211 - Menopause and HRT Flashcards
Who should be treated with hormone replacement therapy?
(In the context of menopause)
People with…
- Moderate to severe vasomotor symtpoms that affect their quality of life
- NO contraindications
- Cannot have hormone-sensitive breast cancer, CHD, VTE, Liver disease, unexplained vaginal bleeding
- LMP less than 10 years ago
If estrogen hormone replacement therapy is only indiated for perimenopausal people with vasomotor symtoms, what treatments are avilable for patients experiencing vulvovaginal symptoms?
- Topical estrogen
- Lubricant, moisturizer, dilator
- SERM
Don’t start systemic therapy if sx are only local
FSH
- FSH is elevated post-menopause
- In the transition period, it will fluctuate; not super helpful to measure
Changes in menstrual bleeding patterns = better predictor of menopausal stage than serum FSH during transition
Heavy periods -> lighter/spaced out -> no more periods
List 3 new health problems that are more likely to arise after menopasue
- Depression
-
Osteoporosis
- Associated with estrogen deficiency
-
CAD/CHD
- Associated with estrogen decline
But estrogen hormone therapy is currently not indicated to prevent CHD (useful in preventing osteoporosis)
SNRI
- Estrogen contraindicated in patients with hx of breast cancer
- SSRIs contraindicated in pts on tamoxifen
Describe the hormonal changes that occur in perimenopause
- Initially, decreased inhibin B
- -> loss of feedback inhibition, resulting in increased FSH
- -> Temporarily increases estrogen from ovary
- -> heavy menstrual periods
- -> Follicle continues to deplete
- -> Can no longer respond to increasing FSH
- -> estrogen falls
- Also - Anti-mullerian hormone diminishes during perimenopause*
- Thank you @Frank!*
Describe the vasomotor symptoms associated with menopause
- Flushing
- Increased HR/palpitations
- Sweating followed by chills
- Hot flashes
The menopasue FISH!
Which cancer drug is an absolute contraindication for SSRIs?
Tamoxifen
- Typical pt: Hx of breast cancer, on tamoxifen*
- Cannot give estrogen therapy or SSRI; use SNRI (venlafaxine)*
What hormones should be used for hormone replacement therapy?
Estrogen is the hormone that will treat vasomotor sx
- If the pt has a uterus, estrogen + progestin
- Unopposed estrogen -> endometrial cancer
- If the patient does not have a uterus, can use estrogen only
List the contraindications to hormone replacement therapy (7)
- Vaginal bleeding (unexplained)
- Liver disease (active)
- VTE or PE (previous)
- Thrombophilia
- HTN (untreated)
- Estrogen-dependent neoplasia
- Hx of CHD, Stroke, TIA
B: Topical estroen
- Safe in pts with hx of breast cancer
- Don’t need systemic therapy if sx are only local
- Offer vaginal moisturizer if pt wantst to avoid estrogen
A
- B is post-menopausal (>1 year since LMP)
- C has primary ovarian insufficiency
What changes in menstrual cycles are likely to occur during perimenopause?
- At first, periods become heavier
- As ovarian estrogen is upregulated in response to increasing FSH
- Then, they become lighter and mose spaced out
- Follicle is depleted, can no longer respond to increasing FSH
- Finally, they stop completely
Which gonadotropin is most reliably elevated in a post-menopausal female?
FSH
(But may fluctuate wildly during transition!)