Block 5: Menopause Flashcards

1
Q

What is perimenopause?

A

Time before menopause and menstrual pattern changes from decreasing estrogen and ovarian function decrease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

What are the sx of perimenopause?

A
  1. Anovulation
  2. Dysfunctional uterine bleeding
  3. Extended menstrual intervaals
  4. Hot flashes
  5. Oligomenorrhea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the labs and primary sx of peri and menopause?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are tx options for perimenopause?

A
  1. Progestins
  2. Low dose COC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is DUB?

A

Anovulatory bleeding from vagina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Tx for DUB?

A

Investigate other possible causes first
1. Progestin only IUD
2. Systemic progestin therapy
3. COC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is menopause?

A
  1. Permanent cessation of menses(at least 1 year) following the loss ofovarian follicular function
  2. FSH levels are > 40 IU/L.
  3. Estrogen has decreased by > 90%
  4. 40-58
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are sx of estrogen deficiency?

A

Vasomotor:
1. Hot flashes
2. Night sweats

Vaginal:
1. Burning, drynesss, itching, irritation
2. GU atrophy
3. Impaired sexual function
4. Lubrication difficulty

Urinary:
1. Urgency
2. Dysuria
3. Recurrent UTI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are GSM?

A

Both vaginal and urinary sx of menopause

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the tx for GSM?

A
  1. Local urinary estrogen (creams, tablet, ring) Only menopausal sx
  2. FemRing (vaginal ring): vulvovaginal candidiasis, vaginal bleeding, breast pain, nausea
  3. Ospemifene (SERM): for painful intercourse and no cancer risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How do you counsel on local vaginal estrogen use?

A

Therapeutic response after 2 weeks of daily use

Maintenance dose is decreased to 2-3 times per week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the advantages of local estrogen?

A
  1. Minimizes systemic absorption
  2. More effective than PO
  3. No progesterone necessary with low dose vaginal estrogen
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the medical concerns associated with perimenopause/menopause?

A

CV health:
1. Estrogen is cardioprocective
2. After menopause -HDL down, LDL up, total cholesterol up

Bone health:
1. Decline in bone health

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How do you assess for menopause?

A
  1. Complete med hx
  2. CV exam
  3. Thyroid assessment
  4. Breast/pelvic exam
  5. Assess the baseline risk of breast cancer and CVD, and consider risk when making recommendation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How do you treat mild vasomotor and vulvovaginal sx?

A

Nonpharmacologic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How do you treat moderate/severe vasomotor and vulvovaginal sx?

A
  1. Menopausal hormone therapy
  2. Systemic estrogen (w/ progesterone if women has a uterus)
  3. Estrogen agonist/antagonist
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How do you treat moderate-severe GSM sx?

A

Local vaginal estrogen - progesterone therapy not recommended with low dose vaginal estrogen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the non-pharm therapy for menopause?

A
  1. Limit alcohol
  2. Low fat-diet
  3. Limit spicy foods
  4. Use cold therapy
  5. Practice relaxation techniques
  6. Massage
  7. Loose Clothes/ layered clothing
  8. Exercise
  9. Lubricants
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the uses of black cohosh? ADR?

A

Hot flaskes and additive effect with tamoxifen

Use should NOT exceed 6 months

  1. HA
  2. Rash
  3. DZ
  4. Weight gain
  5. Cramping
19
Q

What are the OTC menopausse products?

A
  1. Remifemin
  2. Estroven
  3. Black cohosh
20
Q

Indications HRT?

A

Hormonoe therapy alleviates vasomotor and vaginal sx
1. Menopausal sx
2. Osteoporosis prevention

21
Q

How can use HRT?

A

Women with a uterus = estrogen + progesterone
Women without a uterus = estrogen only

22
Q

How long can HRT be used?

A

<5 years and lowest dose

23
Q

What are the ADRs of estrogen?

A

N, HA, breast tenderness, and heavy bleeding

24
What are HRT products?
1. Conjugated estrogens (Premarin®) 2. Conjugated estrogens and medroxyprogesterone acetate (Prempro®): Continuous progestin = no menstruation 3. Conjugated estrogens (Premarin®) vaginal cream (2g/dose or lowest effective dose)
25
What are BBW of estrogen?
1. Endometrial cancer risk 2. CV risk (VTE, stroke) 3. Dementia risk
26
Function of transdermal estrogne?
Micronized 17-beta-estradiol that delivers estradiol at a continuous rate 1. Lower risk for estrogen ADR 2. Oral estrogen should be avoided in women with hypertriglyceridemia, liver disease, and gallbladder disease 3. Should be applied to lower abdomen below the waistline, should NOT be applied to breast
27
What are examples of progesterone products?
1. Medroxyprogesterone (Depo-Provera, SC/IM) 2. Micronized progestins(e.g. Prometrium)
28
What are examples of combo regimens?
1. Continuous Cyclic Estrogen/Progestogen 2. Continuous- Combined Estrogen/Progestogen: Reserved for women 2 years post menopause 3. Continuous Long-Cycle Estrogen/Progestogen: Decreases incidence of uterine bleeding, but heavier bleeding 4. Intermittent-Combined Estrogen/Progestogen: Lower incidence of uterine bleeding
29
What does dosing of Phemphase look like?
Days 1 - 14 = Conjugated estrogens Days 15 - 28 = Conjugated estrogens + medroxyprogesterone Monthly withdrawal bleeding often occurs
30
HRT dosage forms?
**Estradiol vaginal rings – Replace every 3 months** 1. Femring® 2. Estring ® **Estradiol transdermal patch – Replace twice weekly** 1. Alora ® 2. Estraderm ® 3. Vivelle Dot ® **Estradiol transdermal patch – Replace weekly** 1. Climara ® 2. Combipatch ® (estradiol + norethindrone) with uterus may be used on days 14-28 = withdrawal bleeding
31
What are the indications for androgen products? Examples?
Improve loss of sexual desire and bone density more than estrogen alone Methyltestosterone + Estrified estrogen
32
What are the CI of androgen therapy?
**Absolute:** Pregnancy/lactation, androgen-dependent neoplasia **Relative:** : Concurrent use of CEEs, low sex hormone binding globulin levels, moderate to severe acne, clinical hirsutism, androgenic alopecia
33
Risks of estrogen and progestin use?
1. Invasive breast cnacer 2. Coronary disease events 3. PO 4. Stroke 5. Decreased hip fracture 6. Decreased colorectal cancer
34
How should you counsel patients on MHT?
1. Discussion of risks and benefits 2. Patient should be reassessed every 6-12 months and discontinuation of therapy should be considered 3. Follow-up appointment in 6 weeks after initiating HRT 4. If d/c HRT, make sure to taper so vasomotor symptoms do not reoccur
35
What are absolute CI of MHT?
1. Abnormal genital bleeding 2. Hx of breast cancer 3. Estrogen- or progesterone-dependent neoplasia 4. DVT, PE 5. Liver dysfunction or dx
36
What are relative CI of MHT?
1. Elevated BP 2. HTG 3. Impaired liver function 4. Hypothyroidism 1. Fluid retention 1. Severe hypocalcemia 1. Ovarian cancer 2. Exacerbation of endometriosis
37
Evista | Brand, MOA, ADR, CI
Raloxifene **MOA:** bind to estrogen receptors and function as tissue-specific estrogen antagonists or agonists * Prevents bone loss and spinal fractures; invasive breast cancer **ADR:** exacerbate vasomotor sx, increases risk for VTE **CI:** thrombosis hx
38
Duavee | Brand, Indication, ADR
Conjugated estrogens and bazedoxifene **Indication:** treatment of moderate to severe vasomotor symptoms and prevention of osteoporosis **ADR:** Muscle spasms, NV, throat, neck and/or upper abdominal pain, and indigestion
39
Ospenifene | Brand, Indication, ADR
Osphena **Indication:** women with a uterus may require a progestin, moderate to severe dyspareunia (vulvular and vaginal atrophy) **ADR:** Hot flashes, muscle cramps, vaginal discharge, hyperhidrosis
40
Prasterone | Brand, Indication, ADR, CI
Intrarosa **Indication:** Moderate to severe dyspareunia, related to menopausal vulvar and vaginal atrophy **MOA:** Inactive endogenous steroid that is converted to active androgens and estrogens **ADR:** Vaginal discharge, abnormal pap smear **CI:** Undiagnosed abnormal genital bleeding, Current or past history of breast cancer
41
Bremelanotide | Brand, Indication, Counseling, ADR
Vyleesi **Indication:** Hypoactive sexual desire disorder (HSDD) in premenopausal women **Counseling:** * Inject Vyleesi under the skin of the abdomen or thigh at least 45 minutes before anticipated sexual activity  * Patients should not use more than one dose within 24 hours or more than eight doses per month.  * Patients should discontinue treatment after eight weeks if they do not report an improvement in sexual desire and associated distress **ADR:** NV, HA, nasal congestion
42
What is bio-identical HRT?
Identical to the individual’s endogenous hormones (E1, E2, E3, and P4): Increased estrone levels are linked to increased risk of estrogen receptor (ER) positive breast cancer
43
What is the difference between progesterone and progestogens?
**Progesterone:** molecule identical to endogenous products **Progestogens:** natural or synthetic products that act like progesterone in uterus
44
What is first line if MHT is CI? ADR?
**SSRI:** Paroxetine, Fluoxetine ADR: HA, N, weight gain **Venlafaxine:** ADR: Dry mounth, N, decreased appetite
45
What are other therapies for hot flashes besides MHT and SSRI?
1. Megestrol acetate: linked to breast cancer 2. Clonidine: dry mouth, drowsiness 3. Gabapentin: somnolences, DZ