Menopause Menopause in Women With IBDin Women With IBD

MenopauseMenopause

Natural menopause results from gradual decline Natural menopause results from gradual decline in number of estradiol-producing ovarian folliclesin number of estradiol-producing ovarian follicles

Surgical menopause may occur at any age as Surgical menopause may occur at any age as a result of oophorectomya result of oophorectomy

Estradiol decreases; estrone becomes primary Estradiol decreases; estrone becomes primary circulating hormonecirculating hormone

Testosterone declines at varying rateTestosterone declines at varying rate

No data on effect of menopause on IBDNo data on effect of menopause on IBD

Carr BR, Bradshaw KD. In: Braunwald E, et al, eds. Carr BR, Bradshaw KD. In: Braunwald E, et al, eds. Harrison’s Principles of Internal Medicine.Harrison’s Principles of Internal Medicine. 15th ed. New 15th ed. New York, NY: McGraw-Hill; 2002.York, NY: McGraw-Hill; 2002.

Menopausal SymptomsMenopausal Symptoms

Bone loss—may be accelerated in CD and by Bone loss—may be accelerated in CD and by corticosteroid usecorticosteroid use

Vasomotor symptoms—“hot flashes” (50%–85%)Vasomotor symptoms—“hot flashes” (50%–85%)

Increases in total and LDL cholesterol Increases in total and LDL cholesterol

Urogenital symptoms (45%)Urogenital symptoms (45%)– DyspareuniaDyspareunia– DysuriaDysuria– IncontinenceIncontinence– Urinary tract infectionsUrinary tract infections

U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. 1996. Available at: U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. 1996. Available at: http/www.ahcpr.gov/clinic/cpsix.htm. Accessed January 28, 2003. http/www.ahcpr.gov/clinic/cpsix.htm. Accessed January 28, 2003.

Postmenopausal HRTPostmenopausal HRT

Replaces estrogen in postmenopausal womenReplaces estrogen in postmenopausal women

Goal: manage symptoms caused by loss of estrogenGoal: manage symptoms caused by loss of estrogen

Unopposed estrogen: only for women who have Unopposed estrogen: only for women who have had hysterectomieshad hysterectomies

Combined estrogen/progestin: recently found to Combined estrogen/progestin: recently found to increase risks for breast cancer, heart attacks, strokeincrease risks for breast cancer, heart attacks, stroke

HRT Protective Against Disease HRT Protective Against Disease Activity After MenopauseActivity After Menopause

Cohort of post-menopausal womenCohort of post-menopausal women

Disease activity pre and post menopauseDisease activity pre and post menopause

Those taking HRT less likely to have a disease flare in 2 Those taking HRT less likely to have a disease flare in 2 years post menopauseyears post menopause

Dose response for length of useDose response for length of use

Form of menopause did not matterForm of menopause did not matter

Kane SV Am J Gastro 2008; 103(5):1193-96.Kane SV Am J Gastro 2008; 103(5):1193-96.

Potential Benefits vs Risks Potential Benefits vs Risks of HRTof HRT

Potential BenefitsPotential Benefits

Decrease in Decrease in vasomotor vasomotor symptomssymptoms

Slower changes in Slower changes in body morphologybody morphology

Fewer osteoporotic Fewer osteoporotic fracturesfractures

Improvement in lipid Improvement in lipid balancebalance

Reduce IBD flareReduce IBD flare

Potential RisksPotential Risks

Increase in invasive breast Increase in invasive breast cancer cancer

Side effects: bloating, Side effects: bloating, irritability, weight gain, irritability, weight gain, depression, vaginal bleedingdepression, vaginal bleeding

Increased risk of Increased risk of thromboembolic events thromboembolic events (blood clots, stroke)(blood clots, stroke)

Increase in CVDIncrease in CVD

Clements D, et al. Clements D, et al. Gut.Gut. 1993;34:1543-1546. Stampfer MJ, et al. 1993;34:1543-1546. Stampfer MJ, et al. N Engl J Med.N Engl J Med. 1991;325:756-762. Women's 1991;325:756-762. Women's Health Initiative. Health Initiative. JAMA.JAMA. 2002;288:321-333. 2002;288:321-333.

HRT Guidelines for HRT Guidelines for IBD PatientsIBD Patients

As with all therapeutic choices, therapy for As with all therapeutic choices, therapy for menopausal symptoms should be individualizedmenopausal symptoms should be individualized

For women with severe osteopenia or osteoporosis, For women with severe osteopenia or osteoporosis, HRT benefits may outweigh risks if alternatives are not HRT benefits may outweigh risks if alternatives are not feasiblefeasible

For women at increased risk for breast cancer, HRT For women at increased risk for breast cancer, HRT risks may outweigh benefitsrisks may outweigh benefits

CVD risk vs benefit is controversial, but risk may CVD risk vs benefit is controversial, but risk may outweigh benefitoutweigh benefit