Updates from the 2021 NAMS Annual Meeting – Part 2

By: Tara Iyer, MD • Posted on December 14, 2021

In part-one of my column series, I shared the latest menopause updates on weight management, hair loss treatments and sleep problem treatments from the North American Menopause Society (NAMS) annual meeting.

And now in part-two of my column series, I would like to share more information from the North American Menopause Society annual meeting - the latest updates on cardiovascular disease, breast cancer and cervical cancer risks for menopausal women. It's important for menopausal women to get the right care and treatment for their symptoms, and staying up to date on the latest updates is the best place to start!

CARDIOVASCULAR UPDATES

Menopause and Cardiovascular Disease Risk

Menopause, independent of natural aging, increases cardiovascular disease (CVD) risk in women
Perimenopause may be one of the most impactful stages with the most changes influencing CVD risk due to a known increase in cholesterol, visceral fat, metabolic syndrome and vascular remodeling

Menopause characteristics linked to an increase in CVD risk:

Earlier age at menopause
Sleep disturbance
Depression
Vasomotor symptoms: hot flashes and night sweats
Type of menopause: surgical vs induced

Traditional and emerging risk factors for atherosclerotic CVD in women

Atherosclerosis is thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery.

TRADITIONAL RISK FACTORS	EMERGING RISK FACTORS
Diabetes	Preterm delivery
Smoking	Hypertensive Disorders of Pregnancy (PIH)
Obesity and overweight	Gestational diabetes
Physical inactivity	Autoimmune disease
Hypertension	Breast cancer treatment
Dyslipidemia	Psychosocial disorders (depression)

Hormone Therapy

There is established CV benefit for women who take hormone therapy (HT) within 10 years of menopause and under the age of 60. Especially if women experience early (less than 45 years old) menopause, premature (less than 40 years old) menopause or undergo surgical menopause.
Additionally, in these women HT has been shown to improve CVD risk, insulin resistance, diabetes risk and bone health.

Statin use

While statin use for the primary prevention of CVD in women remains controversial, it is still the recommended pharmacological treatment for hyperlipidemia in men and women.
If patients or physicians are on the fence regarding initiation of statin use, risk enhancers and certain tests (coronary artery calcium score, lp(a) levels) can help assist with decision making.

BREAST CANCER UPDATES

Breast cancer risk assessment

Breast cancer is the most common cancer in women in the US. However, mortality for breast cancer is not lower in the US despite increasing availability of mammogram screening because breast cancer risk assessment and chemoprevention are under-utilized by patients.

Patients with genetic mutations are at an increased risk for breast cancer. Luckily, 1 in 4 women meet the criteria for genetic testing. More genetic testing means prevention of thousands of cases of breast cancer annually. Below is the genetic testing criteria for women:

Known mutation in the family
Diagnosed with breast cancer at age 50 or younger
Diagnosed with two primary breast cancers
First-degree female relative (mother, sister) who was diagnosed with breast cancer at age 50 or younger or was diagnosed with ovarian cancer at any time in their life
Two or more first-degree relatives who were diagnosed with breast, prostate, and/or pancreatic cancer
A male in the family that has been diagnosed with breast cancer
Ashkenazi Jewish (Eastern European) heritage

What other factors increase breast cancer risk?

Early puberty
Late menopause
Never given birth to a child
Late age of first pregnancy
Atypical hyperplasia
Lobular Carcinoma In Situ (LCIS)
Breast density
Heterogeneously dense breasts
Extremely dense breasts

How do we assess breast cancer risk?

Use the Gail Model and/or Tyrer-Cruzik Model to assess breast cancer risk.

What else can I do to lower my risk of getting breast cancer?

1. Improve your modifiable risk factors

Women could prevent 33% of breast cancer cases PER YEAR if they changed modifiable risk factors. Modifiable risk factors include:

Eat a healthy diet
Exercise
Maintain an ideal body mass index (BMI)
Do not smoke
Minimize alcohol intake
Keep vitamin D levels normal

2. Utilize chemoprevention when appropriate

16% of women are eligible to take chemoprevention, but only 4% actually take it.

Premenopausal women may qualify for tamoxifen.
Postmenopausal women may qualify for aromatase inhibitors (i.e. anastrazole, exemestane) or selective estrogen receptor modulators (i.e. tamoxifen, raloxifene).

Target patients for chemoprevention include patients with:

Atypical hyperplasia or lobular carcinoma in situ
Gail 5 year risk 3% or greater
Tyrer-Cruzik 10 year risk of 5% or greater
Genetic mutations predisposing to estrogen receptor positive tumors:
- BRCA1 over age 50
- BRCA2
- ATM
- CHEK2
- CDH1
- PALB2

Polygenic risk score is on the horizon, which may assist in risk stratification and the decision to take chemopreventive medications.

CERVICAL CANCER SCREENING UPDATES

Human Papilloma Virus (HPV) vaccination

The HPV vaccine remains recommended in patients ages 9-26 to prevent HPV infection (ideally patients should get the vaccine at ages 9-12 years).
A new Swedish study published in 2020 found that girls who were vaccinated before age 17 were 88% less likely to develop cervical cancer.
In patients ages 27-45, studies indicate that HPV vaccination does not treat recurrent HPV, but can be helpful if patients are still having new sexual partners (especially if the patient has a history of few sexual partners).
Some new studies show that HPV vaccination post-LEEP (Loop Electrosurgical Excision Procedure) for moderate to severe cervical dysplasia may decrease the risk of recurrence by up to 50%.

For more information on menopause, visit speakingofwomenshealth.com/menopause.

Be Strong, Be Healthy, Be in Charge!
- Tara Iyer, MD, Center for Specialized Women’s Health Fellow

About Tara Iyer, MD

Dr. Tara Iyer is a NAMS-certified Menopause Practitioner and currently working as the Lead Physician at Brigham and Women's Menopause and Midlife Clinic in the Fish Center for Women’s Health and as a clinical instructor at Harvard Medical School. She is a board-certified family medicine physician, specializing in women's health, menopause care, and weight management medicine.

She received her M.D. from Rutgers Robert Wood Johnson Medical School and completed her residency with an obstetrics and women's health track at Saint Joseph Hospital Family Medicine Residency in Denver, Colorado. She then completed a two-year specialized women's health fellowship with me at Cleveland Clinic.

Dr. Iyer is also board-certified in Obesity Medicine and works as an attending physician at the Center for Weight Management and Wellness within the Endocrine Division of Brigham and Women's Hospital. She intends to foster stronger clinical and research partnerships between the Division of Women’s Health and the Center for Weight Management and Wellness, to create a more comprehensive and collaborative approach to the management of midlife women’s health issues.

women's health, menopause, nams, north american menopause society, breast cancer, cervical cancer, cardiovascular disease, hpv vaccine, midlife women, perimenopause, postmenopause

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