CMS250 - Week 11

• The expected numbers of postmenopausal females will be 1.1 Billion worldwide by 2025.
• Approximately 6000 US females will age to menopause daily with a life expectancy of ~81.5 years with 1/3 of this time being postmenopausal.

Ontario Breast Cancer Risk Categories and Criteria, 2021

• Average risk: These are considered asymptomatic women who meet the following criteria: Are aged 50-74 and have no personal history of breast cancer, current breast implants, Mastectomy, or a screening within the last 11 months.
• If transfeminine, They have been using feminizing hormones for 5 consecutive years.
• Potentially high risk: people considered asymptomatic aged 30-69 with the following criteria 1st degree relative of a carrier of a gene mutation that is associated to breast cancer
• personal or family hx of 2 or more cases of breast cancer with ages of Dx at <50
• Bilateral breast or ovarian cancer
• breast cancer before 35
• Invasive serous ovarian cancer.
• known ashkenazi jewish family link.
• have any associated blood conditions
• male present breast cancer

Canadian Breast Cancer Screening Guidelines (2018)

• These guidelines are specific to women ages 40-74 without personal or family history of breast cancer, known BRCA1 or 2 mutation.
• Recommendations state to not screen with either mammography or clinical exams.
• The decision to undergo screening should be on the patient with consultation.
• It is recommended that if women (same guidelines from before) be screened that they use mammography every 2-3 years if aged 50-74.

Sample Mammogram Reports Overview

• Breast tissue density can reduce the imaging effectiveness
• The report should confirm no masses are present as well as report any abnormalities
• The report should clearly state BIRADS, highly suggestive of malignancy. Recommend either a core needle biopsy or directed ultra-screening.

SOGC for Women With Breast Cancer Summary Recommendations

• Breast cancer risk is a complex metric compounded with menopause.
• If women have previously suffered any breast cancer, systemic MHT is often contraindicated
• if so consider non-hormonal care and management
• HMT does not increase breast cancer risk from premenapusal stages for BRCA, just that women using these techniques need to have their screening managed.
• for low risk regimens use the least invasive route possible for care
• optimized life choices can reduce the risk factors such as smoking, weight, lifestyle choices such as exercise needs encouragement
• Paced therapeutic methods including breathing coupled with acupuncture.
• Second line pharmacotherapy such as valerifine should be recommended in breast cancer patients
• Paroxentine, gabapentin, oxybutynin, and clonidien are options but need care in tamoxifen cohort's
• MHT methods should always be tailored.

Dermatological Issues

• Hormonal linked changes can include decreases in skin thickness, blood supply, sebum secretions, and elasticity.
• Separating natural vs artificial ageing is very difficult.
• Topical steroids are not often successful or recommended to reverse signs of ageing.
• During menopause, significant hair changes can occur such as telogen defluvium/loss of body hair as well as increased terminal hairs to facial regions.

MHT (Hormone Replacement Therapies)

• The goal is to reduce adverse symptoms from GSM and menopause with a highly personalized method, consider both wants and needs before drugs.
• Always opt to recommend life choices that can be used both alone or in conjunction and recommend in early menopause (<45 years) at regular or lower doses to increase and reduce early rise in osteoporosis/cardiovascular disease.
• Continue treatment until women are ~50

Contra Indicators to MHT

• Check pre-existing issues
• known suspected risks of existing breast cancer history
• Estrogen depended neoplasia + active venous thromboembolisms
• History of Strokes or attacks
• Untreated hypertension

Management of Peri vs Post-Menopausal symptoms summary

• Patients will present often with combined changes through multiple stages that should be assessed and tested
• Focus on nonpharmalogic (smoking/drinking cessation + stress and weight mgnt) and encourage inter professional cooperation (gynecologist, psychologist, etc.
• GSM will include dryness as major factors + dysfuctions

Additional Considerations

• Consider vaginal therapy with patients who only experience GSM
• The usage of a progestogen for patients who use vaginal treatments isn't a requirement
• The usage of CHC may be useful during premenopausal treatment requiring contraception.

Patient Centred Management

• During the transition + questions on symptoms consider any education or management as a tool to ease the patient and encourage the lowest impact
• Consider the lowest effective doses for treatments
• Follow up with MHT is 1 week to a month after before assessing efficacy as well as to evaluate contra factors </