3 - Menopause Flashcards
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?
- 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?
Define menopause
- 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
Median age of onset of menopause in Canada?
52 (varies from 42-56)
What type of women must rely on symptoms to estimate actual time of menopause?
women who have had a hysterectomy (removal of the uterus)
Is menopause a disease?
No lol it is natural life event
Symptoms of menopause
- 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
How common are hot flashes?
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
What are the goals of therapy for menopause
1) relieve symptoms that the patient is experiencing
2) improve QOL
3) minimizing adverse effects
Desired outcomes are best achieved by individualizing treatment based on: ?
- medical history
- social history
- family history
What are some non-pharms for menopause?
- 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
Do herbal remedies or acupuncture have evidence?
limited or no evidence
What has some evidence to help with menopause?
- weight loss
- CBT/MBSR
- Hypnosis
- Stellate ganglion block ? (promising)
Herbal remedies for menopause:
Describe soy/isoflavones
Phytoestrogen with possible estrogenic effects
-lots of literature but studies of poor quality, manufacturing not consistent
Herbal remedies for menopause:
Describe black cohosh
- modulation of 5-HT pathways?
- estrogenic activity?
Herbal remedies for menopause:
Describe dong quai, fennel, evening primrose oil
likely no better than placebo
What are some non-hormonal drugs for menopause?
Antidepressants:
- SSRIs (paroxetine, citalopram, escitalopram)
- SNRIs (venlafaxine, desvenlafaxine)
Anticonvulsants (gabapentin, pregabalin)
Clonidine
How do non-hormonal drugs affect vasomotor symptoms?
By 25-69%
placebo by 30%
Rule of thumb for non-hormonal drugs for menopause?
- Low doses are often effective
- Start low & titrate up if necessary to minimize side effects
- Allow 2-4 weeks for effect
Should we start with hormonal therapy or non-hormonal therapy for menopausal patients seeking treatment?
- 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
What makes a person a good candidate for menopausal hormone therapy (MHT) ?
- No family or personal history of breast cancer
- Symptoms are severe
- If they have osteoporosis, estrogen will also help this
List some potential benefits of MHT
- 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
What are some hormonal treatment considerations?
- Who?
- Risks
- With what?
- Duration of treatment
Who is able to get hormonal therapy/who should get it?
- Unremitting symptoms affecting QOL
- No absolute contraindications
- Other non-drug options not effective
- Risks and benefits discussed
- Agree to limited duration of treatment
Who needs progesterone?
women with a uterus
SE of hormones?
- breast tenderness
- bleeding
- bloating
- mood changes
*these are lower dose than OC so at lower risk for these SE
Does combined therapy or estrogen only therapy have higher risk for breast cancer, venous thromboembolism, and coronary events?
combined therapy (estrogen and progesterone)
What is an important message to send to women about risk of cancer and and CV disease and hormone therapy?
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
When is breast cancer risk the highest for combo therapy?
after 4-5 years of COMBO hormone use
When is breast cancer risk the highest for only estrogen therapy?
do not have an increased breast cancer risk for > 8 years
When does breast cancer risk return to normal upon d/c hormone therapy?
within 2 years of d/c
When is ovarian cancer risk the highest?
increase risk steepens after 4 years of hormone therapy
When is CVD risk the highest ?
- older than 60 and more than 10 years after menopause
- increase risk steepens after 4 years
What are contraindications to hormone therapy (CI to estrogen) ?
- unexplained vaginal bleeding
- acute liver dysfunction
- estrogen-dependent cancer (endometrial and breast cancer)
- coronary heart disease
- previous stroke
- active thromboembolic disease
What increases a person’s risk for breast cancer?
Increase risk especially in those with 1st degree family history, previous OCP use, current smoking & other high-risk factors
Describe the risk associated with having a single 1st degree relative in whom breast cancer was diagnosed AFTER age 50
have little increase in risk over the 12% risk of the general population
Describe the risk associated with having TWO 1st degree relatives in whom breast cancer was diagnosed AFTER age 50
24% lifetime risk
Describe the risk associated with having a single 1st degree relative in whom breast cancer was diagnosed BEFORE age 50
24% risk
Describe the risk associated with having TWO 1st degree relative in whom breast cancer was diagnosed BEFORE age 50
48% risk
If a person has these genetic factors that increase risk for breast cancer, does hormonal therapy add to that risk?
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
Should we treat menopause systemically or locally?
If they’re having systemic symptoms - treat systemically
If they’re having local symptoms - treat locally
Why do we have to add progestin to estrogen if they have a uterus?
Can cause endometrial hyperplasia which predisposes them to dysplasia & cancer
Describe using an Estrogen with a SERM (Duavive)
- 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 ?
What type of bleeding may occur with cyclical or continuous regimen?
If you use cyclical estrogen, you may have withdrawn bleeding
If you use continuous, you may have breakthrough bleeding
If last menstrual period < 1 year prior, what type of hormone therapy is recommended?
a sequential combined regimen recommended (ex. continuous estrogen with 12-14 days progesten/month)
If last menstrual period > 1 year and they wish to avoid monthly withdrawal bleeding, what regimen is recommended?
may start continuous combined regimen
What do we do if breakthrough bleeding occurs following switch to continuous combined & does not settle within 3-6 months, what do you do?
consider switch back to sequential for 1 or more years
If bleeding is heavy or erratic on sequential regimen, what do you do?
consider increase dose of progestin (ex. double)
Persistent bleeding beyond _______ warrants referral/investigation
6 months
___% of females persisting with regimens will eventually be bleed free
90%
When are estrogen patches generally applied?
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)
What are some advantages of estrogen?
- 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
When should you consider topical/transdermal estrogen over oral estrogen?
- 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
What are bio-identical compounded hormones?
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
What is the approximate estrogen equivalent dose?
1/2 - 1/6 of OCP dose
Which oral estrogen is plant based?
Prometrium
Describe the prices of gel, pill and transdermal estrogens
gel > transdermal > pill
When should patients expect adequate symptom relief after starting estrogen?
6-8 weeks
If the side effects are due to progestin (like mood swings, bloating, bleeding, breast tenderness), what do we do?
may decrease dose by 1/2 and/or decrease duration to 7-10 days
If heavy bleeding or erratic on sequential regimen, what do you do?
consider increasing progestin dose (ex. x2)
Women receiving MHT must be evaluated ______, with the risk-benefit profile as well as the woman’s expectations should be reviewed
annually
2 key points for MHT
- use lowest dose possible to address symptoms
- use for the shortest period of time
How long should she continue MHT?
- 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
How should you taper MHT?
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
What is vaginal atrophy ?
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
If a woman is experiencing vaginal dryness, UTI’s, or painful fissures, what can we recommend?
Local symptoms to treat locally
What are local options?
- 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
Can estrogen cream increase the risk of a reoccurrence of cancer?
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
Do the same contraindications to oral hormonal therapy apply to topical estrogen therapy?
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
Is vaginal estrogen associated with risk of increasing breast cancer?
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
If you start a patient on Replens, when do you want to monitor them?
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)
What are local symptoms?
dryness, pain with intercourse, avoidance of intercourse, UTI frequency
