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Clinical 2 (Part B) > 3 - Menopause > Flashcards

3 - Menopause Flashcards

1
Q

When a person approaches you saying they are having hot flashes and are about menopause age, what questions should you ask/what do you want to know?

A
  • How long since last period?
  • Rule out illness/viral infection
  • Any other symptoms?
  • Hysterectomy? *important for treatment approach
  • Frequency, severity and duration of hot flashes?
  • Things that make it better or worse?
  • Do other people notice?
  • Any medications?
  • Smoker/drinker?
  • Medical conditions?
  • Family history?
  • Happen in day & night?
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2
Q

Define menopause

A
  • The permanent cessation of menses following the loss of ovarian follicular activity
  • If 12 consecutive months have passed without a menstrual period - menopause has occurred
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3
Q

Median age of onset of menopause in Canada?

A

52 (varies from 42-56)

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4
Q

What type of women must rely on symptoms to estimate actual time of menopause?

A

women who have had a hysterectomy (removal of the uterus)

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5
Q

Is menopause a disease?

A

No lol it is natural life event

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6
Q

Symptoms of menopause

A
  • Vasomotor (AKA “hot flashes”)
  • Changes in mood
  • Worsened sleep
  • Decreased sexual libido
  • Urogenital symptoms (vaginal dryness, vaginal discharge, vaginal bleeding, UTIs that keep returning, loss of bladder control)
  • Arthralgias
  • Altered cognition ?
  • Decreased bone density
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7
Q

How common are hot flashes?

A

60-80% of women:

  • 60% have them for < 7 years
  • 15% persist for > 15 years
  • 25% have “severe” symptoms
  • we don’t really know what severe symptoms are
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8
Q

What are the goals of therapy for menopause

A

1) relieve symptoms that the patient is experiencing
2) improve QOL
3) minimizing adverse effects

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9
Q

Desired outcomes are best achieved by individualizing treatment based on: ?

A
  • medical history
  • social history
  • family history
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10
Q

What are some non-pharms for menopause?

A
  • stay hydrated
  • try going without coffee, tea, or alcohol to see if it’s a trigger
  • yoga
  • dress in layers
  • have a fan
  • smoking cessation

*limited or no evidence

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11
Q

Do herbal remedies or acupuncture have evidence?

A

limited or no evidence

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12
Q

What has some evidence to help with menopause?

A
  • weight loss
  • CBT/MBSR
  • Hypnosis
  • Stellate ganglion block ? (promising)
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13
Q

Herbal remedies for menopause:

Describe soy/isoflavones

A

Phytoestrogen with possible estrogenic effects

-lots of literature but studies of poor quality, manufacturing not consistent

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14
Q

Herbal remedies for menopause:

Describe black cohosh

A
  • modulation of 5-HT pathways?

- estrogenic activity?

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15
Q

Herbal remedies for menopause:

Describe dong quai, fennel, evening primrose oil

A

likely no better than placebo

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16
Q

What are some non-hormonal drugs for menopause?

A

Antidepressants:

  • SSRIs (paroxetine, citalopram, escitalopram)
  • SNRIs (venlafaxine, desvenlafaxine)

Anticonvulsants (gabapentin, pregabalin)

Clonidine

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17
Q

How do non-hormonal drugs affect vasomotor symptoms?

A

By 25-69%

placebo by 30%

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18
Q

Rule of thumb for non-hormonal drugs for menopause?

A
  • Low doses are often effective
  • Start low & titrate up if necessary to minimize side effects
  • Allow 2-4 weeks for effect
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19
Q

Should we start with hormonal therapy or non-hormonal therapy for menopausal patients seeking treatment?

A
  • It doesn’t matter
  • Hormonal is more effective but some don’t want to take hormones so it’s just a discussion with a patient on what they want to try
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20
Q

What makes a person a good candidate for menopausal hormone therapy (MHT) ?

A
  • No family or personal history of breast cancer
  • Symptoms are severe
  • If they have osteoporosis, estrogen will also help this
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21
Q

List some potential benefits of MHT

A
  • decrease vasomotor symptoms (frequency and severity decrease by 50-100%)
  • decrease sleep problems
  • decrease mood or anxiety problems
  • decrease aches and pains
  • osteoporosis prevention/treatment
  • reversal of vulvar and vaginal atrophy
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22
Q

What are some hormonal treatment considerations?

A
  • Who?
  • Risks
  • With what?
  • Duration of treatment
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23
Q

Who is able to get hormonal therapy/who should get it?

A
  • Unremitting symptoms affecting QOL
  • No absolute contraindications
  • Other non-drug options not effective
  • Risks and benefits discussed
  • Agree to limited duration of treatment
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24
Q

Who needs progesterone?

A

women with a uterus

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25
Q

SE of hormones?

A
  • breast tenderness
  • bleeding
  • bloating
  • mood changes

*these are lower dose than OC so at lower risk for these SE

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26
Q

Does combined therapy or estrogen only therapy have higher risk for breast cancer, venous thromboembolism, and coronary events?

A

combined therapy (estrogen and progesterone)

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27
Q

What is an important message to send to women about risk of cancer and and CV disease and hormone therapy?

A

short term treatment prob won’t increase risk of cancer and CV disease, the longer you treat, the more you increase your chance for those disease

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28
Q

When is breast cancer risk the highest for combo therapy?

A

after 4-5 years of COMBO hormone use

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29
Q

When is breast cancer risk the highest for only estrogen therapy?

A

do not have an increased breast cancer risk for > 8 years

30
Q

When does breast cancer risk return to normal upon d/c hormone therapy?

A

within 2 years of d/c

31
Q

When is ovarian cancer risk the highest?

A

increase risk steepens after 4 years of hormone therapy

32
Q

When is CVD risk the highest ?

A
  • older than 60 and more than 10 years after menopause

- increase risk steepens after 4 years

33
Q

What are contraindications to hormone therapy (CI to estrogen) ?

A
  • unexplained vaginal bleeding
  • acute liver dysfunction
  • estrogen-dependent cancer (endometrial and breast cancer)
  • coronary heart disease
  • previous stroke
  • active thromboembolic disease
34
Q

What increases a person’s risk for breast cancer?

A

Increase risk especially in those with 1st degree family history, previous OCP use, current smoking & other high-risk factors

35
Q

Describe the risk associated with having a single 1st degree relative in whom breast cancer was diagnosed AFTER age 50

A

have little increase in risk over the 12% risk of the general population

36
Q

Describe the risk associated with having TWO 1st degree relatives in whom breast cancer was diagnosed AFTER age 50

A

24% lifetime risk

37
Q

Describe the risk associated with having a single 1st degree relative in whom breast cancer was diagnosed BEFORE age 50

A

24% risk

38
Q

Describe the risk associated with having TWO 1st degree relative in whom breast cancer was diagnosed BEFORE age 50

A

48% risk

39
Q

If a person has these genetic factors that increase risk for breast cancer, does hormonal therapy add to that risk?

A

Genetic factor is so big, adding hormones only plays a small role.

*Use of hormones not found to be associated with an increase in overall risk of breast cancer

Theory: Since the influence of genetic factors is so large, it generally overshadows any small potential increment resulting from lifestyle or hormonal exposure

40
Q

Should we treat menopause systemically or locally?

A

If they’re having systemic symptoms - treat systemically

If they’re having local symptoms - treat locally

41
Q

Why do we have to add progestin to estrogen if they have a uterus?

A

Can cause endometrial hyperplasia which predisposes them to dysplasia & cancer

42
Q

Describe using an Estrogen with a SERM (Duavive)

A
  • Prevents hyperplasia
  • No significant effects on CVD or breast cancer risk
  • Safety data only 2 years
  • Maybe for those intolerant to all types of progestin ?
43
Q

What type of bleeding may occur with cyclical or continuous regimen?

A

If you use cyclical estrogen, you may have withdrawn bleeding

If you use continuous, you may have breakthrough bleeding

44
Q

If last menstrual period < 1 year prior, what type of hormone therapy is recommended?

A

a sequential combined regimen recommended (ex. continuous estrogen with 12-14 days progesten/month)

45
Q

If last menstrual period > 1 year and they wish to avoid monthly withdrawal bleeding, what regimen is recommended?

A

may start continuous combined regimen

46
Q

What do we do if breakthrough bleeding occurs following switch to continuous combined & does not settle within 3-6 months, what do you do?

A

consider switch back to sequential for 1 or more years

47
Q

If bleeding is heavy or erratic on sequential regimen, what do you do?

A

consider increase dose of progestin (ex. double)

48
Q

Persistent bleeding beyond _______ warrants referral/investigation

A

6 months

49
Q

___% of females persisting with regimens will eventually be bleed free

A

90%

50
Q

When are estrogen patches generally applied?

A

twice a week (if they need to taper, instead of cutting a patch, you could just extend the time you keep a patch on, to taper off)

51
Q

What are some advantages of estrogen?

A
  • Avoids 1st pass effect.
  • Compared to oral: decrease risk in liver disease, decrease lipid effect, decrease gallbladder disease, decrease VTE, equal efficacy for vasomotor symptoms and in preserving bone density
52
Q

When should you consider topical/transdermal estrogen over oral estrogen?

A
  • increased CVD risk
  • smoking
  • HTN
  • DM
  • gallstones
  • obesity
  • these are all risk factors for VTE, DVT, PE
  • if they have all these risk factors, consider topical
53
Q

What are bio-identical compounded hormones?

A

The sales pitch:

  • May be natural
  • Claim they are bio-identical (but no one has a definition for that)
  • Individualized, but there is little scientific support

Concers:

  • safety & efficacy not rigorously tested
  • quality control
  • expensive
54
Q

What is the approximate estrogen equivalent dose?

A

1/2 - 1/6 of OCP dose

55
Q

Which oral estrogen is plant based?

A

Prometrium

56
Q

Describe the prices of gel, pill and transdermal estrogens

A

gel > transdermal > pill

57
Q

When should patients expect adequate symptom relief after starting estrogen?

A

6-8 weeks

58
Q

If the side effects are due to progestin (like mood swings, bloating, bleeding, breast tenderness), what do we do?

A

may decrease dose by 1/2 and/or decrease duration to 7-10 days

59
Q

If heavy bleeding or erratic on sequential regimen, what do you do?

A

consider increasing progestin dose (ex. x2)

60
Q

Women receiving MHT must be evaluated ______, with the risk-benefit profile as well as the woman’s expectations should be reviewed

A

annually

61
Q

2 key points for MHT

A
  • use lowest dose possible to address symptoms

- use for the shortest period of time

62
Q

How long should she continue MHT?

A
  • however long she wants (as long as symptoms persist)
  • if she continues past 4-5 years, she is increasing her risk of cancer and at that point her symptoms should be starting to become resolved
63
Q

How should you taper MHT?

A

There is no right answer. Talk to patient about preference, lots of creativity to create a regimen around what they want.
May have to do trial and error to see how their symptoms are being managed with decreasing hormonal therapy

64
Q

What is vaginal atrophy ?

A

AKA atrophic vaginitis - thinning, drying, and inflammation of the vaginal walls occurring in 50% of women within 3 years of menopause and is a common cause of sexual pain

65
Q

If a woman is experiencing vaginal dryness, UTI’s, or painful fissures, what can we recommend?

A

Local symptoms to treat locally

66
Q

What are local options?

A
  • Vaginal lubricants (ex. OTC Replens, Hyalfem) - non-hormonal
  • Vagifem vaginal tablets
  • Premarin vaginal cream
  • tablets and cream often start with “induction therapy” of daily dosing x 1-2 weeks
  • Estring vaginal ring
67
Q

Can estrogen cream increase the risk of a reoccurrence of cancer?

A

low-quality evidence that estrogen cream may be associated with increased endometrial thickness vs estrogen ring (may have been due to the higher doses of cream used)

nonetheless - low-dose vaginal estrogen doesn’t necessitate a progestogen for women with a uterus

68
Q

Do the same contraindications to oral hormonal therapy apply to topical estrogen therapy?

A

CVD/TE risk: systemic absorption of vaginal estrogen is minimal - not CI in women with CI to systemic estrogen therapy, including recent stroke and TE disease EXCEPT:
-if they have unexplained vaginal bleeding (this requires investigation)
OR
-if they have breast cancer and are receiving aromatase inhibitors

69
Q

Is vaginal estrogen associated with risk of increasing breast cancer?

A

vaginal estrogen use not associated with increased risk of recurrence of breast cancer in women treated with tamoxifen

**BASICALLY up to the patient whether or not vaginal symptoms are severe enough that they are ok with a chance of getting breast cancer again

70
Q

If you start a patient on Replens, when do you want to monitor them?

A

In 1-2 months, monitor her symptoms that she was experiencing and ask about application difficulties (such as messiness, expulsion during urination or intercourse, sensing ring during intercourse)

71
Q

What are local symptoms?

A

dryness, pain with intercourse, avoidance of intercourse, UTI frequency

Clinical 2 (Part B) (30 decks)

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