Clinical Review

2019 Update on menopause

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Expert panel creates evidence-based guidance

Against this backdrop, The North American Menopause Society and the International Society for the Study of Women's Sexual Health convened a group comprised of menopause specialists (ObGyns, internists, and nurse practitioners), specialists in sexuality, medical oncologists specializing in breast cancer, and a psychologist to create evidence-based interdisciplinary consensus guidelines for enhancing quality of life and sexuality for breast cancer survivors with GSM.

Measures to help enhance quality of life and sexuality

The group's key recommendations for clinicians include:

  • Sexual function and quality of life (QoL) should be assessed in all women with or at high risk for breast cancer.
  • Management of GSM should be individualized based on shared decision-making involving the patient and her oncologist.
  • Initial treatment options include:

—over-the-counter vaginal moisturizers used several times weekly on a regular basis
—lubricants used with intercourse
—vaginal dilator therapy
—pelvic floor physical therapy.

  • Low-dose vaginal estrogen therapy may be appropriate for select women who have been treated for breast cancer:

—With use of vaginal estrogen, serum estradiol levels remain in the postmenopausal range.
—Based on limited data, use of vaginal estrogen is associated with a minimal risk for recurrence of breast cancer.
—Because their use is associated with the lowest serum estradiol levels, vaginal tablets, rings, or inserts may be preferable to creams.
—Decisions regarding use of vaginal estrogen in breast cancer survivors should involve the woman's oncologist. Appropriate candidates for off-label use of vaginal estrogen may be survivors:

–who are at relatively low risk for recurrence
–with hormone receptor-negative disease
–using tamoxifen rather than an AI
–who are particularly concerned about quality of life.

—Given that AIs prevent recurrence by lowering estrogen levels, oncologists may be reluctant to consider use of vaginal estrogen in survivors using adjuvant agents.
—With respect to use of vaginal estrogen, oncologists may be more comfortable with use in patients taking tamoxifen.

  • Neither intravaginal dehydroepiandrosterone (DHEA; prasterone) nor the oral selective estrogen receptor modulator ospemifene has been studied in breast cancer survivors.

In women with metastatic disease, QoL, comfort, and sexual intimacy are key considerations when weighing potential therapies; optimal choices will vary with probability of long-term survival.

Although more data addressing the safety of vaginal estrogen as well as prasterone and ospemifene in breast cancer survivors clearly are needed, these guidelines should help clinicians who care for breast cancer survivors with GSM.

Framework provided for managing depressive disorders in perimenopausal women

Maki PM, Kornstein SG, Joffe H, et al; Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25:1069-1085.

Although perimenopausal women are more susceptible to the development of depressive symptoms and major depressive episodes (MDE), there is a lack of consensus regarding how to evaluate and treat depression in women during the menopausal transition and postmenopausal period.

Recently, an expert panel comprised of representatives from The North American Menopause Society and the National Network of Depression Centers Women and Mood Disorders Task Group developed clinical guidelines addressing epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of HT, and efficacy of other therapies. Here we provide a summary of the expert panel's findings and guidelines.

Continue to: Certain factors are associated with higher risk for depression...

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