Episode 38 - Menopause - a podcast by Rio Bravo Family Medicine Residency Program
from 2021-01-25T15:49:32
Episode 38: Menopause Tips.
Asthma treatment update, menopause tips, MMR associated fever and seizures.
Today is January 25, 2021.
Updates on asthma: As you know asthma is a significant burden for our healthcare system, and for the most part it is not preventable nor curable, but advances in management have changed many patient’s lives over the last 40 years. On our episode 27, we mentioned the updated practice guidelines by the Global Initiative of Asthma (GINA). Today we will give you the updated recommendations by the National Asthma Education and Prevention Program (NAEPP) posted on December 3, 2020. It contains recommendations for the treatment of asthma in children, adolescents, and adults[1]. This is an update from the NAEPP 2007 guidelines and are slightly different than GINA regarding step 1 and step 2 management.
-Step 1 (intermittent asthma): NAEPP did not make any changes from 2007. They continue to recommend short-acting β2-agonists [SABAs] for rescue therapy. Remember that GINA recommends against use of SABA as a sole therapy for step 1.
-Step 2 (mild persistent asthma): Either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA.
-Step 3 and step 4 (moderate persistent asthma): formoterol combined with an inhaled corticosteroid in a single inhaler (also known as single maintenance and reliever therapy – SMART) is recommended as the preferred therapy. For step 3 a LOW-dose ICS-formoterol therapy is recommended, and for step 4 a MEDIUM-dose ICS-formoterol therapy is recommended for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended.
-Step 5 (severe persistent), adding a long-acting muscarinic antagonist (LAMA) is recommended in patients whose asthma is not controlled by ICS-formoterol therapy.
-Fractional exhaled nitric oxide testing (FeNO) is recommended to ASSIST in diagnosis and monitoring of symptoms, but is should not be used ALONE for the diagnosis and monitoring of asthma, and do NOT use in younger than 5 yo patients. Another recommendation is to control allergens in patients with relevant sensitivity. This may not sound so new, but there are several strategies for allergen mitigation, for example, use of impermeable pillow and mattress covers only as part of a multicomponent allergen mitigation intervention. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort. If you are still confused about these 2020 NAEPP guidelines updates, I recommend you go online and review them, it is easier to read them than listening to them. Find the link in our posted script.
This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.
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Menopause Tips
by Valerie, That's me, Dr. Civelli w/ a C!
and your friendly medical student neighbor Patrick De Luna
TIP #1: Hot Flashes.
Hot flashes, aka vasomotor symptoms occur in 70% of women in menopause. Hot flashes can last 1-5 minutes; can be characterized by perspiration, flushing, chills, clamminess, anxiety, and on occasion, heart palpitations; and can cause sleep disturbances. Hot flashes are the most common indication for hormone replacement therapy (HRT). Contraindications for HRT include undiagnosed vaginal bleeding, a history of breast cancer, VTE, or Severe liver disease.
Dr Wonderly, how do you treat hot flashes? [Listen to her answer in Episode 38]
TIP #2: Hormonal replacement therapy for hot flashes.
Estrogen or estrogen/progesterone combo is the most effective therapy for menopausal hot flashes. It’s FDA-approved and has a grade A research according to AAFP and ACOG. Topical methods are preferable as they have fewer adverse effects. But how do you choose? There’s Estrogen? Or estrogen/Progesterone combo? And what is the cancer risk? Remember if using hormones: Dose, duration and risk factors are key! Combined estrogen/progestogen therapy is recommended over estrogen alone, but still increases the risk of breast cancer after three to five years of use. There is no evidence that using low-dose local estrogen increases the risk of breast cancer recurrence. Combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene may also be used, especially when the patient still has a uterus. The decision to start HRT or to continue for more than three to five years should be made after reviewing all risks, benefits, and symptoms with each patient.
Dr Wonderly, when do you decide to continue HRT for longer than 3-5 years? [Listen to her answer in Episode 38]
TIP #3: Nonhormonal options to treat hot flashes.
Vasomotor symptoms are best managed with systemic HT, but FDA approved, nonhormonal treatment options are available which are SSRIs, SNRIs, and clonidine. All have been shown to be effective. Antidepressants for nonhormonal treatment of vasomotor symptoms specifically include: citalopram, escitalopram, clonidine, desvenlafaxine, venlafaxine, gabapentin, pregabalin, and paroxetine.
TIP #4: Natural remedies for menopause.
There is no high-quality, consistent evidence that all-natural herbal alternatives are effective. This includes black cohosh, botanical products, omega-3 fatty acid supplements, or lifestyle modifications. AAFP and ACOG do not endorse any of these as appropriate alternatives. For effective, evidenced based, proven therapies to alleviate hot flashes, think estrogen, estrogen/progesterone combo or antidepressants.
TIP #5: The “timing hypothesis” in HRT?
It is possible that a patient may ask you about your opinion regarding the timing hypothesis. This hypothesis suggests that starting hormone therapy early in menopause (compared with starting it 10 years or more after the onset of menopause) may be cardioprotective because of estrogen's apparent ability to slow the progression of atherosclerosis in younger women. Although the evidence suggests that beginning hormone therapy near the start of menopause decreases the risk of cardiac disease, further study is needed. Current guidelines recommend against using hormone therapy to prevent or treat cardiac disease. Further, the American Academy of Family Physicians recommends against using hormone therapy for the prevention of chronic conditions.
Dr Wonderly, when is the ideal time to start HRT? [Listen to her answer in Episode 38]
TIP # 6: Genitourinary syndrome in menopause (GSM).
In 2014, a consensus conference endorsed new terminology: the term genitourinary syndrome of menopause is now recommended to use and replaces the terms vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. Keep in mind this change is because new terminology accounts for the genital tract symptoms that commonly occur in women with menopause.
Genitourinary Syndrome of Menopause (GSM) is a chronic, progressive, vulvovaginal, sexual, and lower urinary tract condition characterized by a broad spectrum of signs and symptoms due to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The low estrogen level causes structural changes such as vaginal dryness, dyspareunia, and reduced lubrication. These can have a great impact on patients’ quality of life.
Treatment: Women with GU syndrome in menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved for dyspareunia due to menopausal atrophy).
Dr Wonderly, do you think UTIs are commonly misdiagnosed in menopause when the GU symptoms are actually being caused by low estrogen? [Listen to her answer in Episode 38]
TIP #7: The MenoPro® app.
This app has several unique features, including the ability to calculate your 10-year risk of heart disease and stroke, which is important in deciding whether a treatment option is safe for you. It also has links to online tools that assess your risk of breast cancer and osteoporosis and fracture[7].
Dr Wonderly, do you know any comprehensive app to be used in menopause? [Listen to her answer in Episode 38]
Conclusion: Menopause is likely undertreated because patients suffer in silence and do not disclose their symptoms to the doctor because these symptoms are seeing as “normal part of life” and lack of treatment is not fatal, but treatment can improve quality of life significantly. So, be aware of these symptoms and be prepared to treat them appropriately.
Estrogen Medications for the Treatment of Vasomotor Symptoms
| MEDICATION | AVAILABLE DOSAGES (MG) | BIOIDENTICAL? | COST* |
| Oral | |||
| Enjuvia (conjugated estrogen) | 0.3, 0.45, 0.625, 0.9, 1.25 (per day) | No | $87 |
| Estrace (estradiol) | 0.5, 1.0, 2.0 (per day) | Yes | $131 |
| Menest (esterified estrogen) | 0.3, 0.625, 1.25, 2.5 (per day) | No | $48 |
| Premarin (conjugated estrogen) | 0.3, 0.45, 0.625, 0.9, 1.25 (per day) | No | $143 |
| Transdermal patch (estradiol) | |||
| Alora | 0.025, 0.05, 0.075, 0.1 (twice per week) | Yes | $90 |
| Climara | 0.025, 0.0375, 0.05, 0.06, 0.075, 0.1 (once per week) | Yes | $50 |
| Minivelle | 0.025, 0.0375, 0.05, 0.075, 0.1 (twice per week) | Yes | $137 |
| Vivelle Dot | 0.025, 0.0375, 0.05, 0.075, 0.1 (twice per week) | Yes | $84 |
| Transdermal gel (estradiol) | |||
| Divigel | 0.25, 0.5, 1.0 (per day) | Yes | $118 |
| Elestrin | 0.52 (per day; adjust dosage based on response) | Yes | $109 |
| Estrogel | 0.75 (per day) | Yes | $126 |
| Transdermal spray (estradiol) | |||
| Evamist | 1.53 per spray (start with 1 spray per day, adjust up to 3 sprays per day based on response) | Yes | $118 |
| Vaginal (estradiol) | |||
| Femring | 0.05, 0.10 (for 90 days) | Yes | $355 |
*—Estimated retail price of one month's treatment based on information obtained at http://www.goodrx.com(accessed June 13, 2016).
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Speaking Medical: MMR
by Heather Langner, MS4
MMR is a vaccine against measles, mumps, and rubella which contains live attenuated viruses. In the US, children should get two doses of MMR vaccine, starting with the first dose at 12 to 15 months of age, and the second dose at 4 through 6 years of age (usually before starting preschool or kindergarten). MMRV (MMR combined with varicella, brand name ProQuad) has been proposed as a way to simplify administration. Let’s listen to what our future doctor has to say about it[8].
According to the CDC there are 2 adverse events that occur most often during the 42 days after the first dose of the MMR/MMRV vaccine: Fever of 102F or higher and rash. The highest rates happening between 5-12 days after vaccination.
Risk of fever: When the MMR vaccine and the Varicella vaccine are given separately the risk of fever (above 102F) is slightly higher than when given the combined MMRV vaccine (1 in 7 vs 1 in 5 children).
Risk of seizures: A study published in Pediatrics explored the risk of febrile seizures in the MMR vs MMRV vaccine. The study included over 83,000 MMRV vaccine recipients and over 376,000 MMR+V vaccine recipients. The study found that the fever and seizures were clustered around day 7-10. The MMR+V vaccine had a febrile seizure risk of 4 in 10,000 doses and the MMRV vaccine had 5 in 10,000 doses. So, the risk of seizures is slightly higher when MMR and varicella are given combined (MMRV).
After first dose: Data suggests febrile seizure post MMR vaccination are primarily seen after the first dose in children aged 12-47 months. The second dose of the vaccine is less likely to cause fever than the first dose. This means that having a febrile seizure after the first vaccination is not a contraindication for receiving subsequent doses. Something to consider: if there is a personal or family history (parent or sibling) of febrile seizures, the child should receive the separate MMR and Varicella vaccine. As children get older the risks for the MMR vs MMRV vaccine are the same.
Contraindications: Per the AAP the only absolute contraindications for the MMR or MMRV vaccine: anaphylactic reaction to MMR vaccine or its components (neomycin or gelatin), pregnancy, and immunosuppression. Relative contraindications include: history of thrombocytopenia (small risk for thrombocytopenia post vaccination, but no hemorrhagic complications have been reported), recent receipt of blood products (may interfere with seroconversion), patients receiving high-dose steroid therapy (immunosuppression), and severe acute illness (precaution intended to prevent complicating management with vaccine reactions). Egg allergy reactions to the MMR vaccine are now considered extremely rare and is therefore no longer a contraindication. Breastfeeding and fevers are also not contraindications for MMR vaccine administration.
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Question of the month: Diabetes management
by Steven Saito, MD
This is a reminder of our question for this month. Please answer before Feb 8, 2021. The best answer will receive a prize.
Question: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.
Send your answer to RBresidency@clinicasierravista.org. Don’t miss this chance to win.
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For your Sanity: Random Jokes
by Katherine Schlaerth, Manuel Tu, and Cassandra Levitske
-If those who can’t hear are deaf, and those who can’t see are blind, what do you call those who can’t smell or taste?
-Covid positive
-What does a gynecologist and a deaf person have in common? They're pretty good at reading lips.
-Why did Tigger stick his head in the toilet?
-He was looking for Pooh.
-Why is pea soup more special than mashed potatoes?
-Because anyone can mash potatoes.
Conclusion: Now we conclude our episode number 38 “Menopause Tips”, we started with some updates on asthma management, then Dr Civelli and our “future doctor” De Luna gave us some tips about the treatment of menopause symptoms. Our wonderful Dr Wonderly also answered a few questions about the management of this unavoidable, “period-free” period in a woman’s life. Then doctor-to-be Heather explained her findings on risks associated with MMR, specifically fever and seizure risks. Don’t forget our question for this month. Send us a brief, original, and relevant answer to our email before Feb 8, 2021. We hope you enjoyed this episode.
Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, Patrick De Luna, Sally Wonderly, Cassandra Levitske, Manuel Tu, Katherine Schlaerth, Tana Parker, and Steven Saito. Audio edition: Suraj Amrutia. See you next week!
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References:
Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF, Pace W, Schatz M. Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program. JAMA. 2020;324(22):2301–2317. doi:10.1001/jama.2020.21974 (https://jamanetwork.com/journals/jama/article-abstract/2773482)
2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group, https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines.
Asthma: Updated Diagnosis and Management Recommendations from GINA, Am Fam Physician. 2020 Jun 15;101(12): 762-763. https://www.aafp.org/afp/2020/0615/p762.html.
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2020. Available from: www.ginasthma.org
ACOG Releases Clinical Guidelines on Management of Menopausal Symptoms, Am Fam Physician. 2014 Sep 1;90(5):338-340. https://www.aafp.org/afp/2014/0901/p338.html
Hormone Therapy and Other Treatments for Symptoms of Menopause. Am Fam Physician. 2016 Dec 1;94(11):884-889. https://www.aafp.org/afp/2016/1201/p884.html
Habib, Jamie, NAMS Launches Free Mobile Menopause App, Contemporary OB/GYN, October 16, 2014, https://www.contemporaryobgyn.net/view/nams-launches-free-mobile-menopause-app
David W. Kimberlin, ACIP, AAP support choice of MMRV or separate MMR, varicella vaccines, AAP News January 2010, 31 (1) 10; DOI: https://doi.org/10.1542/aapnews.2010311-10. https://www.aappublications.org/content/31/1/10.1
Meissner, H. Cody, MD, FAAP, What are the indications, precautions, contraindications for MMR vaccination?
AAP News, May 14, 2019, https://www.aappublications.org/news/2019/05/14/idsnapshot051419.
Febrile Seizures and Childhood Vaccines, Questions and Concerns, Centers for Disease Control and Prevention, last reviewed on August 14, 2020, https://www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html.
MMRV Vaccine and Febrile Seizures, Centers for Disease Control and Prevention, last reviewed on June 4, 2020, https://www.cdc.gov/vaccinesafety/vaccines/mmrv/mmrv-febrile-seizures.html.
VSD MMRV Safety Study, Centers for Disease Control and Prevention, last reviewed on June 29, 2020, https://www.cdc.gov/vaccinesafety/vaccines/mmrv/vsd-mmrv-safety-study.html.
Klein Nicola P., Bruce Fireman, W. Katherine Yih et al, Measles-Mumps-Rubella-Varicella Combination Vaccine and the Risk of Febrile Seizures, Pediatrics, July 2010, 126 (1) e1-e8; DOI: https://doi.org/10.1542/peds.2010-0665. https://pediatrics.aappublications.org/content/126/1/e1.
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