VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANI

1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn ), F.I.A.O.G.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. What is VMS ?
• Vasomotor symptoms (VMS) are the
cardinal symptom of menopause,
affecting more than three-quarters of
midlife women.
• Symptoms typically last 5 to 7 years,
although some women continue to
experience symptoms for longer than 10
or 15 years…!!!
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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3. • The decline in estrogen levels that is
associated with menopause results in a wide
range of symptoms.
• The most common are vasomotor symptoms,
which include hot flashes (also referred to as hot
flushes) and night sweats.
• Other Menopausal symptoms may also
include dizziness, rapid irregular heartbeat,
atrophic vaginitis, bladder irritability, mood
changes, sleep disturbances, headaches,
myalgias, arthralgias, difficulty concentrating,
memory impairment, and general malaise.
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Dr Shashwat Jani.
99099 44160.
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Dr Shashwat Jani.
99099 44160.
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5. • Menopausal vasomotor symptoms occur in
as many as 74% of menopausal women and
evidence indicates that these symptoms are
present in higher percentages (up to 88%) of
perimenopausal women.
• These symptoms generally subside within
1 year; however, for some women, the
symptoms may persist for more than 30 years.
• Furthermore, they can have a marked
negative impact on health-related and global
quality of life (QOL) and often prompt visits to
health care professionals.
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Dr Shashwat Jani.
99099 44160.
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6. Signs and Symptoms During the
Menopausal Transition
Adapted from Bungay G et al. Br Med J 1980;281:181–3;
Van Keep PA et al. Maturitas 1990;12:163–70.
Vasomotor Symptoms
Sleep Disorders
Mood Changes
Urogenital Atrophy
Dyspareunia
Osteoporosis
Atherosclerosis
Coronary Heart Disease
Cerebrovascular Disease
40 yrs 50 yrs
Menopause
60 yrs
Menstrual Disorders

7. Physiology Of
Vasomotor Symptoms
• Correlated closely with estrogen withdrawal that
occurs with natural or surgical menopause.
• The key role of estrogen in menopausal
symptoms is supported by the fact that hormone
replacement is generally acknowledged as the
most effective therapy for reducing their
occurrence.
• However, estrogen withdrawal alone does not
explain the cause of menopausal vasomotor
symptoms.
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Dr Shashwat Jani.
99099 44160.
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8. • Estrogen withdrawal is necessary but not
sufficient to explain the occurrence of
menopausal symptoms.
• Normally the body maintains an optimal
temperature for metabolic activity through
vasodilatation and sweating when overheated
and shivering when cold.
• Postmenopausal women are thought to
have narrowing of this “thermoneutral zone”
such that small changes in temperature can
evoke the regulatory response of sweating or
shivering.
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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9. Hot Flashes
• Beginwith suddenonset of heat sensationin
the upper body,chestand face
– May be followed by sweating, palpitations, chills,shivering
• Causedbydisruption within
thermoregulatory circuits
– Coretemperature is regulated by the preoptic
nucleusin the hypothalamus, which is
innervated by serotonergic projections and
estrogenreceptors.
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Dr Shashwat Jani.
99099 44160.
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10. • Small increases in body temperature cantrigger hot
flashes
– Women experiencing hot flashes have anarrower
thermoregulatory zone than asymptomatic women
– Small changesin symptomatic women are sufficient to cross
the upper/lower normal thresholds, thereby provoking either
sweating andshivering
• Severity varies.
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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11. Night Sweat
• Night sweat are closely related to hot flashes,
Both usually occur simultaneously .
• Sweat can occur any time of the day or night,
they are more common at night .
• The sweat can be severe enough to wake up
the women from a sound sleep and may make
it difficult for her to go back to sleep .
• The sudden waking up from sleep can cause
palpitation and sometimes panic attacks
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Dr Shashwat Jani.
99099 44160.
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12. • The psychological changes are mainly
manifested by frequent headache, irritability,
fatigue, depression and insomnia .
• Although these are often said to be due to
changes in the hormonal levels, they are more
likely to be related to the loss of sleep due to
night sweat.
• Diminished interest in sex may be due to
emotional upset or may be secondary to painful
intercourse due to a dry vagina.
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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13. D/D of Vasomotor Symptoms
• Premenstrual syndrome (serum FSH
normal)
• Hyperthyroidism
• Pheochromocytoma (episodic HT)
• Carcinoid
• Occult infection
• Hodgkins disease
• Pre-existing obesity and weight gain (for
increased perspiration and warmth)
• Anxiety, guilt, strong emotions
• Rosacea
• Exercise, sex and stressful conditions
• Alcohol use and intolerance
• Routine spicy food, MSG
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Dr Shashwat Jani.
99099 44160.
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• Sunburns, heat stroke
• Dehydration, & circulatory disorders
• Ch. Bronchitis and emphysema
• Diabetes
• Chronic O2 deprivation
• Polycythemia vera
• Cushing syndrome
• SLE
• Certain Medications LIKE some anti-
diabetics, anticholesterol, some anti HT, Niacin
(all over flushing)

14. Management Options
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99099 44160.
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Advise on a healthy life style
Psychological support
Nonhormonal Therapy
Hormone replacement therapy

15. Healthy Lifestyle
Lifestyle modifications, including
• reducing core body temperature,
• regular exercise,
• weight management,
• smoking cessation,
• avoidance of known triggers such as hot
drinks and alcohol, may be recommended to
reduce mild vasomotor symptoms.
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Dr Shashwat Jani.
99099 44160.
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16. Cooling Techniques
These include Clothing Adjustments …
• dressing in layers;
• wearing sleeveless blouses,
• natural fiber clothing that breathes,
• light cotton night clothes;
• avoiding pullover sweaters/tops and scarves)
Environmental controls
• keeping a hand fan, electric fan, or ice water nearby;
• putting a cold pack under the pillow and turning the pillow when
feeling warm;
• using dual control electric blankets or a bed fan—a simple device
that blows air under the top sheet; and lowering the room
temperature).
However, no clinical trial evidence supports the efficacy of
cooling interventions as treatments for VMS
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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17. Herbals:
• Not FDA regulated
• Efficacy equal to placebo
 Black cohosh
 Red clover
 Soy
 Flaxseed
 Dong quai
 Wild Yam
 Ginseng
 Evening primrose oil
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Dr Shashwat Jani.
99099 44160.
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18. Vit – E
• Vitamin E shows very marginal efficacy in
reducing hot flushes (average reduction of one
hot flush per day).
• Dosage/side-effects: 800 to 1000
international units (IU) per day in divided
doses, taken with food.
• Although safety has not been established
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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19. Non-Hormonal Medications
• SSRI- paroxetine (Paxil)
– 60-65% effective
• SNRIs- venlafaxine (Effexor)
– 60-70% effective
• Gabapentin-(Neurontin)-anti seizure
– 60-70% effective
– Sedating
• Clonidine- anti hypertensive
– 45-50% effective
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Dr Shashwat Jani.
99099 44160.
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20. Non-hormonal treatments for VMS
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99099 44160.
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• SSRIs paroxetine, citalopram, escitalopram
• SNRIs venlafaxine, desvenlafaxine
• Gabapentin ( 300 – 900 mg/day )
• Clonidine ( 25 mcg – 75 mcg twice a day )
• Only Paroxetine 7.5 mg is FDA approved
• Most trials agent vs placebo and not HT
• Venlafaxine XR 75 mg vs estradiol 0.5 both
effective with slight advantage to estradiol

21. Warning…
• Possible acute liver disease with black cohosh use.
• Paroxetine should be avoided in women receiving tamoxifen
because it reduces the formation of one of the major
tamoxifen active metabolites .
• SSRIs must be used with caution in women with breast
cancer receiving adjuvant tamoxifen therapy since SSRIs
reduce the metabolism of tamoxifen to its most active
metabolite, endoxifen.
• MHT increases the risk of invasive breast cancer, which may
occur within 3 to 5 yr of initiation and rises progressively
beyond that time
• Gabapentin may increase the risk of suicidal thoughts or
behavior
• Desvenlafaxine may be associated with increase in
cardiovascular events and hepatotoxicity .
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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22. Hormones
 Estrogen and progesterone
Pills, patches
 Estrogen only
 H/0 Hysterectomy
Oral-Pills
 Usually about 1/4th dose of OCPs
Topically or transdermal-gels, patches
IM depot
Vaginally-creams, rings and tabs
 Low dose vaginal estrogen can be used in a woman with a uterus
 No guidelines for monitoring, at this time
 Progestins only, are also effective
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Dr Shashwat Jani.
99099 44160.
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24. HRT
• Includes a wide range of hormonal
products (estrogens, progesterone,
androgens, tibolone) with various methods
and routes of administration, and potentially
different risks and benefits.
• The International Menopause Society (IMS)…
HRT should be part of an overall strategy for
maintaining the health of peri- and
postmenopausal women.
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Dr Shashwat Jani.
99099 44160.
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99099 44160.
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• Individualized and tailored according
to symptoms.
• lowest effective dose for shortest
possible time – natural menopause

26. Estrogens & Progesterones Used
Estrogen Ultra Low Low Standard High
Conjugated equine estrogens (mg) 0.15 0.3 0.625 1.25
Micronized 17β-estradiol (mg) 0.52
1 2 4
Estradiol valerate (mg) 1 2
Transdermal 17β-estradiol (μg) 143
25 50 100
standard low
Medroxyprogesterone
acetate
2.5-5 mg/day 1.5 mg
Micronised progesterone 100-300 mg/day 50mg/day
Dydrogesterone
Noethisterone acetate
5-10mg/day
0.5mg/day 0.5 mg/day

27. • 17 beta estradiol(3.2mg patch)50 micro/day
• Changed twice a week;Effective E2/E1 ratio
TRANSDERMAL PATCH
• CEE(1.25MG/DAY)
• atrophic vaginitis, urinary symptoms
VAGINAL CREAM
PERCUTANEOUS GEL
IMPLANT, RINGS
• MDPA(2.5-5 mg/day)
• Decrease hot flushes, prevents osteoporosis
PROGESTINS
• 10-20 microgram/day 14microgram/day
• in combination with estrogens
LNG-IUS
FIBROPLANT
• 19-nortestosterone derivativeTIBOLONE
• Improves sexual healthANDROGENS

28. Types Of Oestrogens
• Oestrogens are available as tablets, skin patches,
and gels.
• Patches or gels may be better for those with gut
absorption problems.
• Patches or gels are also better for those who have
high triglyceride concentrations or who are at risk
of venous thromboembolic disease . This includes
those who are overweight and smokers.
• Vaginal oestrogen in creams, pessaries or tablets
is available for vaginal dryness or dyspareunia.
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Dr Shashwat Jani.
99099 44160.
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29. Uterus
Sequential therapy without tablet break
Regular bleeding at end of cycle
How is HRT Given?
Continuous Sequential HRT
Estrogen
Progestogen
Day 14
De Villiers TJ et al. Climacteric 2013;16:316–337.
.
Continuous Estrogen
Estrogen
No tablet break
No bleeding as no uterus
Uterus
Continuous Combined HRT
Estrogen
Progestogen
Day 14 Combined therapy without tablet break
No bleeding at end of cycle

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99099 44160.
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• Estrogen Therapy:
– Is the most effective treatment of menopausal vasomotor
symptoms (VMS).
– Must be paired with a progestogen for women with a
uterus.
– Prescribe the lowest effective dose.
– Vasomotor symptoms recur in up to half of women who
stop HT, regardless of age or duration of HT use.
• Effect of HT on mood:
– Mixed evidence; some short term RCTs suggest benefit and
others showing no mood benefit to treatment with HT.

31. Standard Dose Estrogen Therapy
• Oral Conjugated Estrogen (CE; Premarin):
0.625 mg/d
• Oral 17-β Estradiol (Estrace): 1 mg/d, 2 mg/d
• Transdermal 17-β Estradiol (Climara): (50-100
mcg patch)/wk
• Vaginal estrogen (Estradiol acetate; *Femring
vaginal ring): 0.05-0.1 mg/every 90 days
24-Dec-18
Dr Shashwat Jani.
99099 44160.
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32. Low Dose Estrogen Therapy
• Oral CE: 0.45 mg/d, 0.3 mg/d
• Oral 17-β Estradiol: 0.5 mg/d, 0.25 mg/d
• Transdermal 17-β Estradiol: 25 mcg patch/wk
• Microdose Transdermal Estrogen Therapy:
17β- estradiol, 0.014 mg/day
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Dr Shashwat Jani.
99099 44160.
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33. Progestogens
• Medroxyprogesterone acetate (MPA):
2.5-5-10 mg/d
• Megestrol acetate: 20, 40, 80 mg/d
• Oral micronized progesterone:
Prometrium 100, 200 mg/d
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Dr Shashwat Jani.
99099 44160.
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34. E + P Combinations
Oral continuous: (CE) and (MPA),
• 0.625 CE and 2.5 or 5 mg MPA
• 0.3 or 0.45 CE and 1.5 mg MPA
• Low dose: 0.5 mg 17β-estradiol and 0.1 mg norethisterone
acetate
Oral Sequential: 0.625 mg CE and 5 mg MPA
Transdermal continuous:
• 1 mg 17-β Estradiol plus 5 mg Norethindrone
• 0.05 mg 17-β Estradiol plus 0.015 mg Levonorgestrel
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Dr Shashwat Jani.
99099 44160.
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35. Vasomotor symptom reduction
with various therapies
THERAPY % REDUCTION
• Hormone therapy 90%
• Venlafaxine 60%–75%
• Gabapentin 50%–60%
• SSRI 50%
(fluoxetine,paroxetine,sertraline)
• Vitamin E/soy 25%
• Placebo 20%–30%
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Dr Shashwat Jani.
99099 44160.
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36. Persistent VMS
• In Persistent VMS Cases, Rule Out Other
Potential Causes…
(hyperthyroidism, pheochromocytoma, alcohol
use, infections such as tuberculosis,
malignancies such as lymphoma, medications
such as nitrates, niacin)
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Dr Shashwat Jani.
99099 44160.
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37. • Tapering of hormone therapy rather than
stopping abruptly may be preferred if
discontinuation is desired in patients with
history of severe VMS .
• Given the natural history of VMS, it is
reasonable to try discontinuing hormone
therapy every 12 months. If symptoms recur,
restarting and then gradually tapering the
dose or the number of days per week that
hormones are used may be helpful.
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Dr Shashwat Jani.
99099 44160.
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38. To Conclude
• In women who need relief …
• For Mild Vasomotor Symptoms
lifestyle changes, either alone or combined with a
nonprescription remedy, such as dietary isoflavones, black
cohosh, or vitamin E.
• For Severe VMS…
Prescription systemic estrogen-containing products
remain the therapeutic standard for moderate to severe
menopause-related hot flashes.
Recommended options for women with concerns or
contraindications relating to estrogen-containing treatments
include prescription progestogens, venlafaxine, paroxetine,
fluoxetine, or gabapentin.
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Dr Shashwat Jani.
99099 44160.
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Dr Shashwat Jani.
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