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The Menopause Manifesto with Dr. Jen Gunter

Jen Gunter, MD and Neda Frayha, MD
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Menopause is as natural a transition as puberty, but is not as openly discussed and can even feel taboo. Dr. Jen Gunter is trying to change this and even wrote a book about it: The Menopause Manifesto. In this conversation, Neda discusses her book and what primary care clinicians need to know about menopause.

Pearls:

  • Provide anticipatory guidance for your patients about the natural process of menopause and what to expect in that transition.

  • When people have menopausal symptoms but are not yet in menopause, they may be in early transition and may respond to symptomatic treatment.

 

  • Definitions:

    • Menopause = phase of life that happens at the end of ovulatory function that technically starts with the final menstrual period but can also refer to the entire menopause transition onwards

    • Menopause transition = pre-menopause = time leading up to the final menstrual period, kind of like puberty but in reverse

    • Perimenopause = menopause transition + 1 year after the final menstrual period

  • Why is it underdiagnosed and dismissed?

    • Women are dismissed

    • Language:

      • Treatment of symptoms are couched in unpleasant terms like increasing your risk of breast cancer and heart attack

      • Words used to describe the science is often described as loss or insufficiency, when the process is a natural thing that happens

  • Menopause symptoms that may be neglected:

    • Sleep disturbance

    • Depression

    • Joint pain

  • Work-up:

    • Ask people to make a list of symptoms that bother them so you can really hone in on concerning symptoms

      • "I want to hear everything because what's bothering you might not be what's bothering me."

    • Set expectations:

      • "Well, if there's a long list, this is a complex problem and we’ll need several visits to help you feel better."

      • "Let's focus on the two most bothersome symptoms and let's see what we can do about those. And let's see what happens to the other ones."

      • “This is a process.”

    • Pearl: DO NOT order hormone testing routinely for menopause. Just like we don’t order tests for a child who is going through the normal process of puberty, we don’t need testing for the clinical diagnosis of menopause.

  • Weight gain in menopause:

    • Menopause itself is NOT associated with weight gain. Rather people age through the menopause transition. Aging is associated with loss of muscle mass and increase in visceral fat, which contributes to a slowing in metabolism.

    • Weight loss is possible with traditional means of caloric reduction and an increase in activity that you do during the day; however, it is slow.

      • Pearl: Take up a resistance or weight training program in one’s 30s

  • Management - MHT:

    • The Women's Health Initiative in 2002 has had a long-lasting impact on the reputation of menopausal hormonal therapy (MHT).

    • Indications:

      • MHT works well for: irregular bleeding, hot flashes, sleep disturbance

      • FDA approved for: hot flashes, prevent bone loss, treat vaginal dryness and atrophy, and also treat premature low estrogen levels

    • Ideal candidates:

      • Women < 60 or within 10 years of menopause without contraindications

    • Contraindications:

      • Personal history of breast cancer

      • Women who start MHT > 10 years after menopause or Women > 60 because of the higher risk of heart disease, storke, blood clots and dementia

    • Key points:

      • Important to set expectations that at least a 3 month trial is warranted for full effect

      • Start with the lowest effective dose

      • Transdermal estradiol is the safest

  • Management - non-MHT:

    • Hot flashes - gabapentin, venlafaxine, cognitive behavioral therapy

    • Sleep disturbance - progesterone 300mg daily, venlafaxine, gabapentin

    • Depression - venlafaxine, gabapentin

    • Supplements  are not recommended as they are unregulated and may be adulterated

    • Pearl: provide people with reliable online sites like the North American Menopause Society

 

References:

  1. Gunter, Jen. The Menopause Manifesto: Own Your Health with Facts and Feminism. New York, Citadel Press Books, 2021.

  2. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017 Jul;24(7):728-753. PMID: 28650869.

  3. North American Menopause Society. Link. Accessed 15 August 2021.

Christine W. -

Transdermal estrogen - wouldn't you need to use progesterone with it if a patient still has a uterus? It would be unopposed estrogen unless your patient has a hysterectomy.

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