Help Patients Understand and Manage Menopause & Andropause

The Age Wave is upon us. Every day in America, approximately 10,000 people reach retirement age¹ and by the year 2050, one in five Americans will be older than age 50.² (Currently, nearly 40 percent of patients in a typical U.S. chiropractic practice are at least 50 years of age.³) In the next two decades, the proportion of aging adults will continue to increase and we as chiropractors need to be prepared to help our patients age well. The public's health concerns also will change with the graying of our nation.

The Age Wave also means more than one-third of our patients are currently going through, or have already gone through, menopause or andropause (male menopause). It is essential for health professionals to gain a better understanding of the public health ramifications of menopause and andropause, and what role doctors of chiropractic might play in managing "patients of a certain age."

Menopause and Overall Health

Menopause impacts a woman's overall health in profound ways. Chiropractors can help patients with health-promotion and disease-prevention strategies to minimize the negative health impact of declining hormones. Some think menopause simply means a woman stops having menstrual periods. It's important to understand that menopause is a complex health issue and does not suddenly happen. For 6-8 years before menopause (perimenopause), a woman may experience a variety of symptoms as her hormones begin to decline. Periods may become irregular and heavier, and hormones can fluctuate. This fluctuation leads to mood swings and irritability, making perimenopause a challenge for both the woman and her family. During and after menopause, declining hormones are also associated with an increased likelihood of the following:^3-5

• 

  Cancers including breast, ovarian and uterine
• Osteoporosis or bone loss
• Loss of muscle mass / increase in fat mass
• Heart disease
• Cognitive or memory loss
• Depression
• Irritability / mood swings
• Hot flashes, flushes, night sweats
• Loss of libido and sexual changes

Health Promotion and Prevention

First, as members of the public health community, chiropractors should encourage their aging female patients to get the recommended evidence-based health screenings for heart disease, cancers, bone loss and other health concerns in menopausal women. Examples include a mammography every 1-2 years after age 50 and regular blood-pressure checks.

Many menopausal symptoms may respond favorably to changes in health behaviors and lifestyle, another appropriate role for the doctor of chiropractic.^3,6 According to the most recent Practice Analysis of Chiropractic, more than 97 percent of U.S. chiropractors recommend exercise to their patients.2 Exercise is one of the most important and effective ways to prevent or improve each of these health concerns.^7-8

More than 94 percent of U.S. chiropractors also offer patient recommendations related to nutrition, diet and herbal remedies.² Chiropractors can play a role in discussing such remedies with patients. For example, the isoflavones found in soy and red clover have been shown to decrease bone loss and lower blood pressure, but show inconsistent results related to the menopausal symptom of hot flashes and flushes.⁴ Black cohosh may be effective in the mild to moderate vasomotor symptoms associated with menopausal sleep and mood disturbances,^4,6 and St. John's wort may improve depression.⁴ And a recent systematic review of ginseng showed improvement in sexual dysfunction, depression and overall physical well-being compared to placebo.⁹

Some chiropractors may wish to share information on acupuncture with patients. While a systematic review of 11 acupuncture studies showed no effect on menopausal symptoms, two newer trials showed a positive effect related to hot flashes and general menopausal symptoms.^10-11

Some patients may ask their chiropractors for their opinion on using hormone replacement therapy for menopausal symptoms and prevention of menopause-related health concerns. The Women's Health Initiative study on hormone replacement therapy¹² was cancelled due to significant increases in breast cancer, dementia, blood clots and heart disease.¹³ It is prudent for chiropractors to guide patients to the Women's Health Initiative summary of study results so they can make informed choices about such drug therapies.

Male Menopause: Andropause

The male equivalent of menopause is andropause or primary hypogonadism. Men experience a marked decline in hormones in their 50s and beyond, just as women do. While few men have significantly low testosterone at age 40, by age 50 the decline of bioavailable testosterone in many men becomes clinically significant. By age 80, most men have significantly low testosterone.¹⁴ Declining testosterone has general health ramifications beyond just changes in sexual function.

During andropause, the declining testosterone in middle-aged males can result in significant health concerns and troubling sexual changes. Some of the general health issues related to declining testosterone include:^14-18

• Loss of sexual function (which may be the most concerning of all to men)
• Increased risk of atherosclerosis
• Weight gain around the middle
• Declining physical function and muscle strength
• Clinically significant fatigue
• Memory loss
• Bone loss
• Anemia

The term "low-T" (low testosterone) is being used commonly on television commercials advertising pharmaceutical andropausal therapies. Pharmaceutical interventions for low-T represent one of the fastest growing sales areas, with prescriptions for testosterone therapy increasing threefold in the past 10 years.¹⁹ Due to the increasing popularity of testosterone therapy, chiropractors should familiarize themselves with possible health concerns / side effects related to testosterone therapy:^20-24

• Polycythemia or very high hemoglobin levels
• Possible increased risk of prostate cancer
• Aggravation of sleep apnea
• Gynecomastia (enlargement of the breasts)
• Liver tumors and liver failure (most likely only with oral testosterone therapy)

High hemoglobin levels caused by testosterone therapy can be particularly dangerous in patients with cardiovascular disease or hypertension. Patients on testosterone therapy should have regular blood tests to check hemoglobin levels and should be encouraged to donate blood regularly.²² Testosterone therapy also may increase the risk of prostate cancer, an androgen-sensitive cancer, but the evidence is unclear on this connection.^23-24

Health Promotion and Prevention

Doctors of chiropractic may have a role in encouraging patients who are using testosterone therapy to consider the following screening tests:^23-24

• Discuss PSA blood tests and digital rectal exams with their doctor (to screen for prostate cancer)
• Hemoglobin and hematocrit blood tests (to screen for polycythemia)
• Lipid profiles (to monitor cardiovascular risk factors)

Additionally, testosterone levels are significantly lower in sedentary patients and increase naturally with increases in physical activity.²⁵ It is important for doctors of chiropractic to encourage regular physical activity that promotes healthy weight and increased lean body mass in men considering testosterone therapy.

It is important that patients concerned about declining testosterone get as much physical activity as they can. Good cardiovascular health and sexual health are achieved through the same set of health recommendations. Any activity or dietary change that is "heart-smart" also may have a positive effect on sexual function, since good cardiovascular health is often related to better sexual health. Nutritional recommendations should include a Mediterranean diet (higher in fruits, vegetables, whole grains and fish). As mentioned earlier, chiropractors are already promoting exercise and good nutrition to their patients. Our opportunity to help men age well through andropause is clear.

What We Know

Menopause and andropause are increasingly common public health concerns in an aging population. Our patients' health risks change, particularly after reaching menopause / andropause. Chiropractors, who often see their patients regularly, are well-positioned to monitor patients for menopausal / andropausal health concerns. Evidence-based health-promotion and disease-prevention strategies within our scope of practice also may help reduce the negative impact of these hormonal changes on our patients' lives.

References

1. West LA, Cole S, Goodkind D, Wan H. "65+ in the United States: 2010," U.S. Census Bureau, P23-212, Government Printing Office, Washington, DC, 2014.
2. Christiansen MG, Kollasch MW, Hyland JK. Practice Analysis of Chiropractic 2010: A Project Report, Survey Analysis, and Summary of Chiropractic Practice in the United States. National Board of Chiropractic Examiners, 2010.
3. Abernathy C. The Menopause. In: Andrews G (editor): Women's Sexual Health, 6th Edition. Philadelphia: Bailliere Tindall Publishers, pp. 423.
4. Kim MY, Choi SD, Ryu A. Is complementary and alternative therapy effective for women in the climacteric period? J Menopausal Med, 2015 Apr;21(1):28-35.
5. Montogomery JC, Studd JW. Pscychological and sexual aspects of the menopause. British J Hosp Med, 1991;45:300.
6. Aidelsburger P, Schauer S, Grabein K, Wasem J. Alternative methods for the treatment of post-menopausal troubles. GMS Health Technol Assess, 2012;8:Doc 03.
7. Jette AM, Lachman M, Giorgetti MM, et al. Exercise - it's never too late: the Strong for Life program. Am J Public Health, 1999 January;89(1):66-72.
8. Stevenson JC, Lees, B, Fielding C. Exercise and the Skeleton. In: Smith R (editor): Osteoporosis. London: Royal Court Press, 1990.
9. Chang A, Kwak BY, Yi K, Kim JS. The effect of herbal extract (EstroG-100) on pre-, peri- and post-menopausal women: a randomized double blind placebo-controlled study. Phytother Res, 2012;26:510-516.
10. Borud EK, Alraek T, White A, et al. The acupuncture on hot flushes among menopausal women (ACUFLASH study), a randomized controlled trial. Menopause, 2009;16:484-493.
11. Kim KH, Kang KW, Kim DI, et al. Effects of acupuncture on hot flashes in peri-menopausal and post-menopausal women-a multicenter randomized clinical trial. Menopause, 2010;17:269-280
12. The Women's Health Initiative. A study funded by the National Institute of Health; National Heart, Lung, and Blood Institute. Updated 9/21/2010.
13. Heiss G, Wallace R, Anderson GL, et al. Health risks and benefits 3 years after stopping randomized treatment with estrogen and progestin. JAMA, 2008;299(9):1036-1045.
14. Bassil N. Morley JE. Late-life onset hypogonadism: a review. Clin Geriatr Med, 2010;26:197-222.
15. Baumgartner RN, Waters DL, Gallagher D, et al. Predictors of skeletal muscle mass in elderly men and women. Mech Ageing Dev, 1999;107:123-136.
16. Kenny AM, Kleppinger A, Annis K, et al. Effects of transdermal testosterone on bone and muscle in older men with low bioavailable testosterone levels, low bone mass, and physical frailty. J Am Geriatr Soc, 2010;58:1134-1143.
17. Srinivas-Shankar U, Roberts SA, Connolly MJ, et al. Effects of testosterone on muscle strength, physical function, body composition, and quality of life in intermediate-frail and frail elderly men: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab, 2010;95:639-650.
18. Travison TG, Basaria S, Storer TW, et al. Clinical meaningfulness of the changes in muscle performance and physical function associated with testosterone administration in older men with mobility limitation. J Gerontol A Biol Sci Med Sci, 2011;66:1090-1099.
19. Caminiti G, Volterrani M, Iellamo F, et al. Effect of long-acting testosterone treatment on functional exercise capacity, skeletal muscle performance, insulin resistance, and baroreflex sensitivity in elderly patients with chronic heart failure: a double-blind, placebo-controlled, randomized study. J Am Coll Cardiol, 2009;54:919-927.
20. Kaplan AL, Lenis AT, Shah A, Rajfer J, Hu JC. Testosterone replacement therapy in men with prostate cancer: a time-varying analysis. J Sex Med, 2015;12:374-380.
21. Vigen R, O'Donnell Ci, Barón AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA, 2013;310:1829-1836.
22. Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS One, 2014;9:e85805.
23. Bassil N, Alkaade A, Morley JE. The benefits and risks of testosterone replacement therapy: a review. Therapeutics & Clin Risk Management, 2009;5:427-448.
24. Huhtaniemi I. Late onset hypogonadism: current concepts and controversies of pathogenesis, diagnosis, and treatment. Asian J Andrology, 2104;16:192-202.
25. Chahla EJ, Hayek ME, Morley JE. Testosterone replacement therapy and cardiovascular risk factors modification. Aging Male, 2011;14:83-90.