3 - Menopause Flashcards
1
Q
Define menopause, peri-menopause, and post-menopause
A
- Menopause = permanent cessation of menses for 12 consecutive months due to the loss of ovarian function
- Perimenopause = transition into menopause (beginning of sx; usually 2 years before menopause)
- Post-menopause = 1 year after menopause & beyond
- Women now spend 1/3 of their lives in post-menopause
2
Q
Sx of menopause
A
- Vasomotor (“hot flashes”) – most common
- Genitourinary
- Mood changes
- Sleep disturbance
- Sexual function
- Skin wrinkles
- Hair thinning/loss
- Joint pain; increased risk of osteoporosis
3
Q
Describe the vasomotor sx of menopause
A
- Hot flashes or flushes, night sweats
- Average duration of sx = 7-8 years
- 60% have < 7 years; 15% persist > 15 years
- ~80% perimenopausal women & ~40% postmenopausal women have hot flashes 3+ times/day
4
Q
Genitourinary syndrome of menopause
A
- Associated w/ decreased estrogen, & will generally persist or worsen w/ aging
- Vaginal atrophy doesn’t improve overtime (unlike hot flashes)
- Genital – dryness, burning, itching, discharge, irritation
- Urinary – loss of bladder control, recurrent UTIs
- Sexual – lack of lubrication, discomfort/pain, impaired function
5
Q
Menopause quick 6 screen
A
- Any changes in your periods? *
- Are you having any hot flashes? *
- Any vaginal dryness or pain or sexual concerns?*
- Any bladder issues or incontinence? *
- How is your sleep?
- How is your mood?
- If yes to any of the first 4 questions = may be a candidate for tx
6
Q
Goals of therapy for menopause
A
- Relieve sx (vasomotor, urogenital, mood-related changes)
- Improve QOL & well-being during & after this transition period
- Minimize adverse effects of therapy (endometrial/breast cancer, MI, stroke, VTE)
7
Q
What are the pharm options for menopause?
A
- Hormone tx (estrogen, combination estrogen & progestogen)
- Non-hormone tx (SSRI, SNRI, gabapentinoids, clonidine)
8
Q
Who should get hormone therapy for menopause?
A
- Unremitting sx affecting QoL
- No absolute contraindications
- Other non-drug options not effective
- Risks and benefits discussed
- Agree to limited duration of tx
9
Q
What are the contraindications to hormone therapy use in menopause?
A
- Unexplained vaginal bleeding
- Acute liver dysfunction
- Estrogen-dependent cancer (endometrial & breast cancer)
- Coronary heart disease, previous stroke, active thromboembolic disease
10
Q
Does hormone therapy work for menopause?
A
Most effective tx option for moderate to severe vasomotor sx
11
Q
What are the risks associated w/ hormone therapy use?
A
- Increased risks of breast cancer, coronary heart disease, thromboembolic events, stroke
- Continuing HT w/ the lowest effective dose beyond age 60 w/ clinical supervision may be considered in some circumstances
- Women should be advised of the increased risks; HT should be individualized & not stopped solely based on age
- Highest risk for breast cancer after 4-5 years of combo HT; ovarian cancer after 4 years; CV disease after 4 years in those age > 60, > 10 years after menopause
12
Q
What are the available formulations of hormone therapy? When should one be used over the other?
A
- Systemic (combined vs. estrogen only; cyclic (sequential) vs. continuous; oral vs. transdermal)
- Local (cream, ring, tablets)
- If LMP < 1 year -> recommend cyclic timed to endogenous cycle; minimizes risk of breakthrough bleeding
- If LMP > 1 year -> consider continuous to avoid monthly withdrawal bleed
- Breakthrough bleeding generally resolves < 3-6 months (longer than this = referral)
- Consider topical/ transdermal if increased CVD risk, HTN, DM, smoking, obesity, gallstones
- Consider vaginal estrogen for urogenital sx b/c less systemic effect; ok even if breast cancer hx if failed non-hormonal tx
- Low-dose vaginal estrogen (0.5 g twice/week) doesn’t necessitate a progestogen for women w/ a uterus
13
Q
What are the non-hormonal tx options for vasomotor sx?
A
- SSRI (off-label)
- SNRI (off-label)
- Gabapentinoids (off-label)
- Clonidine 0.05 mg BID (4-6 week trial)
- Rule of thumb – low doses are often effective; start low & titrate up if necessary to minimize SEs; allow 2-4 weeks for effect
14
Q
Which NHPs are marketed for menopause? Do they work?
A
- In general, these appear ineffective, but evidence is limited
- Watch for DI’s & CI’s
- Purity of compounds a concern
- Soy/isoflavones – phytoestrogen w/ estrogenic effects? – may or may not be more effective than placebo
- Black cohosh – modulation of 5-HT pathways? Estrogenic activity? – Cochrane review = no different than placebo
- Dong quai, fennel, evening primrose oil – likely no better than placebo
15
Q
Describe some non-pharms for menopause
A
- Useful – vaginal moisturizers (alternative to vaginal estrogen) for urogenital sx (vaginal dryness, dyspareunia)
- Apply HS 3 times/week
- Some evidence to support – weight loss, clinical hypnosis, cognitive behavioural therapy
- Reasonable to try, but limited evidence – smoking cessation, healthy diet, cooling techniques, exercise, yoga, avoidance of triggers
- Limited or no evidence, but potential harm/cost – NHPs, acupuncture
