B8.029 Prework: Menopause Hormone Therapy Flashcards by Lauren Sinik

prescription of estrogen therapy

unopposed estrogen is prescribed:

a) systemically for women who do not have a uterus
b) locally in very low doses for any woman with vaginal symptoms

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prescription of estrogen-progestogen therapy

added to ET to protect women with a uterus against endometrial cancer, which can be caused by estrogen alone

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bioidentical hormone therapy

consists of hormones chemically identical or very similar to those made in the body

1) FDA approved and tested
2) unapproved and untested from compounding pharmacies

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genitourinary syndrome of menopause

genital symptoms:
dryness, burning, irritation
sexual symptoms:
lack of lubrication, discomfort or pain, impaired function
urinary symptoms:
urgency, dysuria, recurrent urinary tract infections

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vasomotor symptoms of menopause

hot flashes
night sweats
episodes of profuse heat accompanied by sweating and flushing, experienced predominantly around the head, neck, chest, and upper back

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natural estrogens

E2- estradiol
-primary in reproductive years
E1- estrone
-weakest
-produced by placenta
E3- estriol
-primary post menopause
-aromatization of fat

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clinical use populations of HT

hypogonadism
menstrual abnormalities
premature ovarian insufficiency
menopause hormonal deficiency

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clinical use of estrogen therapy

prevent and treat vasomotor symptoms (VMS)
prevent and treat genitourinary syndrome of menopause (GSM)
prevent osteoporosis
premature ovarian insufficiency/menopause
-helps prevent premature osteoporosis, heart disease, dementia

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why would perimenopausal women use hormonal contraception?

offers a viable option for both symptomatic perimenopausal women and those who wish to avoid pregnancy
menopausal EPT will NOT suppress ovulation and will result in unpredictable uterine bleeding

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which contraceptives are used in perimenopausal women

combination estrogen progestin (pills, patch, ring)

depo-medroxyprogesterone acetate is an alternative hormonal contraception that may help vasomotor symptoms

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who cannot get OCP

women >35 who smoke

other potential contraindications: HTN, DM, obesity

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noncontraceptive benefits of hormone contraceptions

suppress vasomotor symptoms
restore predictable bleeding
decrease dysmenorrhea
enhance BMD
lower risk of endometrial and ovarian cancer

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when to stop hormonal contraception

INDIVIDUALIZATION
consider stopping 51-52
stop at 55 if requires contraception
if pregnancy is a concern, check FSH/E2 on day 7 placebo x 2

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what can happen when you transition from hormone contraception to HT

hot flashes may reappear transiently

low dose OCPs have higher hormone levels than HT

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progestogen indications

endometrial protections from systemic ET
women with an intact uterus using systemic ET
not indicated with low dose local ET for GSM

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HT for vasomotor symptoms

ET with or without progestogen

almost all systemic HT products are approved for vasomotor symptom relief

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HT for vaginal symptoms

ET is most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy
systemic and local ET products available

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HT for osteoporosis

reduced fracture risk in postmenopausal women
HT approved for PREVENTING postmenopausal osteoporosis not TREATING it
benefits quickly dissipate after discontinuation of HT

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how does low dose ET improve sexual satisfaction

improves lubrication and increases blood flow and sensation in vaginal tissue
*not recommended as sole treatment of other sexual function problems (low libido)

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HT for urinary tract health

local ET may help some with overactive bladder
vaginal ET helps decrease recurrent UTI
ultra low dose transdermal has no effect on incontinence

HT effect on coronary heart disease

ET may reduce CHD and coronary artery calcification when initiated in younger and more recently postmenopausal women
*currently not recommended for solely cardiac disease prevention

black box warning for HT

includes adverse HT risks: cardiovascular disorders, endometrial cancer, breast cancer, and probably dementia

contraindications to ET/EPT

undiagnosed AUB (for local ET)
known, suspected, or history of breast cancer
known or suspected history of E dependent neoplasia
active or history of DVT, PE
active or history of arterial thrombotic disease (MI, stroke)
liver dysfunction or disease
known/suspected pregnancy
known hypersensitivity ET or EPT

potential adverse effects of ET

uterine bleeding
breast tenderness
nausea
changes in shape of cornea (contact lens intolerance)
headache, migraine

potential adverse effects of progestogens

``` abdominal bloating fluid retention in extremities headache, migraine dizziness mood changes uterine bleeding ```

FDA approved oral estrogen products

17B-estradiol (bioidentical) | conjugated estrogens

use of ospemifene

SERM, agonist in vulvar/vaginal region | for moderate to severe dyspareunia, symptoms of vaginal atrophy

paroxetine

for moderate to severe vasomotor symptoms | non-hormonal option

transdermal estrogen products

patch, gel, spray | all 17B-estradiol

local vaginal estrogen products

``` creams: -17B-estradiol -conjugated estrogens rings: -17B-estradiol -estradiol acetate tablet: -estradiolhemihydrate softgel suppository: -estradiol ```

progestogens available

medroxyprogesterone acetate micronized progesterone intrauterine levonorgestrel IUD

types of EP therapy regimens

``` continuous cyclic (sequential) continuous cyclic (sequential) continuous combined ```

continuous cyclic (sequential) HT

E daily | P 12-14 d/mo

continuous cyclic (sequential) long cycle HT

E daily P 14 d q 2-6 mo not recommended as standard therapy require endometrial monitoring

drospirenone

progestogen agent analog to spironolactone used for hirsutism increased risk of clots!

dosing of HT

use lowest dose that treats symptoms | titrate every 4-6 weeks

HT and risk of VTE

oral ET increases VTE risk in postmenopausal women VTE risk emerges soon after HT initiation and decreases over time higher risk in women > 60 lower risk with transdermal and lower oral HT doses higher risk in obese women and those with factor V leiden

oral estrogen and first pass effect

``` increases: -plasma fibrinogen -clotting factors VII and X -triglycerides -platelet aggregation decreases: -antithrombin III ```

non oral estrogen drug delivery effects

``` decreases: -CRP -prothrombin activation peptide -antithrombin activity -tissue plasminogen activator little to no increase: -triglycerides -factors VII and X ```

discuss the difference in delivery of transdermal and ring ET from oral ET

transdermal and ring bypass the GI conversion of estradiol to estrone with less increase in triglyceride levels, clotting factors, and globulins

progesterone and thromboembolism risk

synthetic forms may increase risk of TE | micronized P does not appear to increase risk of TE

HT and stroke risk

both ET and EPT appear to increase ischemic stroke risk and have no effect on hemorrhagic stroke risk moderate risk age 60-69 high risk 70+

HT and diabetes

EPT (but not ET) reduces new onset DM, but not approved for this use

HT and endometrial cancer

not recommended with history of surgically treated endometrial cancer greater than stage 2 unopposed systemic ET in postmenopausal women with an intact uterus is associated with increased endometrial cancer risk related to dose and duration of use

HT and cognitive aging/dementia

evidence is mixed | certain forms of progestins, lead to declines in memory

HT and use in premature menopause/POI

likely risks are smaller and benefits greater in younger women (<50) use of HT or oral contraception until median age of menopause is recommended, at which time decision can be reevaluated

bioidentical hormones

compound preparations not recommended | not tested for efficacy, safety, batch standardization, or purity

duration of use of HT

with EPT, increased risk of breast cancer and mortality with 3-5 years of use with ET, no increase of breast cancer with early menopausal use with ET, potential cardiac benefits with early use

SUMMARY OF HT

absolute risks in healthy women 50-59 are low long term use or HT initiation in older women, however, has greater risks breast cancer risk increased with EPT beyond 3-5 years ET can be considered for longer duration of use due to its more favorable safety profile