Welcome to CME on ReachMD. This activity titled: Menopause Matters, Let's Start Paying Attention to Racial and Ethnic Differences, Addressing Patient Needs, is sponsored by the Academy for Continued Healthcare Learning, and Purdue University College of Pharmacy, and is supported by an educational grant from Astellas. Before starting this activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
Hello, everyone, I am Dr. Ekta Kapoor. In this module, Dr. Kagan, Dr. Neal-Perry, and I will discuss how we address unmet clinical needs in the care of menopausal women from diverse racial and ethnic backgrounds.
So before we get to that, let's start by summarizing the current guidelines for treatment of menopause symptoms in general. And then we can extend our discussion to the special considerations in women from diverse backgrounds.
So how do we manage menopause symptoms? So I like to think of that in two groups. So women who are having symptoms that relate to hot flashes, night sweats, sleeping difficulties, mood problems, etcetera, versus women who have almost exclusive or predominantly genitourinary symptoms. So if we’re talking more in terms of systemic symptom, meaning hot flashes, night sweats, sleeping problems that are moderate to severe and intensity, and my patient is less than 60 years old, within 10 years of menopause, and she doesn't have any contraindications to hormone therapy that we had previously talked about. And those would be - the prominent ones would be a history of an estrogen-sensitive cancer like breast cancer or endometrial cancer, previous cardiovascular disease, liver dysfunction, previous history of an unprovoked DVT. If none of those exists, then hormone therapy would be a reasonable option for a patient like that. Also important to remember that a woman who's gone through premature menopause, meaning menopause prior to the age of 40 years, even if she does not have symptoms, she will be a candidate for hormone therapy in replacement doses. And that's mostly to prevent the long-term morbidity and mortality that's associated with premature estrogen deprivation, again, assuming that there is no contraindication to estrogen use.
Now, what happens if we're dealing with a patient who is either older than 60, or she is more than 10 years out from menopause, or she has a reason that they couldn't use hormone therapy, or someone who even after all this long discussion is having symptoms but does not want to go on hormone therapy? Then we consider the nonhormonal treatment options that we've discussed in the previous modules.
And the patient who's having predominantly genitourinary symptoms doesn't really need systemic hormone therapy for management of her symptoms. Even though if she is on systemic hormone therapy for another reason, she may see benefit in her genitourinary symptoms with that. So almost exclusive genitourinary symptoms will be managed with moisturizers and lubricants as first-line therapy. And if they are not successful, then we go on to vaginal estrogen therapy, which can be delivered in a variety of formulations, including cream, tablet, gels, etcetera. Then we also have the option of using vaginal DHEA therapy. That seems to be a popular option. And patients who are breast cancer survivors who are on aromatase inhibitor therapy, want to avoid vaginal estrogen patients like that. And there are some data to suggest that DHEA does not get converted to estradiol and, therefore, may potentially be safer.
And then the last thing I want to mention here is ospemifene, which is an oral medication for use for patients with genitourinary symptoms due to menopause. If the patient absolutely wants to avoid vaginal products, then that's an option.
Okay, so moving on. Now to Neal-Perry, may I please request you to summarize the racial and ethnic differences in menopause-related symptoms that we discussed in this activity? And what special considerations would you use when you're selecting therapy for these women?
Thank you, Dr. Kapoor. So the Study of Women Across the Nation has really done a very good kind of characterizing racial differences in onset of menopause, as well as the symptoms of menopause. And what they demonstrated, a paper by ___ was that Hispanic women and African American women are likely to have an earlier menopause anywhere from, you know, 1.5 to 2 years earlier than their white counterparts as well as Asian counterparts.
The other thing of importance is that African American women tend to have vasomotor symptoms that are more severe, and they can last for more than 10 years. And so, it's really important to listen to a patient. So, if you have an African American woman, or any woman for that fact, who's telling you that they have hot flashes, and you know it's not due to some other endocrinopathy, it is really important to treat them for reasons that we've previously talked about. And that there's data that demonstrates that women with vasomotor symptoms are more likely to have preclinical heart disease. So this is really important in terms of how we provide care and how we reduce disparities.
You know, there is certainly, you know, the use of SSRIs as a intervention for hot flashes. And what many people don't know is that there's anywhere from a quarter to one-third of African American women who have an alteration in the CYP2D6 which is important for metabolism of SSRIs. So that they have a change in that particular enzyme, and they don't metabolize the same way so that SSRIs may be less effective for a significant number of African American women.
So in terms of treatment, usually, for a young woman who's presenting with bothersome vasomotor symptoms will begin with estrogen. Estrogen and progesterone, certainly, if someone has your uterus intact, but really starting with estrogen is often the first approach, providing the patient doesn't have any other risk factors or contraindications that you previously mentioned.
Similarly, treatment may be extended, right, you know, when the recommendation is generally 5 years. But for women who continue to have severe to moderate hot flashes, you really want to think about that extension.
And the other thing that's really important to know when we when we talk about disparities is that women who have a history of mental health dysfunction, that withdrawing hormones may actually trigger some of those mental health concerns. And so you really, again, want to be thoughtful and careful in those patients, and in terms of how you manage them.
Okay, thank you, Dr. Neal-Perry. So our patient, Chanez, described use of hormone therapy from her family and friends, let's hear her story.
Well, before I started menopause, I knew nothing about hormone therapy. It's a strange thing that when you're young, and, you know, that's not something that you think about. You think about it as being something that an old person or more senior person goes through. So that's not something that's on your mind to even, you know, indulge in a conversation with someone about.
However, because my mom was a midwife, I would hear her have different conversations with her patient. I would hear her have conversations about her patient. There was a time where this woman apparently was going through menopause, and my mom was talking with her husband and her mother. And she said, ‘You have to be very careful because she can easily lose her mind.’ I didn't know at the time what she was referring to. Only after I become an adult, and have the conversation later with my mom. In basically in the African American community, especially with women, it is a thing about taking more natural substance as opposed to prescribed substance and becoming - there's a thing of, you know, the fear of becoming addicted to a prescribed medication. And so, when my mom said to me, ‘don't take any of that medicine,’ what she meant was don't take any prescribed medicine from my doctor. And I didn't quite understand it then, but I understand it now. And so hence, I started taking the black cohosh.
Wow, such fears and misperceptions out there. I'm going to ask this question to both of you. We can probably start with Dr. Kagan and then move on to Dr. Neal-Perry. How would you address such fear surrounding medications for menopause symptoms? And, you know, what other concerns do your racially and ethnically diverse patients bring up during these discussions, Dr. Kagan?
Oh, it’s education, education, and education. And making sure that the education is at a level that people understand. And even the language that people understand. So you might have to do it with an interpreter as well. Or going out to the groups in which there are like a, not just me and the patient, although I do enjoy doing that, but I think sometimes having a group, going to church groups, going to a community center, giving a lecture where then people can ask Q&A and hear their friends ask questions.
I'm very concerned when someone thinks they're going to get addicted to estrogen. Really, what the concern is, is that when they try to go off, if they don't want to be on for very long, they're going to not be able to get off the medicine. And that's not really what happens. I mean, we know from many studies, that when women want to go off, whether you taper off slowly, or whether you stop abruptly, about 50% of women need to go back on something. But 50% of people do okay, or they have some mild symptoms, and they will gradually get better. What we can do, though, is go explain that we can use lower doses, different delivery systems, sometimes people are much better with a transdermal very even low dose, and really explain the reason why it's so important to use something that we have efficacy for.
Because taking black cohosh, we know there's a placebo response, but when you really look at the studies and carry them out further, they're wasting their money. And so as I say, if we could bottle about placebo, that would be great.
Most people do come having tried from their book group and their church group, from their mother, their sister, trying to beat it on their own, as they say. But I think that's why embrace the fear, find out where the fear comes from, find out who told them what. You know, I have a case, an example. It's a woman who's in this book groups, okay. And what I find out is that she has to be on estrogen, she cannot survive without estrogen. And she calls herself a closet user, because she's afraid to tell her book group because they're so anti-estrogen. And so we decided that I would go to the book group, and now – or the club or the church or the, you know, community center, and I would talk to all of them, and give them accurate evidence-based information at their level of understanding. And no question. Everything is on the table. There's no stupid question, I say.
So that's, I think you just have to really focus on where the fear comes from.
Thank you for sharing that. Dr. Kagan. Yeah, it's just disappointing and sad that there are so many misperceptions and fears out there. And we just have to do our part in dispelling all those misconceptions. Dr. Neal-Perry, do you have anything to add to that?
Yeah, I think the most important thing is to understand what why. And so rather than, you know, just saying, ‘No, you should do this,’ like, ‘well, what are your concerns, so that we can have a real deep conversation.’
And I think it's important to be culturally sensitive and aware that people, you know, there is a reason that African Americans may be concerned, and not trust healthcare system, it's not baseless, it is, you know, based on history. And so understanding what those concerns are, and then having conversations, you know, that are really focused on what the concern is, and being able to provide some data, sharing data. It definitely has to be, you know, digestible data. You know, there has to be that level of trust between the provider and the patient so that the patient feels comfortable asking questions.
You know, the other thing that I think is often missed, is that we can write a prescription for a patient, but, you know, we don't know whether they can buy it, right? And so we have patients who we write prescriptions for, and quite frankly, almost, you know, many of the estrogen, you know, treatments may not be covered by insurance. You know, whereas a patch may be the ideal treatment for a patient, you know, they may not use it, because they can't afford it.
And so, just being aware and asking questions about what are your concerns, and then showing data, you know, to help them understand that, you know, this is why it's needed for you, this is how it can help you, here are the things that, you know, that if you take this, these sort of things that we wouldn't, you know, when we would stop using them, right, and to really just be honest and open and allow a dialogue between, you know, yourself and a patient so that they feel comfortable, you know, asking questions, and you know, and even, you know, I mean, sometimes I'll say bring in your friend, you know, your friend has concerns and they're sharing this, let's all talk about this. You know, knowledge is power.
Wonderful. Yeah, exactly Dr. Neal-Perry, all very great points.
I think it is the ultimate shared decision-making. Really, you have to have a participation in making those decisions, empowering the patient, or the woman that she is going to help decide what she wants to do.
Exactly. So well stated. So I think education is at the core of what we want to do for these patients. And I always make this point that, you know, when it comes to educating people about menopause, I think it's best that we focus on the consumers, the patients themselves, so they go to their providers empowered, and almost with a plan of their own, which they want executed in collaboration with their provider, rather than walking in very helplessly, not knowing what's the right thing for them and feeling very ambivalent about their symptoms and management. So yeah, I completely agree, knowledge is power, that's where we need to focus.
And I think it's just not education of the patient, it's education of the provider. Because just as many patients who have concerns, there are providers who project their concerns our patients, so that they may not offer something that's really well, you know, well studied and we know it's effective, because of their own concerns, or ambivalence about, you know, different types of treatments.
So Dr. Neal-Perry, speaking about a patient like Chanez, so any specific considerations with regard to selection and duration of therapy for a woman like her?
You know, I agree with Dr. Kagan, it's usually the lowest effective dose. You know, that's what we're working with. And that's what I tell a patient. You know, depending on what the symptoms are, you know, it's going to be the lowest dose that works for you.
And, again, in terms of the duration, I don't say it, after 5 years, it's, you know, it's 5 years or plus, right, that's it. You get it no more after 5 years, because as we already discussed, symptoms can persist for well over 10 years. And so again, it's about listening to the patient, and having that dialogue with the patient, about what you know, what the concerns are for them, as well as what the concerns are for, you know, as a provider.
Wonderful, thank you. And, you know, as this discussion is bringing out, counseling patients on therapy options can be time consuming, challenging, and nuanced, because every patient brings something different to the table. So there are multiple determinants that go into decision-making. Let's go back to Mary Kim’s experience and see what she has to say.
Well, I think a couple things that were really important to me. And when I really look at, when I first started addressing this topic with my OB/GYN was a little bit of lack of empathy, lack of understanding, or lack of the fact that these are real symptoms, and that they're, you know, they do impact your daily life. They not only impact your daily life as physical symptoms, but they do impact your daily life in the way that they affect you emotionally. Because sometimes you just feel like, there's all these things, your body's changing, just like the emotions you have in your hormones are changing when you're pregnant. But it seems like when you're pregnant, there's more of an understanding of what's going on in your body. And there's more people who are trying to help or at least be empathetic and lend a listening ear.
I think when you get to the point that you're a woman who's in the perimenopausal phase, or the menopause phase, that you're basically being somewhat dismissed. Maybe it's because the physicians don't fully understand, you know, menopause, they're not trained well enough, or it's just not something that's doctors are taking an interest in right now. But I think the biggest thing that they could have offered me was to really listen to what I had to say. And I think whether it is an over-the-counter, whether it's other alternatives for hormone replacement therapy, or any other options that are out there, I do know, with other types of diseases, you have many drugs that within a category, and so maybe the Vivelle-Dot with the progesterone, even though it was the lowest possible dose, wasn't right, but maybe it was how my body was reacting to that, and it may have needed a different brand or a different type of hormone combination of sorts. I was not offered any creams. I was basically not offered anything.
And I think that's where it became pretty frustrating, feeling like I was completely alone. And women are not as eager to talk about their menopausal symptoms with you know, their friends openly, to even have a dialogue to find out what's worked for someone else.
So I think in the end, what I would have appreciated was a little bit more empathy, a little bit more compassion, and again, trying to find options that could help me.
So my frustration was pretty high. And I knew there had to be answers. And maybe not the answers that I necessarily wanted, but I felt there needed to be something more. So I continued my search to find another physician who might have more knowledge, take better interest in the menopausal woman. And I actually went did research and went through even anyone who was affiliated with the North American Menopause Society. So I felt very lucky. I was willing to go into Boston into the big city and drive deep and find a practitioner. But I was lucky enough to find someone closer to where I live, who when I made an appointment with her, this woman was amazing. My first appointment was probably close to an hour and 15 minutes. That's exactly what she takes to meet new patients to really understand their needs and what they're looking for. She gave me the support. She gave me the empathy. She agreed with a lot of what I was saying that it wasn't just in my mind. She agreed with the importance that just because my other OB told me that I still looked good, that it still bothered me that I had gained weight and my clothes didn't fit. And she was very blunt, she was very honest, she did tell me there were not a lot of options.
But what made me feel better is to know that she listened. She had the compassion, she agreed with what I was saying, she did actually offer some proactive tips and tricks for things that I may encounter going into the future, especially as it relates to intimacy and some of the difficulties that may come along with that. So she gave me really some great alternative options. They didn't do a lot for my vasomotor issues of the night sweats. But again, there's sort of a natural progression that the body takes.
And one of the things that was just really important, when I walked out of her office was really realizing that this is a part of life, she helped me just realize that there may not be a lot of options, but there are people willing to listen. And that even what options are out there, she was proactively willing to give me some things that I might run into as I go about my life, go about my intimate life, and how do I kind of go through menopause feeling good about myself and the healthcare that I have. So I'm extremely grateful to have found her and her listening ear to make this process a little easier. And just make me feel a little better about going through menopause.
Oh, my goodness, another sad story there. So, Dr. Kagan, I wanted to ask you, can you describe how you use the larger clinical team? For example, what resources do you use to educate women? And how is your clinical team trained and equipped, particularly with respect to cultural competence to provide quality care to women from diverse backgrounds?
Well, first of all, we try to find out who has a specialty interest in menopause, because you can't, you know, you take some new young OB who hasn't learned a lot, it's nice if they would shadow somebody like me. We have it very open where the senior people who have been very involved in menopause, pair up with younger colleagues to make sure they know that we are available to help. I think that our medical assistants come from many more diverse backgrounds than sometimes the practitioners. So many of our medical assistants are very actively involved. We educate them. They speak various languages that maybe I don't speak. So they can actually be a bridge when we're having - it's really nice if somebody from the team speaks the language of your patient, or even is familiar with that patient, because then the patient develops a trust.
And I use a lot of resources like the North American Menopause Society. The MenoNotes which have a lot of - they come in Spanish, they come in English, I think there's some in French. And this is really something we're trying to work on also as a group visit. There are some models of group visits for menopausal symptoms where you have a group of women together just like they're doing for OB patients, where they get together and they become friends. They can have a very safe environment. You have a leader like one of us or a nurse practitioner, one of our MA’s together, and making sure we carefully pick people that are matched up with the patients or the women that are coming.
So I do believe that there are really good resources out there. But they have to be at their reading level, their grade level, the literacy language. And it's nice to have it be more than just me and the patient, because sometimes I have to have a patient see one of my partner's because I feel like they would be better matched to make sure they have the accurate information.
Great. All great points. Dr. Neal-Perry, do you want to add anything to that?
Yeah, the other resources that patients could use are Red Hot Mamas. And that is actually a group that is a racial, ethnic group, African American women who actually talk about the menopausal experience, as well as the Endocrine Society Hormone Network have very patient-friendly information around the menopause.
And you know, and I think, as Dr. Kagan said, you know, patients respond to providers that actually look like them. So, people who that, you know, who have some understanding of their cultural beliefs so that they can raise those questions, because sometimes they're uncomfortable asking questions, because they don't feel that, you know, the person that's sitting with them may understand what the source of, you know, what source or background of the questions are.
So again, you know, listening, listening, listening to your patients, you know, is really critical. And, you know, and just trying to find a vehicle that will give them information so that they're empowered to make an informed decision. And to me, that's the role. That's our job.
So, Dr. Kapoor, in our previous module, you introduced a new novel pathway for treating vasomotor symptoms. And they will be added, hopefully, and maybe more effective than some of the existing agents or alternatives to hormone therapy that we offer now. As you know, there's just one officially approved, which is the low dose paroxetine at 7.5 milligrams that was studied in randomized control trials. But, you know, again, we really want to help women. So I'm just curious to know what your thoughts are, assuming this new pathway pans out, it looks like it is and the agents that are being studied, hopefully down the road will get approved.
Yeah, that's a great question, Dr. Kagan. I think this group of medications will be a valuable addition to our armamentarium for nonhormonal strategies for management or vasomotor symptoms. And we've already discussed in detail as to who those patients are, who qualify for a nonhormonal strategy.
One thing that may be potentially attractive for this group of medications is the unique mechanism of action that we talked about. So it is possible because of where these medications act, that they may not have some of the side effects, which some of the other nonhormonal agents have. But I don't think we've studied that enough to know for a fact. But it's the unique mechanism of action that may play out into the side effect profile. So we just have to stay tuned and see what the data is.
I mean, the other thing that I have found is some women are reluctant to use what's called an antidepressant or an anti-anxiety medication. And so that's why many will say all take that nerve pain gabapentin at night, because - or try it during the day, because a lot of people use that for nerve pain, but it's not an anti-anxiety or antidepressant.
And that's such a good point. There is a great deal of stigma associated with taking antidepressants, even if you take them at low doses for management of vasomotor symptoms plus the side effects, right, weight gain, and the sexual side effects. So it remains to be seen what this new group of medications will bring to the table. Will we have some of these problems with them too? But again, because of the mechanism of action and the site where they act, so perhaps there'll be free of them.
The other thing that crosses my mind, as I analyze this mechanism of action is that because these receptors are inhibited by estrogen, and one can, you know, hypothesize that perhaps some of the other beneficial effects of estrogen, as they relate to sleep and appetite regulation, are somehow controlled by this group of receptors, of related receptors, because of their location in the hypothalamus. And that's where some of these other symptoms are located also. But again, there is so much we don't know. And I'm excited to find out as to how these receptors interact with other effects of estrogen. So I guess, like I said, we just have to stay tuned and wait for the data.
So with that, we conclude our discussion on interventions to address unmet clinical needs across diverse women. Please be sure to complete the post test and
evaluation to receive CME credit. And on behalf of all three of us, I would like to thank you for watching.
This activity was sponsored by the Academy for Continued Healthcare Learning and Purdue University College of Pharmacy, and is supported by an educational grant from Astellas. To receive your free CME credit, be sure to complete the post test and evaluation at ReachMD.com/CME. This is CME on ReachMD. Be part of the knowledge.