Leah Lawrence

Women who experience an early natural menopause are at significantly greater risk for heart failure than woman who experience menopause between the ages of 50 and 54 years, according to the results of a study published in 

Iffat Rahman, PhD, from Karolinska Institute, Stockholm, and colleagues found that smoking modified this association by increasing the risk for heart failure even among women aged 46 to 49 years at menopause.

“Women who experience menopause at younger ages could benefit from screening for their increased risk of developing heart failure,” Rahman and colleagues wrote. “This could especially be promoted in smokers as a means for improving heart failure prevention strategies.”

The study used data from 22,256 postmenopausal women in the Swedish Mammography Cohort, which included information on the age of natural menopause. The researchers obtained information on heart failure through the Swedish National Patient Register and the Cause of Death Register. The median age at menopause for these women was 51 years.

Women who had early menopause, defined as occurring between ages 40 and 45 years, had an almost 40% increased risk of heart failure compared with women who experienced menopause at a later age (HR=1.36; 95% CI, 1.16-1.60). In comparison, women whose menopause occurred between ages 46 and 49 years only had a 13% increased risk of heart failure (HR=1.13; 95% CI, 1.02-1.26). Each 1-year increase in age at menopause had a 2% lower risk of heart failure.

The researchers wrote that “a plausible explanation for the connection between age at menopause and cardiovascular disease is that the menopausal transition induces alterations in blood lipids, causing them to become more proatherogenic.”

The researchers also looked at how smoking status affected menopause and the risk for heart failure and found a significant association between age at menopause and smoking (

=.019). In the youngest age group of women, a similar increased risk of heart failure was observed regardless of smoking status. However, in women aged 46 to 49 years there was a 28% increased incidence of heart failure among ever smokers compared with 3% among never smokers.

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Women who experience menopause before age 46 have an increased risk of heart disease, and smoking status can modifying this risk in older women.

Early Natural Menopause Ups Risk of Heart Failure

Commercially available vaginal estrogens provide postmenopausal women with effective options for the management of genitourinary syndrome of menopause (GSM), according to a review published by the Society of Gynecologic Surgeons in 

“Among those patients with more bothersome vulvovaginal atrophy symptoms or urinary complaints of urgency, frequency, nocturia, or stress urinary incontinence and urgency urinary incontinence, vaginal estrogen therapy may offer substantial improvement in symptoms,” wrote David D. Rahn, MD, of the University of Texas Southwestern Medical Center, and colleagues from the Society of Gynecologic Surgeons Systematic Group Review.

For the review, the authors identified 44 studies that compared vaginal estrogen application with other methods used to treat genitourinary syndrome of menopause. Treatment methods included in the studies were vaginal estrogen tablets, creams, suppositories, and rings, and comparators included placebo, no intervention, systemic estrogen therapy, vaginal lubricants, and estriol products not approved in the United States but commonly used in other countries.

Fourteen of the studies compared vaginal estrogens with placebo. Results of these studies showed that the use of vaginal estrogen improved a variety of common genital and urinary complaints, including vaginal dryness, itching, dyspareunia, dysuria, urinary urgency and frequency, stress urinary incontinence, and urgency urinary incontinence.

The authors said that no significant differences in adverse events were found in the studies for patients treated with vaginal estrogen compared with placebo. However, they acknowledged that the data included in the studies on adverse events was variable.

Eighteen studies comparing vaginal estrogens to each other were identified, and the results showed that there were no major differences in efficacy or safety between various vaginal estrogen preparations. In addition, very low rates of endometrial hyperplasia and adenocarcinoma were diagnosed among women receiving vaginal estrogen.

Finally, when comparing vaginal estrogens to nonhormonal lubricants, those patients who had at least two symptoms of vulvovaginal atrophy derived greater benefit from the use of vaginal estrogens than they did with nonhormonal lubricants.

Based on the results of this review, the group included several guidelines, three of which were graded as strong guidelines with high-quality supporting evidence:

- The group recommended application of vaginal estrogen, such as estradiol vaginal ring and tablet, when patients present with urogenital atrophy complaints or are reporting urgent urinary incontinence.

- They recommended application of any commercially available vaginal estrogen at approved doses and frequencies in patients with urogenital atrophy complaints.

- They recommended application of vaginal estrogen, such as estradiol vaginal ring and estradiol products, in patients who present with recurrent urinary tract infection with or without urogenital atrophy complaints.

However, the authors also acknowledged that “nonhormonal lubricants may be a useful alternative for patients with mild or few urogenital atrophy complaints and in women at risk for estrogen-responsive neoplasia.”

Vaginal estrogens are effective options for managing bothersome symptoms related to genitourinary syndrome of menopause in postmenopausal women.

The Utility of Vaginal Estrogens for Managing GSM

Postmenopausal woman may have a reliable nonhormonal treatment option available to help reduce vasomotor symptoms, according to the results of a pooled analysis of two phase III studies recently published in 

In the analysis, the use of paroxetine 7.5 mg among postmenopausal woman significantly improved the number of nighttime awakenings caused by vasomotor symptoms and increased sleep duration.

“Improvements in nighttime awakenings and sleep duration occur without increased sedation, reduced sleep onset latency, or increased sleep-related adverse events, suggesting that, in these studies, paroxetine 7.5 mg has a selective therapeutic effect on sleep parameters related to vasomotor symptoms,” wrote researcher JoAnn V. Pinkerton, MD, of the University of Virginia, Charlottesville, and colleagues.

Pinkerton and colleagues collected data from two phase 3 studies of paroxentine. In the studies, postmenopausal woman were randomly assigned to paroxentine 7.5 mg (n=591) or placebo (n=593). Both studies looked at the drug’s efficacy and safety for 12 weeks; one of the two studies extended this analysis to 24 weeks.

All enrolled patients completed regular assessments of nighttime awakenings attributed to vasomotor symptoms, sleep-onset latency, sleep duration, and sleep-related adverse events.

Comparing the two treatment groups, women assigned paroxentine had a 39% reduction in nighttime awakenings due to vasomotor symptoms by week 4 compared with a 28% reduction reported among women assigned placebo (

=.0049). At week 12, women assigned to the study drug had a 54% reduction in awakenings compared with a 43% reduction in the placebo arm (

=.0001). This benefit was sustained among women assigned to paroxetine when looking at data from the study that extended observation to 24 weeks.

Paroxetine was also associated with an increase in sleep duration in the two studies. By week 4, women assigned to the drug reported an 8% improvement in sleep duration, about 31 minutes, compared with a 4% improvement, or 16 minutes, in the placebo arm (

=.0075). This improvement was sustained through weeks 12 and 24.

“The improvement in sleep duration with paroxetine 7.5 mg (an increase of up to 37 min/night from baseline) compares favorably with results obtained with agents used specifically for the treatment of insomnia, such as zolpidem, which has been shown to increase total sleep time by 51 minutes or more per night,” the researchers wrote.

A similar proportion of patients in each arm reported sleep-related treatment-emergent adverse events, with 3.1% of patients in each arm reporting at least one.

Paroxetine may be a reliable nonhormonal treatment option to help reduce vasomotor symptoms and improve sleep in postmenopausal women.

Improving Sleep Duration in Postmenopausal Women

Menopause occurs naturally in most women who live to late adulthood, occurring on average at age 52 years. By 2025, it is estimated that there will be 1.1 billion postmenopausal women worldwide.

Although every woman will eventually experience menopause, either naturally or surgically, each woman may have a unique experience with this stage of life. In the time leading up to menopause, women can experience a variety of symptoms, including irregular periods, mood changes, thinning hair, sleep problems, weight gain, vaginal dryness, and more.

However, research has shown that vasomotor symptoms, or hot flashes, are the symptoms for which most women seek help from a health care professional.2 It is estimated that hot flashes occur in up to 75% of women, and that some women may experience them for 10 years or longer.

“About 50% of patients are having moderate to severe hot flashes when they are asked to grade them, which can be disruptive to their personal lives and professional lives,” said Patricia Sulak, MD, an OB/GYN at Scott & White Hospital/Clinic and Texas A&M College of Medicine. “They are also left wondering what else is going on within their bodies. … What are the invisible consequences?”

According to Sulak, because women are experiencing a new phase of life with a new set of symptoms, it is important that they tune in to their own bodies and experiences and that they have an open partnership with their physician to effectively manage this transition.

Because the symptoms of menopause can be so varied, it is important that any treatment program be individualized to the patient. Treatments options for women experiencing menopause include both nonprescription and prescription options.

Women going through menopause may be advised to increase their calcium intake, either through dietary changes or through calcium supplementation, to help prevent skeletal-related events. Currently, the Institute of Medicine recommends 1,000 mg/d of calcium for women aged 50 years or older. Increased intake of vitamin D or magnesium may also be recommended. However, the best way to ensure high intake of these important nutrients is with a healthy diet that includes vegetables, fruits, low-fat dairy products, whole grains, chicken, fish, and nuts.

Women in the perimenopause stage may be able to take low-dose oral contraceptives, which can help to reduce hot flashes, vaginal dryness, or moodiness. In addition, if an older woman does not wish to conceive, low-dose contraceptives may be advised until 1 year after the last menstrual period.

One of the most effective treatment options for vasomotor symptoms available to women is hormonal therapy. Current recommendations suggest the use of the lowest dose possible for the shortest time possible to control the symptoms of menopause. In many cases, progestin will be prescribed in combination with estrogen. In women who may have contraindications to hormonal therapy with estrogen, selective serotonin reuptake inhibitors have been shown to decrease hot flashes.

Women whose main symptom or concern is vaginal dryness have a few treatments available to them, including lubricants and vaginal moisturizers, and some of these products may include estrogen.

Finally, in women at risk for osteoporosis, physicians may prescribe medications that help to reduce bone loss or the risk for fractures.

“There are a lot of treatment options out there, from lifestyle changes to medications,” Sulak said. “Whenever you try a treatment, you should give it at least 6 to 8 weeks to have an effect.”

Sulak said that one of the first things she discusses with woman going through menopause is that the healthier they are, the more treatment options there are. In contrast, if a woman has a lot of medical problems, certain treatment may be off the table.

“Women can get frustrated about these changes and are not sure if the changes are due to hormones or the aging process,” Sulak said. “I advise my patients to take the time to focus on their health and make sure they are getting good information.”

Health care providers should be providing woman entering menopause with information about the variety of symptoms they may begin to experience and should present the patient with an individualized treatment plan. However, patients may also seek to gain information about menopause from outside sources as well.

Sulak recently partnered with Pfizer on its Tune In To Menopause campaign and the website 

, where women can go to find out more about menopause and take a quiz to find out more about their “menopause style.”

“Remember that when it comes to menopause, it is not one size fits all,” Sulak said.

1. Shifren JL, Gass ML, NAMES Recommendations for Clinical Care of Midlife Women Working Group. The North American Menopause Society recommendations for clinical care of midlife women. 

2. Williams RE, Kalilani L, DiBenedetti DB, et al. Healthcare seeking and treatment for menopausal symptoms in the United States. 

Menopause will be unique for each woman, and a physician-patient partnership is a must if women want effective menopause management.

Leah Lawrence

Articles

Early Natural Menopause Ups Risk of Heart Failure

The Utility of Vaginal Estrogens for Managing GSM

Improving Sleep Duration in Postmenopausal Women

Physicians, Patients Must Partner for Menopause