17. Menopause Flashcards
1
Q
Define: Menopause (2)
A
- lack of menses for 1 yr
- types of menopause
- physiological; average age 51 yr (follicular atresia)
- primary ovarian insufficiency; before age 40 (autoimmune disorder, infection, Turner’s syndrome)
- iatrogenic (surgical/radiation/chemotherapy)
2
Q
Describe clinical features: Menopause (5)
A
- associated with estrogen deficiency
- vasomotor instability (tends to dissipate with time)
- hot flushes/flashes, night sweats, sleep disturbances, formication, nausea, palpitations
- urogenital atrophy involving vagina, urethra, bladder
- dyspareunia, pruritus, vaginal dryness, bleeding, post-coital bleeding, urinary frequency, urgency, incontinence
- inspection may reveal: thinning of tissues, erythema, petechiae, bleeding points, dryness on speculum exam
- skeletal
- osteoporosis, joint and muscle pain, back pain
- skin and soft tissue
- decreased breast size, skin thinning/loss of elasticity
- psychological
- increased anxiety, depression, irritability, fatigue, decreased libido, memory loss
- vasomotor instability (tends to dissipate with time)
3
Q
Describe investigations: Menopause (3)
A
- increased levels of FSH (>35 IU/L) on day 3 of cycle (if still cycling) and LH (FSH>LH)
- FSH level not always predictive due to monthly variation; use absence of menses for 1 yr to diagnose
- decreased levels of estradiol (later)
4
Q
Describe tx of menopause for: Vasomotor Instability (7)
A
- HRT (first line)
- SSRI
- venlafaxine
- gabapentin
- propranaolol
- clonidine
- acupuncture
5
Q
Describe tx of menopause for: Vaginal Atrophy (6)
A
Local estrogen:
- cream (Premarin®)
- vaginal suppository (VagiFem®)
- ring (Estring®)
- lubricants (Replens®)
- oral or transdermal hormone replacement therapy
- intravaginal laser
6
Q
Describe tx of menopause for: Urogenital Health (3)
A
- Lifestyle changes (weight loss, bladder re-training)
- local estrogen replacement
- surgery
7
Q
Describe tx of menopause for: Osteoporosis (7)
A
- 1000-1500 mg calcium OD
- 800-1000 IU vitamin D
- weight- bearing exercise
- smoking cessation
- bisphosphonates (e.g. alendronate)
- selective estrogen receptor modifiers (SERMs) (e.g.raloxifene [Evista®])
- HRT (second-line treatment)
8
Q
Describe tx of menopause for: Decreased Libido (3)
A
- Vaginal lubrications
- counselling
- androgen-replacement testoterone cream or the oral form (Andriol®)
9
Q
Describe tx of menopause for: Cardiovascular disease (1)
A
Manage CVD risk factors
10
Q
Describe tx of menopause for: Mood And Memory (2)
A
- Anti- depressants (first line)
- HRT (augments effect)
11
Q
Describe: Menopause Pathophysiology (Figure)
A
12
Q
Name the single most important health hazard associated with menopause
A
Osteoporosisis
13
Q
Name the leading cause of death post-menopause (1)
A
Cardiovascular disease
14
Q
Increased risk of breast cancer is associated with which HRT? (1)
A
estrogen+progesterone HRT, but not with estrogen-only HRT
15
Q
All women taking HRT should have what type of surveillance? (1)
A
periodic surveillance and counselling regarding its benefits and risks
16
Q
Name primary indication of Hormone replacement therapy (1)
A
primary indication is treatment of menopausal symptoms (vasomotor instability)
17
Q
Describe doses and treatment time for HRT (2)
A
- keep doses low (e.g. 0.3 mg Premarin®)
- duration of treatment short (<5 yr)
18
Q
Describe: HRT Components (6)
A
- estrogen
- oral or transdermal (e.g. patch, gel)
- transdermal preferred for women overall, especially with hypertriglyceridemia or impaired hepatic function, smokers, and women who suffer from headaches associated with oral HRT
- low-dose (preferred dose: 0.3 mg Premarin®/25 µg Estradot® patch, can increase if necessary)
- progestin
- given in combination with estrogen for women with an intact uterus to prevent development of endometrial hyperplasia/cancer
19
Q
Describe this HRT regimen: Unopposed Estrogen
- Estrogen dose
- Progestin dose
- Notes
A
- Estrogen dose: CEE 0.625 mg PO OD
- Progestin dose: None
- Notes: If no intact uterus
20
Q
Describe this HRT regimen: Standard-Dose
- Estrogen dose
- Progestin dose
- Notes
A
- Estrogen dose: CEE 0.625 mg PO OD
- Progestin dose: MPA 2.5 mg PO OD, or micronized progesterone 100 mg PO OD
- Notes:
- Withdrawal bleeding may occur in a spotty, unpredictable manner
- Usually abates after 6-8 mo due to endometrial atrophy
- Once patient has become amenorrheic on HRT, significant subsequent bleeding episodes require evaluation (endometrial biopsy)
21
Q
Describe this HRT regimen: Standard-Dose Cyclic
- Estrogen dose
- Progestin dose
- Notes
A
- Estrogen dose: CEE 0.625 mg PO OD
- Progestin dose: MPA 5-10 mg PO days 1-14 only, or micronized progesterone 200 mg PO OD days 1-14 only
- Notes:
- Bleeding occurs monthly after day 14 of progestin (can continue for years)
- PMS-like symptoms (breast tenderness, fluid retention, headache, nausea) are more prominent with cyclic HRT
22
Q
Describe this HRT regimen: Pulsatile
- Estrogen dose
- Progestin dose
- Notes
A
- Estrogen dose: CEE 0.625 mg PO OD
- Progestin dose: MPA low-dose
- Notes: 3 d on, 3 d off
23
Q
Describe this HRT regimen: Transdermal
- Estrogen dose
- Progestin dose
- Notes
A
- Estrogen dose:
- Estroderm®-Estradiol 0.05 mg/d or 0.1 mg/d
- Estalis®-Estradiol 140 µg/d or 250 µg/d
- Progestin dose:
- Estroderm®-MPA 2.5 mg PO OD
- Estalis®-NEA 50 µg/d
- Notes:
- Use patch twice weekly
- Can use oral progestins (Estroderm®)
- Combined patches available (Estalis®)
24
Q
Describe this HRT regimen: Topical
- Estrogen dose
- Progestin dose
- Notes
A
- Estrogen dose:
- Estrace® 2-4 g/d x 1-2 wk, 1 g/d maintenance
- Premarin® 0.5-2 g/d for 21 d then off 7 d for vaginal atrophy, 0.5 g/d for 21 d then off 7 d or twice/wk for dyspareunia
- Estragyn® 2-4 g/d
- Progestin dose: Crinone® 4% or 8% (45 or 90 mg applicator)
- Notes:
- If simultaneously taking oral estrogen tablet, may need to adjust dosing
- If intact uterus, also take progesterone
25
Name Side Effects of HRT (5)
* abnormal uterine bleeding
* mastodynia: breast tenderness and swelling
* edema, bloating, heartburn, nausea
* mood changes (progesterone)
* can be worse in progesterone phase of combined therapy
26
Name ABSOLUTE contraindications to HRT (6)
* acute liver disease
* undiagnosed vaginal bleeding
* history of breast cancer
* known or suspected uterine cancer/breast cancer
* acute vascular thrombosis or history of severe thrombophlebitis or thromboembolic disease
* cardiovascular disease
27
Name RELATIVE contraindications to HRT (9)
* pre-existing uncontrolled HTN
* uterine fibroids and endometriosis
* familial hyperlipidemias
* migraine headaches
* family history of estrogen-dependent cancer
* chronic thrombophlebitis
* DM (with vascular disease)
* gallbladder disease, hypertriglyceridemia, impaired liver function (consider transdermal estrogen)
* fibrocystic disease of the breasts
28
Describe: Women's Health Initiative (6)
* launched in 1991
* two non-randomized studies investigating health risks and benefits of HRT in healthy postmenopausal women 50-79 yr old
* continuous combined HRT (CEE 0.625 mg + MPA 2.5 mg OD) in 16,608 women with an intact uterus
* estrogen-alone (CEE 0.625 mg) in 10,739 women with a previous hysterectomy
* both arms of the trial were stopped early because of evidence of increased risk of breast cancer, stroke, PE, and CHD in the combined HRT arm, and increased risk of stroke with no CHD benefits in the estrogen-alone arm
* the apparent increase in CHD was in disagreement with results of previous observational trial
* results of the WHI study have since been challenged and revision of how CHD was diagnosed led to loss of statistical significance of the results
* benefits and risks reported as number of cases per 10,000 women each year
29
Name absolute contraindications to HRT (4)
ABCD
* **A**cute liver disease
* Undiagnosed vaginal Bleeding
* **C**ancer (breast/uterine), **C**ardiovascular disease
* **D**VT (thromboembolic disease)
30
Name benefits of HRT (3)
* **Vasomotor Symptoms**: less frequent and severe with use of either combined or estrogen alone HRT
* **Osteoporosis**: 5 fewer cases of hip fractures and 47 fewer cases of all fractures with combined HRT; 6 fewer cases of hip fractures with estrogen alone
* **Colon Cancer**: 6 fewer cases with combined HRT (WHI); one additional case with estrogen alone
31
Name risks of HRT (5)
* **Stroke**: 8 additional cases with combined HRT and 12 additional cases for estrogen alone (WHI)
* **DVT/PE**: 18 additional cases with combined HRT and 9 additional cases for estrogen-alone (WHI)
* **CHD**: 7 additional MIs with combined HRT (WHI); secondary analysis suggests greater absolute risk for women aged \>70 yr and for women who start HRT \>10 yr post-menopause
* **Breast Cancer**: 8 additional cases with combined HRT (WHI); risk only increased after \>5 yr of combined HRT use; no increased risk for estrogen alone
* **Dementia and Mild Cognitive Impairment**: 50% greater risk of developing dementia in women taking estrogen alone after age 65; risk is greater for women taking combined HRT; risk of developing dementia was reduced for women taking HRT before age 65
