.

As a final and overarching viewpoint, the decision of whether and how to use hormonal therapy is truly a paradigm example of the modern terminology of “shared decision making.” Science is evolving, and as our patients are living longer, we can all help them to lead healthier and happier lives.
 

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