Menopause Part I: Diagnosis and Non-Hormonal Therapies

Today’s episode features Dr. Renee Eger! Dr. Eger is an Assistant Professor at the Warren Alpert Brown University SOM, and is a North American Menopause Society (NAMS) Certified Menopause Practitioner. She is talking with us this week and next about menopause.

The ACOG PB 141 on Management of Menopausal Symptoms is an excellent resource for all therapies in use for menopausal symptoms. We’ll cover some additional resources for hormonal therapy on next week’s episode. The high yield points for today include:

-Menopause is the cessation of menses for 1 year. The average age of onset in the US is 51.
-Lifestyle modifications are first-line therapy for both vasomotor symptoms of menopause (VMS) and genitourinary syndrome of menopause (GUSM), formerly known as vulvovaginal atrophy.
-Paroxetine 7.5mg daily (Paxil) is the only FDA-approved non-hormonal pharmacologic treatment for VMS.

Gestational Diabetes Trio, Featuring A Special Interview with Dr. Donald Coustan

Happy Holidays to all, and to celebrate the season we have a very sweet triple episode release today! The first two episodes are focused on the pathophysiology, diagnosis, and treatment of GDM, while the third is a special interview with Dr. Donald Coustan, Professor and Chair Emeritus of the Department of Obstetrics and Gynecology at Brown University. Dr. Coustan was recently profiled by AJOG as a “Giant in Obstetrics and Gynecology.” We hope you enjoy the interview and his perspective on GDM and OB-GYN more generally.

The ACOG PB (PB 190) on GDM was recently updated in February 2018. There is also a new bulletin on Pregestational Diabetes (PB 201), though we don’t spend much time on pregestational diabetes today.

We discuss multiple ways to diagnose GDM, based on different organization’s recommendations. The classic Carpenter-Coustan criteria endorsed by ACOG and the National Diabetes Data Group (NDDG) are based on two-step testing. An initial 50 gram glucose tolerance test is performed, and patients move on to the second screen if their 1hr glucose is measured at 130-140 mg/dL, pending on the institution. It is generally accepted that a value >200 mg/dL is diagnostic without moving on to the second step.

The three hour test is based on a 100g glucose load. The cutoffs vary by time point. Two elevated values are needed to diagnose GDM; however, there is increased risk for the patient even with just one elevated value on three hour testing. The classic Carpenter-Coustan criteria as well as the NDDG criteria are shown here from PB 190:

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ACOG PB 190: The Carpenter-Coustan criteria are the most commonly used in the USA.

There is also single-step testing proposed by the International Association for the Study of Diabetes in Pregnancy, that uses a 75g, two-hour glucose tolerance test. Any one elevated value (fasting > 92, 1 hour > 180, or 2 hour > 153) is diagnostic of GDM, and no second screen is needed. The ADA has endorsed these criteria recently but also admits that there is not clear-cut evidence to support one screening strategy over another. ACOG endorses the two-step screening at this time.

Much of the research regarding treatment of GDM that we review in the podcast is well-reviewed in PB 190, so we won’t rehash it here. If non-pharmacologic treatments fail (monitored fasting and postprandial blood glucose levels are consistently elevated), an oral agent or insulin is required, with insulin being the gold-standard. How do you initiate insulin? See our guide below!

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And remember — postpartum patients with GDM need a 2 hour, 75 gram glucose tolerance test between 4 and 12 weeks postpartum to rule out type 2 diabetes. A fasting > 125 or a 2 hour > 200 is diagnostic. A fasting between 100-125 or a 2 hour between 140-199 demonstrates impaired glucose tolerance. And even with normal values, anyone with GDM has a 15-70% chance of developing T2DM later in life, so it’s an important part of the pregnancy history to correspond back to the patient’s PCP.

Nausea and Vomiting of Early Pregnancy

On today’s episode, we discuss one of the most common ailments of early pregnancy, and recommendations for diagnosis and therapy. ACOG PB 189 (ACOG membership required) goes into all the details and makes for excellent further reading, and to learn all about that PUQE scale!

Probably the highest yield piece of information from PB 189 is the recommended therapy algorithm, which you’ll find below. For your practice, don’t forget about helpful adjunct therapies for acid reflux symptoms, like ranitidine or famotidine.

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ACOG PB 189

Polycystic Ovarian Syndrome (PCOS)

Big shout out to Andrey Dolinko, MD, who suggested today’s topic!
ACOG PB 194 is an excellent resource for your studying on PCOS (membership required).

PCOS is a syndrome, diagnosed clinically by at least 2/3 of the Rotterdam criteria:
1. Hyperandrogenism - hirsutism, male pattern baldness.
2. Oligo- or amenorrhea - 3+ months without menses.
3. Polycystic ovaries on ultrasound - 12+ follicles or increased ovarian volume.

In terms of treatment, the big take home message is to understand whether your patient is planning on pregnancy or not. CHCs are the mainstay therapy of patients not desiring pregnancy due to their multimodal method of action - regulation of HPO axis, increased SHBG, and endometrial protection. Also remember metformin (insulin sensitization) and spironolactone, finasteride, or flutamide (anti-androgens) as other adjuncts in patients not desiring pregnancy.

In those desiring pregnancy, oftentimes the complaint will be infertility. While letrozole is now preferred for ovulation induction over clomiphene due to a higher live-birth rate, letrozole does not yet enjoy FDA approval. For the other symptoms of PCOS in patients desiring pregnancy, the first line therapy is lifestyle modification! The literature doesn’t support metformin for ovulation induction, but some may use it for its other benefits prior to pregnancy.

We didn’t discuss laparoscopic ovarian drilling in this episode, but that would be another surgical treatment for PCOS-related infertility.

Pregnancy Risk Factors and Pregnancy Dating

For today’s episode, we envisioned the “new OB visit,” trying to target two goals from the perspective of the provider.

The first is to look at risk factors in a new pregnancy, and we go over some recommended screenings at the new OB visit to that effect.

The second is to establish an optimal due date, and what to do with suboptimally-dated pregnancies. ACOG CO 700 and CO 688 may be helpful reading in this regard. We also place the table from ACOG CO 700 below in terms of allowed discrepancies between ultrasound and first day of LMP. Remember that your individual institution may have differing policies with respect to suboptimal dating.

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