Estrogens/Antiestrogens/Progesterone

Question 1

Postmenopausal women with an intact uterus should not be prescribed ____

Answer 1

Estrogen alone due to risk for endometrial hyperplasia and endometrial cancer

Question 1

Major contraindication to estrogen therapy:

Answer 1

Clotting disorders

Question 2

Migraines with auras are a contraindication for estrogen use because:

Answer 2

Increased risk of stroke with estrogen use

Question 3

Patients on medroxyprogesterone need to be monitored for:

Answer 3

depression

Question 4

What are the estrogen drugs?

Answer 4

• Conjugated equine estrogen (Premarin)
• Micronized Estradiol (Estrace)

Question 5

What are the indications for estrogen therapy?

Answer 5

• Relief of menopause symptoms (bone loss, hot flashes, night sweats, vaginal dryness/atrophy)
• Low estrogen from hypogonadism

Question 6

What is length of treatment goal with estrogen only therapy?

Answer 6

< 5 years

Question 7

how many weeks should pass before adjusting dosing of estrogen therapy?

Answer 7

6-8

Question 8

What are the monitoring considerations for estrogen therapy?

Answer 8

BP, Lipids, mammograms @ baseline and annually

Question 9

The most common drug interactions for estrogens are:

Answer 9

Anticoagulants
Tricyclic antidepressants
steroids
seizure medications

Question 9

What are the absolute contraindications to estrogen-only therapy?

Answer 9

• Intact uterus
• Pregnancy
• current/prior estrogen dependent cancers
• DVT/VTE within a year
• liver disease
• endometriosis
• undiagnosed, dysfunctional uterine bleeding

Question 10

ADR related to estrogen therapy can be severe. What are they?

Answer 10

• Endometrial cancers
• Thromboembolic events:
  -DVT
  -Stroke
  -MI

Question 11

Patient education of adverse effects for medroxyprogesterone (Depo Provera) include:

Answer 11

Depression and weight gain

Question 12

Blackbox warning for medroxyprogesterone (Depo Provera) injection include:

Answer 12

Decreased bone density

Question 13

True or False

Intermittent spotting or a “light period” during the first few months of using medroxyprogesterone (Depo Provera) is normal

Answer 13

True. Some spotting is normal in the first few months, and should improve

Question 14

Effects of estrogen include:

Answer 14

• Regulation of the menstrual cycle
• Maintenance of bone density by increasing bone reabsorption
• Maintenance of the normal structure of the skin and blood vessels

Question 15

Patients taking hormonal contraceptives and hormone replacement therapy need to take the drug daily at the same time to prevent:

Answer 15

Breakthrough bleeding

Question 16

What signs/symptoms should patients be taught to report (regarding thromboembolic events)

Answer 16

Leg pain, visual disturbances, and severe headache

Question 17

What is a major lifestyle risk factor that increases risk of thrombolytic events when using estrogen?

Answer 17

Smoking

Question 18

Tamoxifen and Raloxifene belong to a class of drugs called:

Answer 18

Selective estrogen receptor modulators

Question 19

Tamoxifen blocks cancer by:

Answer 19

Blocking estradiol induced cancer cells by altering local production of growth factors and/or inhibiting the development of the tumor’s blood supply

Question 20

Similarities/Differences between Raloxifene & Tamoxifen:

Answer 20

Similarities: both estrogen agonist on bone and an antagonist on breast and uterus. Differences: raloxifene is neutral on vaginal tissues.

Question 21

What are the effects of progestin in reproductive organs?

Answer 21

• thickening of the endometrium in preparation for pregnancy
• thickening of cervical mucus
• thinning of the vaginal mucosa
• relaxation of smooth muscles of the uterus and fallopian tube

Question 22

Contradindications for using progesterone:

Answer 22

thromboembolic disease

Question 23

Considerations for patients using progesterone:

Answer 23

* Breast cancer may become worse * impaired liver function can have trouble metabolizing exogenous hormones * drug may need to be discontinued if depression recurs or occurs to a serious degree

Question 24

Drug interactions with progestin:

Answer 24

aminoglutethimide and rifampin

Question 25

Clinical uses/indications for progestin:

Answer 25

* Used for their effect on endometrial tissue * Also used for perimenopausal and postmenopausal hormonal therapy * As a contraceptive alone and in combination with estroge

Question 26

Patient education for progesterone:

Answer 26

* Use suncreen to decrease risk of hyperpigmentation * routine physical exercise to combat weight gain * smoking cessation

Question 27

Required monitoring for patients taking progestins:

Answer 27

* Seizure activity as progestins lower seizure threshold * migraines (progestins may worsen) * preexisting depression * diabetes (progestin may cause fluctuations in BG) * increased risk for thromboembolic, cardiovascular events & cancer

Question 28

Progestins should not be used in:

Answer 28

first 12 weeks of gestation because of masculinization of the female fetus

Question 29

To improve use of oral contraceptives, women should:

Answer 29

Use of a back-up method if they have vomiting or diarrhea during a pill packet

Question 30

Ashley comes to the clinic with a request for oral contraceptives. She has successfully used oral contraceptives before and has recently started dating a new boyfriend so would like to restart contraception. She denies recent intercourse and has a negative urine pregnancy test in the clinic. An appropriate plan of care would be:

Answer 30

Prescribe oral contraceptives and have her start them the same day as the visit with a back-up method used for the first 7 days.

Question 31

Progesterone only pills are reccomened for women who:

Answer 31

1. Are breastfeeding 2. Have a history of migraine 3. Have a medical history that contradicts the use of estrogen

Question 32

Women who are prescribed progestin-only contraception need education regarding which common adverse drug effects?

Answer 32

Irregular vaginal bleeding for the first few months

Question 33

The goal of prescribing estrogen only therapy and menopausal hormonal therapy is:

Answer 33

Reduce vasomotor symptoms

Question 34

The advantage of vaginal estrogen preparations in the treatment of vulvovaginal atrophy and dryness is:

Answer 34

Relief of symptoms without increasing cardiovascular risk

Question 35

Women with an intact uterus should be treated with both estrogen and progestin due to:

Answer 35

Increased risk for endometrial cancer if estrogen alone is used

Question 36

Ongoing monitoring for women on ERT includes:

Answer 36

1. Lipid levels, repeated annually if abnormal 2. Annual health history and review of risk profile 3. Annual mammogram

Question 37

Selective estrogen receptor modifiers (SERMs) treat osteoporosis by selectively:

Answer 37

Selectively acting on the estrogen receptors in the bone

Question 38

What is the duration of SERM use for menopausal issues?

Answer 38

The bone health impact allows long-term use

Question 39

Why are SERMS generally not ordered for women early into menopause?

Answer 39

The rapid onset of severe hot flashes can be unbearable.