The Latest in Menopause: Part 2

By: Madeline Cohn, DO • Rachel Novik, DO • Posted on October 25, 2023

Cardiovascular Health and Obesity

Weight Management in Midlife Women

Weight gain and obesity are often multifactorial. Weight management counseling should include a discussion on calorie restriction with a goal calorie intake of 1300–1500 kcal/day.

Calorie restriction in addition to decreasing saturated fat and cholesterol in the diet can prevent weight gain during menopause.
While dietary changes in conjunction with behavior modification and physical activity are superior to physical activity alone, improving quality of life through symptomatic control of vasomotor symptoms and insomnia have been found to have significant improvement on a person's ability to maintain lifestyle, modifications, and weight loss.
Hormone therapy has been shown to not only improve vasomotor symptoms associated with menopause, but also decrease muscle mass loss and central adiposity deposition, and shown to improve metabolic parameters.

Anti-Obesity Medications in Midlife Women

Physicians should avoid medications associated with weight gain, such as certain SSRIs and gabapentin.
The GLP1 and SGLT2 diabetes medications have been found to be effective weight loss medications. They have also been shown to have additional cardiovascular benefits. However, they are often not covered by insurance for weight loss.
At this time bariatric surgery remains the most effective treatment for obesity with decreased cardiovascular events, cirrhosis, kidney disease, and mortality associated with the procedure.

Key Takeaways

While conventional treatments, such as lifestyle modification with diet, exercise, and behavior changes are the backbone to wait control, it is often insufficient. Physicians should consider second level therapies such as anti-obesity medications and bariatric surgery.

Managing Cardiovascular Disease Risk Factors

Cardiovascular disease remains the leading cause of death and disability in postmenopausal women. Cardiovascular risk factors, such as hypertension and dyslipidemia often become more significant after menopause and can lead to medical problems, such as ischemic heart disease, stroke, and heart failure. It is important that physicians identify modifiable risk factors with diet and exercise, as well as medication to reduce cardiovascular risk.

Studies have shown that menopausal hormone therapy initiated within 10 years of menopause lowered coronary heart disease, and there was a reduction in all cause mortality. Based on the SPRINT trial, a systolic blood pressure less than 130 is recommended. Additionally, clinical trials have shown that statin medication in addition to PCSK9 inhibitors and icosapent ethyl (Vascepa®) are effective in lowering long-term cardiovascular risk with minimal side effect profile.

There are two FDA-approved medications:

Alirocumab (Praluent®)
Evolocumab (Repatha®)

Reproductive Risk Factors for Cardiovascular Disease

Hypertension disorders of pregnancy and premature age of menopause are risk enhancing factors for cardiovascular disease. Hypertensive disorders of pregnancy have been linked to chronic hypertension and microvascular aging.
Clonal hematopoiesis of indeterminate potential (CHIP) is a common chronologic aged phenomenon. It is a type of genomics instability that may be related to heightened systemic inflammation. It is more prevalent among women with premature menopause and is an independent risk factor for coronary artery disease among post menopausal, middle aged women.
Lifestyle modification, close monitoring, and strict control of cardiovascular risk factors are essential. Physicians should be sure to counsel their patients on cardiovascular disease risk in those who developed hypertensive disorders of pregnancy. They should also be sure to ask patients about their previous pregnancy history when assessing cardiovascular risk. Consider coronary artery calcium scoring for risk refinement when unsure.

Cognitive Health

Hormone Therapy and Cognitive Health

The Kronos Early Estrogen Prevention Study (KEEPS) shows no cognitive differences in patients who used hormone therapy compared to placebo.
The Early versus Late Intervention Trial with Estradiol (ELITE) showed no cognitive differences in patients on hormone therapy based on timing of exposure (i.e. when given within 6 years of menopause versus when initiated greater than 10 years after menopause).

Sexual Health

Postmenopausal Orgasmic Dysfunction

55% of women older than age 55 report orgasmic problems. This can be due to a variety of biological and psychosocial causes. People who are struggling with orgasmic dysfunction should see their clinician to have a full exam including a neurologic exam of their genitourinary system.

While there are no FDA approved treatments for orgasmic dysfunction, there is evidence that other options such as topical estrogen, vaginal DHEA, topical vasodilators and oral medications for hypoactive sexual desire disorder, such as flibanserin, may be helpful.
Options such as clitoral hood reduction, “g-spot” augmentation and “o-shot” are NOT evidence based and NOT recommended.

Menopausal Symptom Management

NAMS Nonhormone Therapy Treatment of VMS

“Hormone therapy remains the most effective treatment for vasomotor symptoms, and should be considered in menopausal women within 10 years of their final menstrual periods. For women who are not good candidates for hormone therapy, whether due to contraindications or personal preference, it is important for healthcare professionals to be well informed about nonhormonal treatment options for reducing vasomotor symptoms that are supported by the evidence.”

Level 1 recommended nonhormone treatments include cognitive behavioral therapy, clinical hypnosis, SSRI/SNRIs, gabapentin, oxybutynin, and fezolinetant. These treatments have consistent scientific evidence.
Level 2 recommendations include weight loss and stellate ganglion blocks. These treatments have limited or inconsistent scientific evidence.
There is insufficient evidence for cooling techniques, paced breathing, clonidine, pregabalin, suvorexant, soy foods/extracts/metabolites, herbal supplements, cannabinoids, acupuncture, calibration of neural oscillations, or chiropractic intervention.
While exercise, yoga, and dietary modification are beneficial for health, none have been associated with improvement of vasomotor symptoms.

More information can be found in The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society.

Caregiver Burden and Obesity Linked to More Menopausal Symptoms

Women make up 61% of informal caregivers in the US. According to a study done at Mayo Clinic, women who are caregivers for 15+ hours per week are more likely to have more menopause symptoms, even when adjusting for mental health problems and stress levels.

Fighting Medical Myths

Combating Medical Misinformation in Menopause

20 years after the WHI, we are still combating myths about menopause and hormone therapy. While there are many benefits to using social media to promote awareness regarding menopause, there are also a lot of myths online and in social media.

Tips for evaluating social media and internet health information from the National Library of Medicine remind social media and content users to actively assess and ask themselves:

Who is running the website and what is their goal?
Is there a sponsor associated with the website?
What does the website or content creator want from the viewer?

Oftentimes, educational sites ending in .org or .edu have evidence based information. Additionally, medical sites run by large institutions are good sources for evidence based information.

Tips to help with the creation of content validity include:

Requiring the disclosure of conflict of interest
Verification of source credibility
Mandates that credentials be listed
Myths notifications
Encouraging professional organizations to play a role in disputing falsehoods and promoting evidence-based care

Note: There is now a set of 3 dots to the right of your google search results, for each result. These dots can show you each website’s source of information, date of creation, and some verification. This can help users decide if they are getting their information from more reputable sources.

Be Strong, Be Healthy, Be in Charge!

Rachel Novik, DO and Madeline Cohn, DO

About Rachel Novik, DO

Rachel Novik, DO is a Board Certified Family Medicine physician. She is a first year clinical Specialized Women’s Health Fellow at the Cleveland Clinic Center for Specialized Women’s Health.

Dr. Novik graduated from New York University with a Bachelor’s Degree in Social Work and a minor in Child and Adolescent Mental Health. She then completed a post-baccalaureate degree for pre-medical sciences at John Carroll University and ultimately attended Ohio University’s Heritage College of Osteopathic Medicine, at their Cleveland campus.

Dr. Novik graduated from University Hospitals St. John Medical Center’s Family Medicine Residency program, where she served as chief resident and helped create a women’s health curriculum. She has a passion for working with women at all stages of their lives. During residency, she developed a desire to focus her practice on women in their middle and later decades, where care gaps often exist.

About Madeline Cohn, DO

Madeline Cohn, DO is a Board Certified Family Medicine physician. She is a first year clinical Specialized Women's Health fellow at the Cleveland Clinic Center for Specialized Women's Health.

Dr. Cohn graduated with her Bachelor's degree in Psychology and Cellular and Molecular Biology from Austin College in Sherman, Texas. She attended medical school at the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth, Texas. Dr. Cohn completed her residency at Case Western Reserve University MetroHealth in Cleveland, Ohio, where she served as chief resident.

Dr. Cohn is passionate about becoming an educator and leader within the field of women's health, and she hopes to empower her patients to become advocates for their own health.

women's health, menopause, cardiovascular disease, obesity, weight, weight gain, obesity medication, midlife, diet, hormone therapy, cognitive health, sexual health, vms, vasomotor symptoms, caregiver

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