Block 5: Menopause Flashcards
What is perimenopause?
Time before menopause and menstrual pattern changes from decreasing estrogen and ovarian function decrease
What are the sx of perimenopause?
- Anovulation
- Dysfunctional uterine bleeding
- Extended menstrual intervaals
- Hot flashes
- Oligomenorrhea
What are the labs and primary sx of peri and menopause?
What are tx options for perimenopause?
- Progestins
- Low dose COC
What is DUB?
Anovulatory bleeding from vagina
Tx for DUB?
Investigate other possible causes first
1. Progestin only IUD
2. Systemic progestin therapy
3. COC
What is menopause?
- Permanent cessation of menses(at least 1 year) following the loss ofovarian follicular function
- FSH levels are > 40 IU/L.
- Estrogen has decreased by > 90%
- 40-58
What are sx of estrogen deficiency?
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
What are GSM?
Both vaginal and urinary sx of menopause
What is the tx for GSM?
- Local urinary estrogen (creams, tablet, ring) Only menopausal sx
- FemRing (vaginal ring): vulvovaginal candidiasis, vaginal bleeding, breast pain, nausea
- Ospemifene (SERM): for painful intercourse and no cancer risk
How do you counsel on local vaginal estrogen use?
Therapeutic response after 2 weeks of daily use
Maintenance dose is decreased to 2-3 times per week
What are the advantages of local estrogen?
- Minimizes systemic absorption
- More effective than PO
- No progesterone necessary with low dose vaginal estrogen
What are the medical concerns associated with perimenopause/menopause?
CV health:
1. Estrogen is cardioprocective
2. After menopause -HDL down, LDL up, total cholesterol up
Bone health:
1. Decline in bone health
How do you assess for menopause?
- Complete med hx
- CV exam
- Thyroid assessment
- Breast/pelvic exam
- Assess the baseline risk of breast cancer and CVD, and consider risk when making recommendation
How do you treat mild vasomotor and vulvovaginal sx?
Nonpharmacologic
How do you treat moderate/severe vasomotor and vulvovaginal sx?
- Menopausal hormone therapy
- Systemic estrogen (w/ progesterone if women has a uterus)
- Estrogen agonist/antagonist
How do you treat moderate-severe GSM sx?
Local vaginal estrogen - progesterone therapy not recommended with low dose vaginal estrogen
What are the non-pharm therapy for menopause?
- Limit alcohol
- Low fat-diet
- Limit spicy foods
- Use cold therapy
- Practice relaxation techniques
- Massage
- Loose Clothes/ layered clothing
- Exercise
- Lubricants
What are the uses of black cohosh? ADR?
Hot flaskes and additive effect with tamoxifen
Use should NOT exceed 6 months
- HA
- Rash
- DZ
- Weight gain
- Cramping
What are the OTC menopausse products?
- Remifemin
- Estroven
- Black cohosh
Indications HRT?
Hormonoe therapy alleviates vasomotor and vaginal sx
1. Menopausal sx
2. Osteoporosis prevention
How can use HRT?
Women with a uterus = estrogen + progesterone
Women without a uterus = estrogen only
How long can HRT be used?
<5 years and lowest dose
What are the ADRs of estrogen?
N, HA, breast tenderness, and heavy bleeding
What are HRT products?
- Conjugated estrogens (Premarin®)
- Conjugated estrogens and medroxyprogesterone acetate (Prempro®): Continuous progestin = no menstruation
- Conjugated estrogens (Premarin®) vaginal cream (2g/dose or lowest effective dose)
What are BBW of estrogen?
- Endometrial cancer risk
- CV risk (VTE, stroke)
- Dementia risk
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
What are examples of progesterone products?
- Medroxyprogesterone (Depo-Provera, SC/IM)
- Micronized progestins(e.g. Prometrium)
What are examples of combo regimens?
- Continuous Cyclic Estrogen/Progestogen
- Continuous- Combined Estrogen/Progestogen: Reserved for women 2 years post menopause
- Continuous Long-Cycle Estrogen/Progestogen: Decreases incidence of uterine bleeding, but heavier bleeding
- Intermittent-Combined Estrogen/Progestogen: Lower incidence of uterine bleeding
What does dosing of Phemphase look like?
Days 1 - 14 = Conjugated estrogens
Days 15 - 28 = Conjugated estrogens + medroxyprogesterone
Monthly withdrawal bleeding often occurs
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
What are the indications for androgen products? Examples?
Improve loss of sexual desire and bone density more than estrogen alone
Methyltestosterone + Estrified estrogen
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
Risks of estrogen and progestin use?
- Invasive breast cnacer
- Coronary disease events
- PO
- Stroke
- Decreased hip fracture
- Decreased colorectal cancer
How should you counsel patients on MHT?
- Discussion of risks and benefits
- Patient should be reassessed every 6-12 months and discontinuation of therapy should be considered
- Follow-up appointment in 6 weeks after initiating HRT
- If d/c HRT, make sure to taper so vasomotor symptoms do not reoccur
What are absolute CI of MHT?
- Abnormal genital bleeding
- Hx of breast cancer
- Estrogen- or progesterone-dependent neoplasia
- DVT, PE
- Liver dysfunction or dx
What are relative CI of MHT?
- Elevated BP
- HTG
- Impaired liver function
- Hypothyroidism
- Fluid retention
- Severe hypocalcemia
- Ovarian cancer
- Exacerbation of endometriosis
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
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
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
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
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
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
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
What is first line if MHT is CI? ADR?
SSRI: Paroxetine, Fluoxetine
ADR: HA, N, weight gain
Venlafaxine:
ADR: Dry mounth, N, decreased appetite
What are other therapies for hot flashes besides MHT and SSRI?
- Megestrol acetate: linked to breast cancer
- Clonidine: dry mouth, drowsiness
- Gabapentin: somnolences, DZ
