Managing a Healthy Menopause Transition Priorities for Consideration - - PDF document

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Managing a Healthy Menopause Transition Priorities for Consideration - - PDF document

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10/17/2019 Managing a Healthy Menopause Transition Health Considerations for all Menopausal Women Managing a Healthy Menopause The menopause transition, a portal Transition: Portal to the Second Half of Life to the second half of life,

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Managing a Healthy Menopause Transition: Portal to the Second Half of Life

Cynthia A. Stuenkel, MD Clinical Professor of Medicine, Department of Medicine Division of Endocrinology and Metabolism University of California, San Diego, School of Medicine

Health Considerations for all Menopausal Women

“The menopause transition, a portal to the second half of life, provides a critical window to:

  • Reassess lifestyle
  • Recognize ongoing and

potential health concerns

  • Encourage a proactive approach

to future well‐being”

Managing a Healthy Menopause Transition

  • Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, Santen RJ.. J Clin Endocrinol Metab 2015;100:3975‐4011.

Managing a Healthy Menopause Transition

Priorities for Consideration

  • Cardiovascular (and brain) health
  • Cancer prevention
  • Bone health

Brown HL, Warner JJ, et al. Circulation 2018;137:e843‐e852.

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A Wider “CV Window” of Opportunity?

  • Routinely screen for CVD risk every 4 to 6 years in

women starting >20 years

  • Consider compelling factors

‐ Pregnancy

‐ Breast cancer ‐ Menopause

  • Ask retrospectively at midlife
  • Better to engage in primary prevention early

Nabel EG. Circulation 2015; 132:989‐991; Brown HL, Warner JJ, et al. Circulation 2018;137:e843‐e852.

.

Preventive Strategies for Optimizing Cardiovascular Health in Women

Risk evaluation

Standardized risk assessment tools Imaging to improve risk stratification Emerging risks in women

Review risk management

Lifestyle Control of hypertension, diabetes, dyslipidemia

Women’s Healthy Lifestyle Project

  • Randomized clinical trial
  • 275 control and 260 lifestyle participants mean age 47 yr
  • Mean body index at baseline 25 kg/m2
  • Intervention: reduced saturated fat and cholesterol intake
  • Prevent weight gain by decreased caloric and fat intake and

increased physical activity

  • By 54 months, 35% were postmenopausal

Kuller LH, Circulation, 2001;103:32‐37; Wildman RP, J Am Coll Cardiol 2004;44:579‐585.

Women’s Healthy Lifestyle Project

With premenopausal diet and exercise intervention, women transitioning through menopause were able to:

  • Stave off midlife weight gain (‐.2 lb vs +5.2 lb)
  • Reduce waist circumference (‐2.9 cm vs 0.5 cm)
  • Reduce anticipated increase in LDL, TG, glucose
  • Reduce progression of subclinical atherosclerosis on

carotid intima‐media thickness2

Kuller LH, Circulation, 2001;103:32‐37; 2. Wildman RP, J Am Coll Cardiol 2004;44:579‐585.

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10/17/2019 3 Modest Caloric Reduction Improves Cardiometabolic Health

  • RCT of 218 nonobese adults ages 21‐50
  • Targeted 25% fewer calories/day
  • After 2 years:
  • Achieved 12% fewer calories (‐279 cal/d)
  • Lost 16.5 lb or 10% of body weight
  • All cardiometabolic risk factors improved
  • How? Just do not eat after dinner

Rubin R. JAMA 2019; August 28; Krauss W, Lancet Diabetes and Endocrinology, 2019 Li Y, et al. Circulation 2018;137: April 30

Estimated Life Expectancy at age 50 According to Number of Low‐Risk Factors

Li Y, et al. Circulation 2018;137: April 30

Low‐Risk Lifestyle Factors

  • Never smoking
  • BMI 18.5‐24.9 kg/m2
  • > 30 min/d moderate to vigorous physical activity
  • Moderate alcohol intake
  • High diet quality score

Estimated Life Expectancy at age 50 According to Number of Low‐Risk Factors

Li Y, et al. Circulation 2018;137: April 30

During 34 y of follow‐up, the multivariate adjusted HR for mortality in adults with 5 compared with zero low‐risk lifestyle factors were:

All‐cause Cancer CVD

0.26 0.35 0.18

(0.22‐0.31) (0.27‐0.45) (0.12‐0.26)

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Estimated Life Expectancy at age 50 According to Number of Low‐Risk Factors

Li Y, et al. Circulation 2018;137: April 30

Menopause Transition: Cognition/Memory

Maki PM and Henderson VW. Menopause 2016;23:803‐805.

Menopause Transition: Cognition/Memory

Maki PM and Henderson VW. Menopause 2016;23:803‐805

  • If the history and PE do not raise new concerns of a

neurologic disorder, assure the patient that cognitive symptoms are:

  • Common
  • Usually self‐limited
  • Not known to lead to dementia later in life
  • Emphasize that brain health is promoted by factors that

maximize cardiovascular health

  • Check and treat risk factors; improve lifestyle

Want to prevent dementia? Improve everyday health habits

  • World Health Organization Risk Reduction of Cognitive Decline
  • Recommends regular exercise, maintaining a healthy weight,

regulating blood sugar levels, and keeping cholesterol within recommended limits

  • Give up unhealthy habits: drinking and smoking1
  • In UK Biobank study, favorable lifestyle was associated with a

lower dementia risk, even in adults with a high genetic risk2

  • ‘Strategies that are good for your heart and overall health are

good for your brain’3

1.WHO Guidelines; Geneva, 2019; 2. Lourida I, et al. JAMA 2019 July 14; 3. Harvard Women’s Health Watch, Vol. 26: Number 12, August 2019

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Mehta LS, et al. Circulation 2018;137:e30‐e66.

CVD and Breast Cancer Shared Risk Factors

Mehta LS, et al. Circulation 2018;137:e30‐e66.

Postmenopausal Women with ‘Normal’ BMI may be Overweight or Obese

Rubin R. JAMA 2018;319:1185‐1187; Sun Y et al. JAMA Network Open 2019; July 3.

WHI RCT and Observational Study

  • N=156,624
  • BMI < 30 kg/m2
  • Waist circumference > 88 cm
  • 2.6% of study population

Elevated risk:

  • All‐cause mortality HR 1.31
  • CVD

1.24

  • Cancer mortality 1.20

Insulin Resistance and Cancer‐Specific and All‐Cause Mortality: The WHI

  • 22,837 participants aged 50‐79 y
  • Baseline fasting glucose and insulin levels (HOMA‐IR)
  • 18.9 years follow‐up
  • Higher HOMA‐IR quartile (even in women with BMI < 25)

associated with higher:

  • Cancer‐specific mortality HR 1.26 p=.003
  • All‐cause mortality

HR 1.63 p<.001

Pan K, et al. J Natl Cancer Inst 2019 Apr 26; HOMA‐IR, homeostasis model assessment of insulin resistance

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Cancer Overtakes CVD as Leading Cause of Death in Wealthy Nations

  • Worldwide, CVD remains the leading cause of

mortality

  • In High Income Countries
  • Cancer mortality 1.7 deaths/ 1000 person‐yr
  • Death from CVD 0.6 deaths/ 1000 person‐yr

Dagenais GR, et al. Lancet 2019; Sept 3

Studies Linking Healthy Lifestyle with Lower Cancer Risks

  • A healthy ‘lifestyle index’ was associated with a

lower risk of endometrial cancer; HR 0.61 (.51‐.72)1

  • Postmenopausal women who lose weight have

lower breast cancer risk; HR 0.88 (.78‐.98); p=.022

  • In women assigned to a low‐fat dietary pattern, a

reduction in deaths after breast cancer resulted; HR 0.65 (.45‐.94); p=.023

  • 1. Arthur R, et al. Am J Epidemiol 2019; 188:261‐273. HLI : diet, alcohol, physical activity, BMI, smoking;
  • 2. Chlebowski RT, et al. Cancer 2019; 125:205‐212; 3.Chlebowski RT, et al. JNCI Cancer Spectr 2019 Jan 7

Fracture Risk and the Menopausal Transition

  • Between ages 42 and 58 y, 1 in 6 women in SWAN fractured
  • Predicted by:
  • Low BMD
  • Indices of femoral neck composite strength
  • High levels of U‐NTX
  • Additional factors:
  • Low education in nonwhite women
  • Diabetes
  • Chronic inflammation: C‐reactive protein > 3 mg/L
  • Plasma triglycerides > 300 mg/dL
  • Obesity: greater impact forces in a fall

Karlamangla AS, et al. Obstet Gynecol Clin N Am 2018;45:695‐708.

Early Intervention to Prevent Osteoporosis

Lifestyle modification

  • Physical activity in midlife
  • Associated with larger femoral neck composite strength indices
  • Healthy diet
  • Adequate calcium intake
  • Maintain serum 25‐OH Vit D > 20 ng/mL
  • Lower levels associated with 85% higher fracture risk
  • Smoking cessation, temper alcohol, review medications

Karlamangla AS, et al. Obstet Gynecol Clin N Am 2018;45:695‐708.

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Arnett DK, et al. JAMA Cardiology 2019; July 31; Arnett DK, et al. Circulation 2019;140:Sept 10

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Part 1, Lifestyle and Behavioral Factors

  • Team‐based care is an effective approach
  • Incorporate social determinants of health into plan
  • Healthy diet: vegetables, fruits, nuts, whole grains, fish
  • > 150 minutes/wk of moderate intensity physical

activity (or 75 min/wk of vigorous‐intensity

  • Achieve and maintain weight loss if overweight/obese
  • Strongly advise to quit tobacco use (at every visit)

Arnett DK, et al. JAMA Cardiology 2019; July 31

Managing a Healthy Menopause Transition

Summary and Conclusions

  • Healthy lifestyle contributes to longevity and

quality of life

  • Improvements achieved in cardiovascular,

cognitive, and bone health with reduced malignancy and mortality risk

  • Small steps may accrue large benefits

“Interestingly, while both groups included men and women, the latecomers featured a much larger percentage of women.”

Tuesday, September 24, 2019 Gretchen Reynolds