Meet the expert: Cynthia Stuenkal
Cynthia opened with a patient case study:
- A 48-year old woman presents for treatment of bothersome hot flashes.
- Her last cycle was 6 months ago without irregularity or spotting.
- At age 46 she was diagnosed with Type-II diabetes.
- Her glucose control has been normalised on metformin.
- She is also hypertensive and controlled on a combination of calcium channel blockers and an ACE inhibitor.
- In spite of her best efforts, her weight remains 90 kg and blood pressure is 150/90.
- Lipid panel showed low HDL, LDL in upper range and elevated triglycerides.
- What approach should be taken to treat her menopausal symptoms?
Something to consider is that compared with men, women have a more adverse CVD risk profile - women with diabetes have a 2-fold excess risk of CHD and rates of heart failure are more frequent with higher mortality.
Cynthia suggested an individualised approach to treating menopausal symptoms could be considered. Some women with diabetes, after evaluation of CVD risk, may be candidates for MHT.
Care should be taken to consider the contraindications to HT:
- Possibility of pregnancy
- Undiagnosed vaginal bleeding
- Oestrogen sensitive cancers
- History of MI or stroke
- History of DVT or PE
- Liver dysfunction or disease
From a US perspective, the Endocrine Society and NAMS are aligned in recommending quantifying 10-year CVD risk. Cynthia's approach to the case study, she confirmed, was algorithm-based with a focus on quantification on risks. However, this is not to say that the clinician-experience and knowledge of the patient should be ignored. A synergistic approach could be applied.
Based on the quantification of risk factors, a transdermal oestrogen and micronized progesterone were discussed as a possible therapeutic option. At low doses, transdermal therapies may be preferable for women with co-morbidities such as hypertension, hypertriglyceridemia, obesity, metabolic syndrome and diabetes.
However, as previously mentioned, an individualised approach to HT could be considered - supported by the position statement of the NAMS. Indications and evidence-based treatment goals should be accounted for, as well as a woman's age, personal health risks and preferences. NAMS also promoted balancing potential benefits and risks of MHT vs. non-hormonal therapies.