B8.029 Prework: Menopause Hormone Therapy Flashcards
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
prescription of estrogen-progestogen therapy
added to ET to protect women with a uterus against endometrial cancer, which can be caused by estrogen alone
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
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
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
natural estrogens
E2- estradiol -primary in reproductive years E1- estrone -weakest -produced by placenta E3- estriol -primary post menopause -aromatization of fat
clinical use populations of HT
hypogonadism
menstrual abnormalities
premature ovarian insufficiency
menopause hormonal deficiency
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
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
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
who cannot get OCP
women >35 who smoke
other potential contraindications: HTN, DM, obesity
noncontraceptive benefits of hormone contraceptions
suppress vasomotor symptoms restore predictable bleeding decrease dysmenorrhea enhance BMD lower risk of endometrial and ovarian cancer
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
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
progestogen indications
endometrial protections from systemic ET
women with an intact uterus using systemic ET
not indicated with low dose local ET for GSM
HT for vasomotor symptoms
ET with or without progestogen
almost all systemic HT products are approved for vasomotor symptom relief
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
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
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)
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
