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Patients with breast cancer receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM). GSM can decrease quality of life and is undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy because of unknown levels of systemic absorption of estradiol. In this article, we review the available literature for treatment of GSM in patients with breast cancer and survivors, including nonhormonal, vaginal hormonal, and systemic hormonal therapy options. First-line treatment includes nonhormonal therapy with vaginal moisturizers, lubricants, and gels. Although initial studies showed significant improvement in symptoms, the US Food and Drug Administration recently issued a warning against CO2 laser therapy for treatment of GSM until additional studies are conducted. In severe or refractory GSM, after discussing risks and benefits of vaginal hormonal therapy, the low-dose 10-μg estradiol-releasing intravaginal tablet or lower-dose 4 μg estrogen vaginal insert and intravaginal dehydroepiandrosterone (prasterone) are options for treatment, because studies show minimal elevation in serum estradiol levels and significant improvement in symptoms. The decision to offer vaginal estrogen therapy must be individualized and made jointly with the patient and her oncologist.

Every woman, if she lives long enough, will transition into menopause, and as the US population ages, women will be spending more time in a postmenopausal state than before. For postmenopausal women, the decision to initiate menopausal hormone therapy should be individualized. A thorough evaluation of the patient's cardiovascular, venous thromboembolic, cancer, and fracture risk should be considered along with the woman's quality of life. Hormone therapy exerts its therapeutic effects on vasomotor symptoms, the skeleton, and the genitourinary system independent of age since menopause and these benefits are lost once hormone therapy is stopped. Here we review the pharmacologic properties dose, formulation, mode of administration, timing of initiation, and duration of hormonal therapies in regard to optimizing benefit and minimizing risk to the patient. This discussion will focus on the effects of common hormonal therapies including estrogen (local and systemic), progesterone, estrogen receptor agonist/antagonist, and local dehydroepiandrosterone and include a brief review of compounded bioidentical hormone therapy.

When treating the genitourinary syndrome of menopause (GSM) in women with breast cancer or at high risk of breast cancer, clinicians must balance the higher cancer risks associated with hormonal treatments against the severity of GSM symptoms, which can be exacerbated by breast cancer treatments. Options for patients who need hormonal therapy include locally applied estrogens, dehydroepiandrosterone (DHEA), and estrogen receptor agonists/antagonists, which vary in their impact on breast cancer risk.

Urinary incontinence is common, underreported, and undertreated. Primary care physicians should be comfortable discussing urinary incontinence with their female patients and managing it with conservative treatment.

To compare bone thickness buccal to the teeth in the esthetic zone of postmenopausal women, premenopausal women, younger men and older men.Retrospective data were randomly selected from 4 groups: 59 premenopausal women, 60 postmenopausal women, 60 men less than age 50, and 60 men more than 50. Half-root and bone crest landmarks were identified on each participant's cone beam computed tomography for teeth 7 to 10 and 23 to 26. Buccal bone thickness was measured by calibrated examiners. Group averages were calculated and compared between groups using analysis of variance (P0.05).When comparing premenopausal to postmenopausal women and postmenopausal women to older men, anterior bone thickness was significantly different for tooth maxillary and mandibular lateral incisors and overall maxillary and mandibular central incisors. In addition, significant differences were observed between these groups within the maxilla comparing lateral incisors, central incisors (P0.05), and within the mandible when comparing lateral and central incisors at (P0.05) at bone crest and half-root, respectively.Buccal bone in the anterior esthetic zone bone is thin in all segments of the population, but significantly thinner in postmenopausal women. In this cohort, when anterior implants are planned, it is essential to make informed treatment planning decisions. Strategies are available to manage the thinner bony housing, but require further research specific to this growing consumer cohort.

In the article by A.C. Moreno, S.K. Sikka, and H.L. Thacker, Genitourinary syndrome of menopause in breast cancer survivors: Treatments are available, Cleve Clin J Med 2018; 85(10):760-766, doi:10.3949/ccjm.85a.17108, Table 2 incorrectly stated that prasterone is contraindicated in women with known or suspected breast cancer. This correction has been made online as follows. "Warning: Estrogen is a metabolite of prasterone; use of exogenous extrogen is contraindicated in women with known or suspected breast cancer; prasterone has not been studied in women with a history of breast cancer."

Objective This study aims to compare periodontitis severity in postmenopausal women whose FRAX (World Health Organization Fracture Risk Assessment Tool) scores indicate a major risk for osteoporotic fracture (OPF) versus controls. Methods Participant charts from the Case/Cleveland Clinic Postmenopausal Wellness Collaboration 853-sample database were selected based on the following inclusion criteria: (1) aged between 51 and 80 years; (2) menopause for more than 1 year but less than 10 years; (3) nonsmoker; (4) hemoglobin A1c less than 7; and (5) no glucocorticoid, hormone, RANKL (receptor activator of nuclear factor-κB ligand) inhibitor, or bisphosphonate therapy within 5 years. FRAX score was calculated, and participants were organized into two groups: women with major OPF risk (FRAX scores >20%) and controls. Periodontal data were obtained from the charts. T test was used to assess differences in periodontal parameters between groups. Results Ninety participants had FRAX scores higher than 20% and were considered to have high OPF risk; 98 participants served as controls. Probing depth (mean [SD], 2.75 [0.66] vs 2.2 [0.57]), clinical attachment loss (3.15 [0.78] vs 2.73 [0.66]), alveolar bone height (0.58 [0.03] vs 0.60 [0.02]), and tooth loss (5.6 [1.96] vs 3.84 [1.94]) were significantly different between groups, whereas plaque score and bleeding on probing were not. Conclusions Postmenopausal women whose FRAX scores suggest major OPF risk have significantly more severe periodontitis endpoints than controls even though oral hygiene scores do not significantly differ. These findings suggest to clinicians treating women after menopause that referral to a periodontist for disease screening may be appropriate for those women with high fracture risk based on FRAX scores.

After the publication of the Women's Health Initiative, attitudes towards management of menopausal symptoms changed dramatically. One alternative that has received much media attention is the use of bioidentical hormone therapy (BHT). The media and celebrity endorsements have promoted a number of misconceptions about the risks and benefits associated with the various forms of BHT. This article will review the available evidence regarding the safety and efficacy of BHT in comparison to conventional hormone therapy. We will also review several cases seen in our midlife women's referral clinics, which demonstrate concerns for the safety and efficacy of BHT, including unexplained endometrial cancer in otherwise healthy BHT users. Due to the lack of sufficient data to support the efficacy or safety of BHT, we recommend the use of United States Food and Drug Administration-approved regimens in the management of menopausal symptoms.

After menopause, women become more susceptible to periodontal disease. We believe the problem is due in large part to estrogen deficiency with resulting bone loss and inflammatory processes. Osteoporosis and periodontal disease are best diagnosed early so that treatment can be started sooner and fractures and tooth loss can be prevented.

Osteopenia/low bone mineral density (BMD) can lead to osteoporosis and is far more prevalent than osteoporosis. The National Osteoporosis Foundation (NOF) has recommendations for prevention and treatment of low BMD; however, the condition remains underrecognized and undertreated. We assessed practice patterns between physician knowledge of low BMD and prescribing of additional pharmacological therapies as defined by the NOF guidelines.This is a retrospective, observational chart review of electronic medical records of 99 postmenopausal women agedor =60 years with T-scores between -1.0 and -2.5 on baseline BMD done in 2003 at the Cleveland Clinic Women's Health Center. Counseling, advisement of weightbearing exercise, recommendation of calcium and vitamin D supplementation, and adequate pharmacological therapy in the form of bisphosphonates, hormone therapy, or selective estrogen receptor modulators (SERMs) were assessed. The management of bone specialists credentialed both by the International Society of Clinical Densitometry and the North American Menopause Society and non-bone specialists was also compared.Bone specialists were more likely than non-bone specialists to offer counseling in the form of letters, phone encounters, and follow-up office visits and recommend weightbearing exercises. Most physicians recommended calcium and vitamin D supplementation regardless of specialty. There is no significant difference in the prescribing of pharmacological agents vs. conservative measures for osteopenic postmenopausal women by non-bone specialists vs. bone specialists as defined by the NOF guidelines, such that non-bone specialists did not treat these women any less aggressively than did bone specialists.Osteopenia is adequately managed in our institution regardless of physician group. However, non-bone specialists should consider more direct counseling about bone health and consider advisement of weightbearing exercise.

The objective was to assess the effects of reminder letters on women returning for repeat bone density. We queried our clinical data repository to identify all women undergoing dual-energy X-ray absorptiometry (DXA) during the entire 2003 calendar year. Women with abnormal DXAs were entered into a database for reminder letters. The electronic medical record was then reviewed for the presence of the reminder letter and whether any repeat DXA scan was done. Approximately half of the women returned for repeat DXA of this group, approximately one-third were improved, one-third deteriorated, and the remaining were unchanged. We suggest a clinical benchmark of a minimum of 50% of women with abnormal bone density returning for repeat DXA on the same machine at a DXA imaging center should be a quality improvement goal. Further research into exploring why patients do not return for serial DXA and the impact of reminder letters on improving treatment outcomes should be conducted.

While Women's Health (WH) Fellowships have been in existence since 1990, knowledge of their existence seems limited. Specialized training in WH is crucial to educate leaders who can appropriately integrate this multidisciplinary field into academic centers, especially as the demand for providers confident in the areas of contraception, perimenopause/menopause, hormone therapy, osteoporosis, hypoactive sexual desire disorder, medical management of abnormal uterine bleeding, office based care of stress/urge incontinence, and gender-based medicine are increasing popular and highly sought after. WH fellowship programs would benefit from accreditation from the American Board of Medical Subspecialties and from the American College of Graduate Medical Education, as this may allow for greater recruitment, selection, and training of future leaders in WH. This article provides a current review of what WH trained physicians can offer patients, and also highlights the added value that accreditation would offer the field. Ultimately, accrediting WH fellowships will improve women's health medical education by creating specialists that can serve as academic leaders to help infuse gender specific education in primary residencies, as well as serve as consultants and leaders, and promote visibility and prestige of the field.

Objectives To assess the effect of menopausal hormone therapy (HT) on reoccurrence, cancer-related mortality, and overall mortality after a diagnosis of breast cancer. Methods We performed a quantitative review of all studies reporting experience with menopausal HT for symptomatic use after a diagnosis of breast cancer. Rates of reoccurrence, cancer-related mortality, and overall mortality were calculated in this entire group. A subgroup analysis was performed in studies using a control population to assess the odds ratio of cancer reoccurrence and mortality in hormone users versus non-users. Results Fifteen studies encompassing 1416 breast cancer survivors using HT were identified. Seven studies included a control group comprised of 1998 patients. Among the 1416 HT users, reoccurrence was noted in 10.0% (95% CI: 8.4–11.6%). Cancer-related mortality occurred at a rate of 2.6% (95% CI: 1.8–3.7%), while overall mortality was 4.5% (95% CI: 3.4–5.8%). Compared to non-users, patients using HT had a decreased chance of reoccurrence and cancer-related mortality with combined odds ratio of 0.5 (95% CI: 0.2–0.7) and 0.3 (95% CI: 0.0–0.6), respectively. Conclusions In our review, menopausal HT use in breast cancer survivors was not associated with increased cancer reoccurrence, cancer-related mortality or total mortality. Despite conflicting opinions on this issue, it is important for primary care physicians to feel comfortable medically managing the increasing number of breast cancer survivors. In the subset of women with severe menopausal symptoms, HT options should be reviewed if non-hormonal methods are ineffective. Future trials should focus on better ways to identify breast cancer survivors who may safely benefit from HT versus those who have a substantial risk of reoccurrence with HT use.

In the USA, over 30 million women are In or near menopause. Menopause Is associated with a cluster of Issues. Vasomotor symptoms (VMS) are the number one complaint of most menopausal women. VMS are disruptive to women during the day and at night, which leads to poor sleep, anxiety, depression and poor concentration. Up until now, the only US FDA-approved medication for moderate-to-severe VMS was hormone therapy. Hormone therapy may not be appropriate for all women. Many drugs are used off-label to treat VMS. The most often used agents are agents that are FDA-approved medications, such as selective serotonin reuptake Inhibitors and serotonin–norepinephrine reuptake Inhibitors. The pharmaceutical company, Noven Pharmaceuticals (FL, USA), has studied paroxetine mesylate 7.5 mg, previously known as low-dose mesylate salt of paroxetine, specifically to treat moderate-to-severe VMS In postmenopausal women. Paroxetine is a selective serotonin reuptake Inhibitor, and Is thought to help decrease VMS by regulating body temperature via neurotransmitters. Paroxetine Is approved to treat various psychiatric disorders, but Is used at much higher doses (20–60 mg/day).

Menopause is a physiologic event in a woman's life that can be a prime time to perform a risk assessment for chronic disease and to initiate preventive health measures, which may include hormone replacement therapy (HRT). Women seek the care of physicians more often than men do; however, a woman's medical care is often fragmented. Women are entering menopause today in vast numbers, a consequence of the aging of the baby boomers . The ranks of this generation of menopausal women will affect the health care system as older women become an increasingly larger percentage of the U.S. population. The new paradigm for health care is the preventive model. A system of properly instituted comprehensive screening for the menopausal woman may help spare institutions and society from an escalating financial and social burden. 44 Health care practitioners can enhance quality years for women with primary preventive health care, using menopause as a positive entry point.

A variety of herbs and other "natural alternative medicines" are marketed directly to consumers and sold over-the-counter as treatments for perimenopausal symptoms. Far from being innocuous placebos, many of these substances have real physiologic effects, including potential adverse effects and drug interactions. Yet they are largely untested and, by law, totally unregulated. This article reviews a few of the untested substances your patients may be taking, along with established treatments.

Director,Women’s Health Center at The Gault Women’s Health and BreastPavilion, Department of General Internal Medicine, Department ofObstetrics and Gynecology,The Cleveland Clinic Foundation;AssociateProfessor of Medicine, Cleveland Clinic Lerner College of Medicine of Case-Western Reserve University

TO THE EDITOR : I much enjoyed the important article by Drs. Lipold, Batur, and Kagan on whether there is a time limit for systemic menopausal hormone therapy.[1][1] The simple answer is no. The authors did a good job of reviewing the factors to consider in terms of contraindications and precautions

Many women are turning to bioidentical hormone therapy on the basis of misconceptions and unfounded claims, eg, that this therapy can reverse the aging process and that it is more natural and safe than approved hormone therapy. The aim of this article is to clarify some of the misconceptions.

Vasomotor symptoms (VMS); (hot flushes and night sweats) are the most common menopausal complaint for which women seek treatment. Several therapies can be considered to help manage these complaints. The objective of this review is to assess the risks and benefits of available and emerging therapeutic options for the management of menopausal VMS.A review of the literature was conducted based on relevant publications identified through a PubMed search for clinical trials of agents used in the treatment of VMS.Hormone therapy (HT) remains the most effective treatment available, but there will always remain a need for nonhormonal options. Evidence does not support the efficacy of alternative or over-the-counter products, such as phytoestrogens and black cohosh, and their long-term safety is largely unknown. There is evidence supporting the efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the management of VMS from clinical trials of paroxetine, venlafaxine, and desvenlafaxine. Gabapentin appears to be effective, but the doses required may cause poor tolerability and reduced patient adherence. Data also suggest that clonidine has a modest effect at the expense of considerable adverse effects.Choosing an appropriate treatment approach for the management of VMS requires careful assessment of the riskbenefit ratio of each alternative, as well as individual patient preference.

Objective The aim of this study was to compare the periodontium of postmenopausal women with known low bone mineral density who are receiving long-term bisphosphonate therapy with those who are not. Methods The periodontal status of 28 white postmenopausal women with low bone density using bisphosphonate therapy for at least 2 years was compared with that of a matching group not using such therapy. All women underwent a cone-beam CT scan of the jaw and a complete periodontal examination evaluating for plaque score, periodontal probing depth, clinical attachment loss, bleeding on probing, and alveolar bone height. Results Bisphosphonate users had higher plaque score, lower probing depth, and lesser clinical attachment loss compared with the controls. These differences were determined to be significant by both t test and Wilcoxon's tests. Bleeding on probing was lower and the alveolar bone height was higher in the bisphosphonate group than in controls, but these differences were not statistically significant. Linear models showed no significant interactions between plaque score and bisphosphonate use, suggesting that the association of periodontal status and outcome measures was constant across all levels of plaque scores. Bisphosphonate use was a significant factor for probing depth but was not significant for the other parameters when adjusted for plaque score. Conclusions Long-term bisphosphonate use seems to have some beneficial effects on the periodontium of postmenopausal women with low bone density, across all levels of plaque score.

Eosinophilia-myalgia syndrome is a recently described clinical syndrome caused by a suspected contaminant of L-tryptophan, an essential amino acid that was manufactured and sold as a nutritional supplement. This study reports the clinical and pathological findings of 22 cases of eosinophilia-myalgia syndrome evaluated at the Cleveland Clinic and includes data for up to 1 year of follow-up (for the epidemic cases). Nineteen of the 22 cases were evaluated and followed prospectively in the time period from November 1989 to November 1990. Two of the 22 represented nonepidemic forms of the syndrome which occurred prior to the 1989 epidemic. During a review of all cases of biopsy-proven diffuse fasciitis with eosinophilia at the Cleveland Clinic since 1978, one of the 22 was retrospectively identified as having an epidemic form of the syndrome, with onset in July 1989. In this study, adverse prognosticating factors in eosinophilia-myalgia syndrome included nerve and muscle involvement, fasciitis, and weight loss. Eosinophilia-myalgia syndrome is striking in its severity and diversity, and its features are similar to those of two other unusual illnesses--toxic oil syndrome and diffuse fasciitis with eosinophilia. With the recent purification of the suspected contaminant, it is hoped that further clues to the etiology of this syndrome and similar syndromes will be uncovered.

In light of the updates that Drs.Hodis and Gass have presented on hormone therapy(HT) for menopausal women and that Drs. Jenkinsand Sikon have presented on nonhormonal optionsfor menopausal management, let’s start our round-table by considering a couple of casestudies that will give us the chance toapply the latest data in a practical way.■

Our goal in this paper is twofold. First, it provides a brief overview of the macrotrends in women's health education over the last 25 years. Second, these trends are a backdrop for a discussion of women's health education as exemplified by a detailed review of the curriculum for the Women's Health fellowship at the Cleveland Clinic Foundation. We have termed the underpinning of the curriculum the “leadership triad” consisting of (1) clinical skills, (2) focused research, and (3) interdisciplinary education. These elements are presented in a detailed curriculum for a 2-year fellowship program. We see these elements as fundamental to the Cleveland Clinic's fellowship program, and a useful model for those contemplating or refining their advanced women's health curriculum.

Hormonal therapy remains the gold standard for treating menopausal symptoms. In addition, some formulations are indicated for preventing and treating bone loss. In this article, we review some of the hormonal regimens that have been approved in the past 5 years.

Several newer hormonal contraceptive agents have become available in recent years. Many of them are slight variations on previous agents. In this article, we review the advantages, side effects, and practical considerations of hormonal contraceptives approved in the last few years.

As a growing percentage of Americans will be reaching their elderly years in the next decade, the prevalence of osteoporosis and its effects will have an even greater impact on the healthcare system. Advancements in bone research and development of newer treatments have allowed for the establishment of more refined guidelines and a growing awareness of the need to prevent, screen, and diagnose osteoporosis. Thus, more women are now being screened with dual x-ray absorptiometry scans (DXA) than ever before. The importance of a true understanding of the test results obtained from such screening is paramount. In our institution, recommendations to consider a secondary evaluation are made by the DXA interpreters when the Z-score is low. Few, if any, studies have evaluated the rates of physician and patient adherence with specific recommendations provided on the bone density report.To assess compliance with such recommendations provided in DXA interpretations, we investigated the number of ordering providers who actually pursued these advisements.We found that among providers ordering DXAs, primary care providers did not pursue recommendations to pursue a secondary workup as often as their subspecialty counterparts. We also found a significant amount of vitamin D deficiency/insufficiency and primary hyperparathyroidism in the population evaluated.Primary care providers should be further educated on treatable secondary causes of osteoporosis as opposed to an often reflexive response of prescribing a pharmacological antiresportive agent without other consideration.

Designing culturally relevant weight-reduction programs requires understanding of ethnic variations and illness beliefs. Preliminary data on the values and beliefs about obesity and weight reduction were obtained from women of different ethnic/racial backgrounds. Purposive sampling was used to recruit African American (AA) and Caucasian (C) women with a body mass index (BMI)[.greaterequal] 30 from the general internal medicine clinics of a large tertiary care facility. Four focus groups (2 with AA women and 2 with C women) consisting of a total of 20 subjects were conducted in a 2-month period. AA women cited culture specific barriers to weight loss more so than did C women. AA women and C women also differed on how health care professionals could help them with weight loss. These findings have implications for nursing's role in the design of culturally relevant weight-loss programs.

Shared medical appointments (SMAs) are a new way to deliver woman-focused interdisciplinary care for midlife women. SMAs are a series of one physician to one patient encounters with other patient observers. The women's health physician addresses each woman's unique medical needs individually but in the context of a shared setting. The major focus is on delivering individual medical care with the benefits of additional time spent educating women patients and answering questions.

Although alternatives exist, hormone therapy remains the most effective treatment for menopausal symptoms such as hot flashes, and it is the only treatment approved by the US Food and Drug Administration (FDA) for this indication. The FDA recommends using the lowest effective dose of hormones. New low-dose preparations and new dosage forms of hormone therapy are available.

Premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS), is characterized by physical and behavioral symptoms that cause marked social impairment during the last half of the menstrual cycle. Symptoms are believed to result from the interaction of central neurotransmitters and normal menstrual hormonal changes. Treatment usually begins with lifestyle changes, over-the-counter medications, and if needed, selective serotonin reup-take inhibitors. Physicians should be aware of the risks of many of the alternative therapies commonly touted in the popular press.

By anticipating issues of mobility, physicians can help older women lead more independent and satisfying lives. Osteoarthritis is a major cause of physical disability in older women. Aerobic exercise, resistance training, and judicious analgesic use can be well-tolerated interventions that reduce pain and disability. Reducing the risk of injurious falls is paramount given the prevalence of osteoporosis. Interventions that may reduce fall risk include minimizing the use of sedative-hypnotic agents, providing training in transfer skills (balance and gait training), and adapting the home environment.

The importance of statins for the prevention and treatment of coronary artery disease (CAD), the recent paradoxical effects of hormone replacement therapy on prevention of CAD, and the role of nontraditional risk factors in CAD in women are examined.

Although the results of the Women's Health Initiative showed an increased risk of breast cancer in women taking hormone replacement therapy (HRT), the absolute risk is very low. We discuss limitations of the study, questions that remain, and how to discuss the study with women at average risk and high risk for breast cancer.