Multidisciplinary Management of Menopause: Symposium Proceedings

Abstract

This proceeding summarizes a symposium on multidisciplinary management of menopause held on July 30, 2021 as part of the Health of Women 2021 conference. The workshop featured presentations by national experts who provided insights into multidisciplinary approaches to the management of menopause, vasomotor symptoms and genitourinary syndrome of menopause, bone health (including osteoporosis, muscular strength, and mobility), as well as sexual and psychological health during menopause. In this study, we highlight the major points of each presentation and the resultant discussion.

Introduction

The world's population of aged individuals continues to grow. According to the United Nation's World Population Prospects: The 2019 Revision, one in six people in the world will be over age 65 (16%) by the year 2050, which is an increase from one in 11 in 2019 (9%). Furthermore, it is estimated that one in four persons living in Europe and North America could be age 65 or over by the year 2050.¹ As the world's population of older individuals grows, so too will the burden associated with menopause in aging women. Menopause, the permanent cessation of menstruation resulting from loss of ovarian follicular activity,² is an often misunderstood and taboo topic.³ Understanding the health concerns surrounding menopause, however, is critical for women everywhere.

On July 30, 2021, the Virginia Commonwealth University (VCU) Institute for Women's Health and VCU Health Continuing Education, in collaboration with the Journal of Women's Health and Women's Health Reports, presented a symposium on Multidisciplinary Management of Menopause as part of the Health of Women 2021 conference. The workshop featured presentations by experts from across the United States, which included an overview of multidisciplinary approaches to the management of menopause, vasomotor symptoms and genitourinary syndrome of menopause (GSM), bone health (including osteoporosis, muscular strength, and mobility), as well as sexual and psychological health during menopause. In this study, we highlight the major points of each presentation and the panel discussion that followed.

Presentation Summaries

Multidisciplinary approach to menopause

The first presentation was given by Dr. JoAnn V. Pinkerton, Professor of Obstetrics and Gynecology and Director, Midlife Health, University of Virginia Health System. She delivered an overview of multidisciplinary approaches to the management of menopause with a special emphasis on hormone therapy. The Women's Midlife Health Center at the University of Virginia, directed by Dr. Pinkerton, has a multidisciplinary team to meet women's health needs. This team, both those located within the center and those closely linked to the center, includes gynecologists, endocrinologists, cardiologists, breast cancer surgeons, neurologists, hematologists, primary care physicians, rheumatologists, psychiatrists, psychologists, social workers, nutritionists, and mind–body experts.

Menopause is a very complex time for women. As estrogen levels begin to decline, menopause first presents with symptoms such as hot flashes and sleep disruptions, while migraines, joint pain, and headaches are also common.⁴ It is important to look beyond typical menopause-related symptoms, however, to address women and their health holistically. For instance, women should be screened for psychosocial stressors in their home or workplace that may coincide with or be worsened by menopause. Children leaving home, aging parents, relationship issues, work or community responsibilities, and many other individual factors can cause stress in a woman's life, and therapy may be a useful tool for helping women as they go through this normal natural event.

Hormone therapy (estrogen or estrogen plus progestogen for women with a uterus) is one option for women going through menopause. However, according to a report in 2002 following the Women's Health Initiative Study, hormone therapy was significantly associated with increases in coronary heart disease and breast cancer; overall, this report concluded that the health risks outweighed the benefits of hormone therapy.⁵ This has, Pinkerton said, led to disproportionate fear driving the conversation regarding hormone therapy in menopausal women.

Are hormones friend or foe? Pinkerton argued that they are more friend than foe because we now know how to use them better. Despite the subsequent published evidence that now suggests hormone therapy is a relatively safe treatment option for symptomatic menopausal women who are under age 60 or within 10 years of menopause, the number of women being prescribed and using hormone therapy continues to decline.^6,7 This has led to a culture where both women and often their health care providers are uncomfortable talking about menopause or hormone therapy.

Further investigation into the Women's Health Initiative study by Manson et al. and others revealed several important findings.⁸ First, when the results of the study were stratified by age, the risk for coronary heart disease with hormone therapy was only significantly elevated among women who began hormone treatment 20 years postmenopause onset. A more favorable risk-to-benefit ratio was seen in younger women, women started on therapy within 5 years of menopause onset, and in those with prior hysterectomy. In addition, younger women aged 50–54 years experiencing moderate or severe hot flashes, night sweats, or both at enrollment had substantial reductions in menopausal symptoms.⁸ Another study that same year supported these findings, demonstrating that in recently menopausal women, the short-term risks of stroke and venous thromboembolism were small.⁹

Furthermore, they observed that estrogen plus synthetic progestin therapy, but not estrogen therapy alone, increased the risk of breast cancer.⁹ Thus, the use of menopausal hormone therapy for <5 years is a reasonable option for the relief of moderate to severe vasomotor symptoms such as hot flashes, night sweats, and sleep disturbances. Longer term durations should be evaluated for risks and benefits in women who remain symptomatic, have significant bone loss, for whom other therapies are not an option, or for quality of life reasons, recognizing that health risks increase as age increases. Reassessment is recommended periodically to determine need for therapy and how to minimize risks if shared decision-making leads to continuation.¹⁰

Research has also elucidated the importance of factors such as race/ethnicity in menopause. One study showed that unadjusted median total menopausal vasomotor symptom (VMS) duration was 7.4 years across all women.¹¹ When these women were classified by race/ethnicity, it was observed that African American/black women reported the longest total VMS duration (median of 10.1 years), and Japanese and Chinese women had the shortest total VMS durations (medians of 4.8 and 5.4 years, respectively). The median total VMS durations were 6.5 years for non-Hispanic white women and 8.9 years for Hispanic women. This same study noted that some of the factors most related to VMS duration were perceived stress, higher symptom sensitivity, lower educational level, depressive symptoms, and African American race/ethnicity.¹¹ Thus, there are many factors (race, ethnic, socioeconomic, stress, etc.) that should be taken into account when deciding on a management approach for a menopausal woman.

Even with multidisciplinary approaches, it can be difficult to know when to initiate hormone therapy in menopausal women given the current body of evidence. Not long ago, the 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) was released.¹² This position statement recommended that previous data regarding hormone therapy in women over age 50 should not be extrapolated to younger postmenopausal women who have early or premature menopause. Furthermore, observational studies suggest that the benefits outweigh the risks for effects on bone, heart, cognition, vulvovaginal atrophy (VVA)/GSM, sexual function, and mood for these women with early menopause, whether natural, surgical, or induced.

For these women, hormone therapy is recommended until at least the natural age of menopause (52 years).¹² According to this report, hormone therapy is not recommended at any age to prevent or treat cognition or dementia, although estrogen therapy may, in fact, have positive cognitive benefits if initiated immediately after early surgical menopause. Furthermore, hormone therapy may help attenuate abdominal adipose accumulation and weight gain that is often associated with the menopause transition. The report goes on to elaborate that observational evidence shows use of hormone therapy does not significantly further raise the risk for breast cancer in women with a family history of breast cancer.

Timing of hormone therapy also matters. Hormone therapy may reduce morbidity/mortality risk if initiated early, between the ages of 50 and 59 years, or <10 years after menopause onset. However, hormone therapy increases coronary heart disease risk if initiated at >10 years after menopause and certainly by 20 years after menopause.^13
–15 It is important to remember that this timing hypothesis refers to initiation, not continuation, of hormone therapy.

Transdermal estrogen hormone therapy is another option that can be considered, such as for women with underlying medical conditions, particularly those with increased risk of stroke, metabolic disease, or venous thromboembolism.¹⁶ A class of drugs known as selective estrogen receptor modulators (SERMs) may also prove to be useful. For example, bazedoxifene paired with conjugated estrogens has been shown to treat menopausal symptoms and prevent osteoporosis while protecting the endometrium from unopposed estrogenic stimulation.¹⁷ Many women request “compounded bioidentical hormone therapy” in the belief that it is “natural” and safer.

It is important to recognize that there are many tested, Federal Drug Administration (FDA)-approved, and monitored systemic bioidentical estrogen therapies (pill, patch, gel, spray, lotion, and vaginal ring) as well as oral micronized progesterone. FDA-approved bioidentical vaginal therapies for use with GSM include vaginal estradiol (cream, tablet, and suppository) and intravaginal dehydroepiandrosterone (DHEA). There is significant concern about the use of compounded bioidentical hormone therapy made by retail pharmacists. These concerns include a lack of regulation and monitoring, possibility of overdosing or underdosing, lack of scientific efficacy and safety data, and lack of a label outlining risks. These custom-compounded products should be used primarily to avoid allergies to certain ingredients or to provide dosages or formulations not available in FDA-approved therapies.¹⁸

In conclusion, women <60 years of age or within 10 years after the onset of menopause who have symptomatic menopausal hot flashes or night sweats and women with premature menopause are most likely to benefit from hormone therapy. For women with early menopause without contraindications, hormone therapy is recommended until at least the age of naturally occurring menopause. Observational studies suggest the risk of thromboembolism and stroke is lower with transdermal therapies, particularly lower dose, than oral hormone therapy.

Estrogen alone in women with prior hysterectomy appears to have fewer risks when used longer term. Custom-compounded bioidentical hormone therapies are not approved by the FDA and thus are not recommended owing to safety concerns, unless allergies are present or special formulations are needed. Hormone therapy is not recommended for primary or secondary prevention of coronary heart disease or dementia. Longer durations of therapy may be considered with periodic evaluation of health, risks and benefits, and documentation of rationale and use of lower doses or transdermal therapies to reduce risks.

Vasomotor symptoms and genitourinary syndrome of menopause

Dr. Diane Todd Pace, Professor and Director, Special Academic Programs, College of Nursing, and Professor, College of Medicine, University of Tennessee Health Science Center, presented data on vasomotor symptoms and GSM. The most common reason that menopausal women seek care is vasomotor symptoms; however, vasomotor symptoms are complicated, and their precise mechanism and triggers are still not fully understood. Vasomotor symptoms are associated with physiological circulatory changes, transient decrease in regional brain flow, diminished sleep quality, irritability, and difficulty concentrating. Vasomotor symptoms affect as many as 80% of menopausal women.¹⁹ Previously, it was thought that vasomotor symptoms lasted only 3 or 4 years, but we now know that these symptoms can last much longer (average of 7.4 years) and also vary in duration depending on factors such as race and ethnicity.¹¹ In addition, most menopausal women with vasomotor symptoms go untreated.²⁰

There are many nonpharmacological approaches for the vasomotor symptoms of menopause, as Pace discussed. Some of these options include yoga, acupuncture, exercise, cognitive behavioral therapy, hypnosis, mindfulness, and weight loss.²¹ Certain supplements may also be helpful; pollen extracts originally used in Sweden and introduced to the United States in 2015 and s-Equol, marketed as Equelle, are examples.^22

–26

Estrogen therapy remains the most effective FDA-approved treatment for menopausal symptoms, including hot flashes and night sweats that can interrupt sleep and impair quality of life.⁸ According to the NAMS 2017 position statement, the benefits of hormone therapy are most likely to outweigh the risks for symptomatic women who initiate this therapy when aged <60 years or <10 years from menopause onset. Per the NAMS position statement, hormone therapy management should be individualized and patient preference should be considered to identify the most appropriate hormone therapy type, dose, formulation, route of administration, and duration of use.¹²

Although there has been some concern regarding the use of hormone therapy for treating menopausal women, particularly in the realm of breast cancer, there is evidence to show that estrogen alone is associated with a lower risk of breast cancer compared with estrogen plus progesterone.⁸ Research has also shown that no statistically significant increased risk of breast cancer was observed in women who used estrogen therapy for <20 years.²⁷ There has also been interest in bioidentical (custom-compounded) hormone therapy. This treatment approach, however, is generally not recommended due to safety concerns.

This is due to concerns related to nonuniformity in dosing of these products, inconsistency in manufacturing standards due to lack of oversight by FDA, and claims from some pharmacies supplying compounded drugs that are not validated regarding efficacy and safety of the products or validated by scientific evidence.²⁸ Pace also discussed the therapeutic utility of transdermal estrogen therapy, as well as SERMs.²⁹ There are also pharmacological nonhormonal options for treating the vasomotor symptoms of menopause; for instance, gabapentin, antidepressants, clonidine, and neurokinin 3 receptor antagonists, which will be launched in the near future, may all be useful in treating these symptoms.^30
–32

Next, Pace discussed GSM, also known as VVA. The prevalence of GSM is high; at least 50% of menopausal women experience symptoms of GSM.^33,34 One problem we face is that, according to the results of a 2013 survey, 81% of health care providers do not proactively ask about sexual health.³⁵ Many women are, in fact, not aware that GSM is a medical condition related to decreased estrogen of menopause and think it is just an unavoidable part of the aging process.³⁶

We need to do better for our patients and be comfortable having these conversations with them. Genitourinary syndrome refers to a constellation of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder. The syndrome may include, but is not limited to, genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections.³⁷

To cope with symptoms of GSM, it has been recommended to make lifestyle modifications such as maintaining regular sexual activity (blood flow to the vagina may improve elasticity), avoiding scented pads/liners to decrease irritants, and avoiding smoking. Using first-line nonhormonal long-acting vaginal moisturizers every few days and lubricants when engaging in penetrative activity are also suggested.³⁸ Because the underlying cause of GSM is lack of estrogen, these first-line therapies will not treat the disorder and may not be enough alone.

Most women will have to go to second-line therapies. Those with FDA approval for GSM include topical vaginal estrogen products such as creams (estradiol and conjugated equine estrogen), tablet (low-dose estradiol), ring (low-dose 3-month intravaginal estradiol) or a vaginal ovule insert (low/ultra-low-dose estradiol), vaginal DHEA, and an oral SERM compound.^39
–41 Vaginal CO₂ and laser therapy may be another option³⁸; however, although a number of studies have demonstrated efficacy and safety, these do not yet have FDA approval and further studies are warranted.⁴² Understanding GSM is important, as is initiating conversations with patients about their vaginal health.

Bone health: osteoporosis, muscular strength, and mobility

Dr. Andrea J. Singer, Director, Women's Primary Care and Director, Bone Densitometry and Fracture Liaison Service, MedStar Georgetown University Hospital, discussed osteoporosis, muscular strength, and mobility. Bone is a dynamic tissue and undergoes an initial period of building (modeling) and a coupled process of resorption followed by bone formation—collectively called remodeling. Modeling, which results in a net increase in bone size and shape, predominates during childhood and adolescence.

In adulthood, the process of remodeling predominates. When resorption and formation are matched, there is no net loss of bone. With menopause and the accompanying decline in estrogen, bone resorption is greater than formation and there is a net loss of bone.³⁹ In fact, women can lose up to 20% of their bone mass in the 5–7 years after menopause, making them more susceptible to osteoporosis.⁴³ Menopause is also accompanied by a decline in muscle mass, and a loss of elastic tissue properties can make repair and recovery of the musculoskeletal system more difficult.⁴⁴

Osteoporosis is a systemic disease characterized by weakened and fragile bone tissue, leading to an increased risk of fracture.⁴⁵ This disease is often underdiagnosed and undertreated.⁴⁶ It is a chronic disease that can be treated effectively but is not cured and so requires lifelong management to reduce the risk for fractures. Sarcopenia is also an age-associated disease of the musculoskeletal system. Coined in 1989, sarcopenia has more recently been defined as “the age-associated loss of skeletal muscle mass and function…. A complex syndrome associated with muscle mass loss alone or in conjunction with increased fat mass.”⁴⁷ Most osteoporosis-related fractures are due to falls, and many falls are related to sarcopenia.⁴⁸

Osteoporosis-related fractures represent a large economic and clinical burden.⁴⁹ For instance, in 2016, 1.6 million Medicare patients suffered 2.1 million fractures. Furthermore, 30% of hip fracture patients die within 1 year of the fracture, about 20% of all fracture patients die within 1 year, and 14% of patients suffer one or more additional fractures in the first year; this is more than three times the rate of new fractures for all Medicare fee-for-service beneficiaries.⁴⁹ In one survey by the Bone Health and Osteoporosis Foundation (formerly the National Osteoporosis Foundation), loss of independence (42%) and loss of mobility (25%) rank as the leading concerns regarding aging among osteoporosis patients.⁵⁰ Of important note, fragility fractures are associated with high rates of disability and loss of independence.^51
–53

There are several treatment options for osteoporosis.⁵⁴ Nonpharmacological approaches include strength and resistance training, balance training, and aerobic exercise. In addition, ensuring adequate amounts of calcium (preferably through dietary sources with supplements used to make up any shortfall), vitamin D, and protein is important, as is eating a balanced diet. There are also a number of pharmacological treatment options, which fall under two “umbrellas.” The first group comprises the antiremodeling (antiresorptive) agents that primarily inhibit bone turnover and include the bisphosphonates, denosumab, estrogen, and the estrogen agonist/antagonist raloxifene.

The second group is osteoanabolic agents, which includes remodeling stimulators that increase bone formation and resorption (teriparatide and abaloparatide), and a modeling stimulator that increases bone formation and also decreases resorption to a lesser degree (romosozumab).^55,56 According to Dr. Singer, osteoporosis encompasses women with fragile bones, but very different levels of fracture risk, and consideration of patient diversity is critical for effective treatment of osteoporosis. Patient diversity, particularly with respect to level of fracture risk, is important in determining initial osteoporosis therapy as well as duration of therapy.

There is accumulating evidence that bone density and fracture outcomes are significantly influenced by the order in which antifracture agents are administered.⁵⁷ According to Singer, when baseline level of risk is very high and when sequential treatment is considered, anabolic therapy followed by an antiresorptive agent is the preferred sequence. In young women without contraindications, hormone (estrogen) therapy may be the ideal therapy to prevent the relatively rapid bone loss in early menopause, especially in women with vasomotor symptoms, and this should be followed by a bisphosphonate to maintain the benefit when estrogen therapy is stopped.⁵ Risk stratification, individualizing treatment approaches, and keeping patient preferences in mind are also important factors when devising treatment strategies for a given patient.

Sexual and psychological health

The final speaker was Dr. Sheryl A. Kingsberg, Chief, Division of Behavioral Medicine University Hospitals Cleveland Medical Center, and Professor, Departments of Reproductive Biology, Psychiatry, and Urology, Case Western Reserve University School of Medicine, addressing postmenopausal sexuality. Dr. Kingsberg aimed to illustrate how postmenopausal women with sexual concerns may present clinically and described the two most common sexual problems experienced by postmenopausal women: hypoactive sexual desire disorder (HSDD) and GSM.

According to the MIDUS II (The Survey of Midlife Development in the United States), a large proportion of women aged 60 years and older (59%) remain sexually active. In addition, according to this survey, psychosocial factors (relationship satisfaction, communication with romantic partner, and importance of sex) matter more to sexual satisfaction than aging among midlife and older women, and romantic partner status was the best predictor of whether one was sexually active regardless of age, including for women in their 70s and 80s.⁵⁸ In other research, decreased sexual desire was associated with negative effects, including poor self-image, mood instability, depression, and strained relationships with partners.^59,60 Sex is, in fact, critical to relationships. Clinical research consistently demonstrates that when sex is bad or nonexistent, it plays an inordinately powerful role in draining the relationship of positive value.⁶¹

One large survey aimed to estimate the prevalence of self-reported sexual problems (any, desire, arousal, and orgasm), the prevalence of problems accompanied by personal distress, and to describe related correlates. Results found that there is a high prevalence of sexual problems in women of any age (>11%) but women aged 45–64 years experienced the highest rates of distressing sexual problems (14.8%) compared with younger (10.8%) or older (8.9%) women. Furthermore, correlates of distressing sexual problems included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence.⁶⁰

HSDD is defined as a lack of motivation for sexual activity manifested by either reduced or absent spontaneous desire (sexual thoughts and fantasies), reduced or absent responsive desire to erotic cues and stimulation, or inability to maintain desire. HSDD may be diagnosed by a loss of desire to initiate or participate, including behavioral responses such as avoidance, not secondary to a sexual pain disorder. Clinically significant personal distress that includes frustration, grief, incompetence, loss, sorrow, or worry must also be present.⁶²

Bancroft's dual control model proposes that the sexual response, such as desire, is experienced if the balance of excitatory and inhibitory factors is tipped toward excitatory.⁶³ Perelman's Sexual Tipping Point extends this further. His model proposes that psychosocial and organic factors can both excite and inhibit sexual response, and psychosocial, behavioral, and cultural factors can modify or trigger inhibitory/excitatory physiological processes. The tipping of the balance toward excitation can be observed when excitatory factors manifest to a greater extent than inhibitory factors.⁶⁴

Treatment options generally fall into one of four categories, and depending on the underlying cause(s) of the disorder, various treatments may be used in conjunction with each other. Psychotherapy typically encompasses sex therapy or couples counseling. For instance, mindfulness-based cognitive behavioral sex therapy shows effectiveness for improving desire and can be especially helpful for women who have a disconnect between genital and subjective arousal, perhaps due to improving attention or focus on bodily sensations.⁶⁵ Physical therapy may include approaches such as systematic desensitization for dyspareunia and vaginismus, where the woman is first taught deep muscle relaxation and then taught to gradually insert dilators of increasing diameter into the vagina.

There are no FDA-approved pharmacological therapies approved for postmenopausal women with HSDD. The two FDA-approved medications for HSDD, flibanserin and bremelanotide, are approved only in premenopausal women. However, there are studies supporting efficacy and safety for flibanserin in postmenopausal women and both are nonhormonal.^66,67 Testosterone has been used off-label for HSDD for decades. The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) was recently published simultaneously in four journals, with authors representing 10 major international medical societies endorsing the use of testosterone for the treatment of HSDD in postmenopausal women.

If testosterone is used, it is recommended that the proper dosing should be used to attain and maintain testosterone levels in the premenopausal physiological range.⁶⁸ According to the International Society for the Study of Women's Sexual Health, androgens (including testosterone) are essential hormones for development and maintenance of female sexual anatomy and physiology and modulation of sexual behavior.⁶⁹

Various vasoactive agents, including those used for male erectile dysfunction, have been investigated for female sexual arousal disorders, but the results to date have not demonstrated efficacy.⁷⁰ However, a phase 2b randomized clinical trial (RCT) is being conducted to evaluate the safety and efficacy of a topically delivered sildenafil cream for women with female sexual arousal disorder. Over-the-counter vaginal lubricants and local or systemic hormone therapies are often effective in women with sexual pain disorders such as dyspareunia, vaginismus, vulvodynia, and vestibulitis. Intravaginal hormone therapies have been shown to be effective in the treatment of VVA, including symptoms of dyspareunia and vaginal dryness, in postmenopausal women with GSM.⁷¹

VVA was renamed GSM in 2014 to reflect the condition more accurately.⁷² This syndrome affects more than just the vagina, and VVA represents only one component of GSM.³² The most common symptoms of GSM are dyspareunia and vaginal dryness, and GSM can be a progressive and chronic condition with symptoms worsening over time from menopause. Women are largely unaware that GSM and the associated vulvar and vaginal symptoms are related to menopause.⁷³ Moreover, GSM remains largely underdiagnosed and undertreated despite many available treatment options.

As noted earlier, lubricants and moisturizers may help reduce discomfort due to dryness, but local hormone therapy and an oral SERM, ospemifene, are effective in treating the vulvovaginal and urogenital tissue. Pelvic floor physical therapy is often a useful adjunct to treating postmenopausal women who have developed pelvic floor dysfunction Dilator therapy, static or expandable, may also be indicated for women who have developed secondary vaginismus due to painful sex causing anticipatory anxiety and involuntary tightening of the vaginal muscles or the GSM-related narrowing and/or shortening of the vagina. CO₂ lasers are also used to treat GSM and RCTs are still needed to demonstrate safety and long-term efficacy.

Closing

The symposium ended with a robust discussion that highlighted the complexities and nuances of menopausal symptoms and management, moderated by Dr. Wendy Klein, Associate Professor Emeritus of Internal Medicine and Obstetrics/Gynecology at VCU.

In conclusion, the Multidisciplinary Management of Menopause symposium provided insights into multidisciplinary approaches to the management of menopause, vasomotor symptoms and GSM, bone health (including osteoporosis, muscular strength, and mobility), as well as sexual and psychological health during menopause and provided a platform to educate the audience on menopause-related topics affecting the health of women.

Footnotes

Acknowledgments

The authors are grateful to Andrea Perseghin and Lisa Phipps for their contributions to the grant and symposium. Medical writing assistance was provided by The Med Writers.

Authors' Contributions

All authors contributed substantially to the writing and editing of this article. All authors reviewed the results and approved the final version of the article.

Author Disclosure Statement

Dr. Singer has received research/grant funding from Radius Health (paid to Georgetown University) and UCB (paid to MedStar Georgetown University Hospital); consulting fees from AgNovos, Amgen, Astellas, Radius Health, and UCB; and fees for speaking/teaching from Amge, Radius Health, and Astellas. Dr. Kingsberg serves as a consultant or scientific advisory board member for Alloy, Astellas, Bayer Daré, Field Trip, Ovoca, Lupin, Materna Medical, Madorra, Mitsubishi Tanaba NA, Palatin Technologies, Pfizer, Sprout, Strategic Science Technologies, and TherapeuticsMD. She is on the Speaker's Bureau for Sprout, Palatin, and TherapeuticsMD. She has stock options with Alloy, Field Trip, Materna Medical, and Viveve. Dr. Pace has served on an advisory board and Speaker's Bureau for TherapeuticsMD, Astellas, Scinexis, and Pharmavite. She is also a Pfizer Spokesperson for Premarin Vaginal Cream. Dr. Kornstein has received grant funding from Pfizer and Marinus and has served as a consultant or advisory board member for AbbVie, Astellas, Janssen, Lilly, Sage Therapeutics, and Sunovion. The rest of the authors declared no disclosures.

Funding Information

This symposium was funded by an independent medical education grant from Pfizer, Inc.

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