Ex. 4 L1 - MHT 1 (35) Flashcards
When menopause is diagnosed
Confirmed after 12 consecutive months of amenorrhea (absence of menstruation)
Premenopause
The time period of endocrine changes BEFORE cessation of menstruation
Perimenopause (Climacteric)
The period of endocrine changes SURROUND the menopause
Menopause Median age of onset US
51 years (40-58)
Postmenopause
The time period of endocrine changes AFTER cessation of menstruation
Women spend _% of their lives postmenopausal
40%
Premature menopause
AKA “premature Ovarian Insufficiency” (POI)
Occurs before age 40
Hysterectomy, radiation therapy, chemotherapy
1% of women develop premature ovarian failure before 40
Increase risk of mortality and morbidity
Symptom statistics
Worst symptoms occur during first 1-2 years
Symptoms last 7+ years for most women
Causes of menopause
Physiologic
-Extensive deterioration of the follicular cells and ova w/aging
-Decrease estrogen and progesterone levels -> increase FSH and LH level
Surgery
-Removal of ovaries (oophorectomy)
Chemotherapy
-Breast cancer chemotherapy
Radiation therapy
Clinical presentations of menopause: Vasomotor
Hot flashes
Night sweats
(50-87% of symptoms)
Clinical presentations of menopause: Mix
Irregular Menses
Episodic Amenorrhea
Sleep Disturbance
Mood changes (depression, irritability)
Fatigue
(generally lower number due to embarrassment of reporting)
Clinical presentations of menopause: Genitourinary
Vulvovaginal atrophy (vaginal dryness, dyspareunia)
Urinary tract dysfunction
Sexual dysfunction
Urinary frequency, urgency
(27-84%)
Lower incidence of reporting due to embarrassment
Long term consequences of menopause
CV disease
Bone loss
Osteoarthritis
Body composition
Skin changes
Balance
Treatment of Menopausal symptoms: Nonpharmacologic therapies: recommended
Weight loss
Cognitive behavioral therapy
Clinical hypnosis
Stellate ganglion block
Treatment of Menopausal symptoms: Nonpharmacologic therapies: NOT recommended
Lifestyle:
-cooling techniques
-Avoid triggers
-Yoga/exercise
-Dietary modifications
Mind body techniques
-Mindfulness-based interventions
Paced respiration
Dietary supplements
-Soy foods and soy extracts, soy metabolite equol
Supplements/herbal remedies
-cannabis
Others:
Acupuncture, calibration of neural oscillations, chiropractic intervention
Indications for menopausal hormone therapy
Vasomotor symptoms
Vulvovaginal atrophy
Osteoporosis prevention (not main tx for osteoporosis)
Contraindications to MHT: ABSOLUTE
Any contraindications = stop immediately
Unexplained vaginal bleeding
Pregnancy
Estrogen-dependent malignancies
-Endometrial cancer
-Breast cancer
Stroke
Active thromboembolic disorders (or prior history)
Active liver disease
Contraindications to MHT: Relative
Contraindications = patient’s choice to continue/discontinue
Uterine leiomyoma
Migraine headaches with aura
Seizure disorders
Diabetes
Hypertriglyceridemia (>400mg/day)
Active gallbladder disease
High risk for heart disease
Family hx of breast cancer
Estrogen monotherapy is only for women (with/without) a uterus
Without
Estrogen monotherapy products: Oral
Premarin (conjugated estrogens)
Menest (esterified estrogen)
Estrace generics (micro ionized estradiol)
Estrogen monotherapy products: topical
Topical Gel (EstroGel, Divigel, Elestrin)
Topical Spray (Evamist)
IF other family members handle these, can cause S.E. (ex. gynecomastia)
Estrogen monotherapy products: IM injections
Estradiol cypionate (Depo-estradiol)
Estradiol valerate (Delestrogen)
not typically used
Used more so in gender changing therapy
Estrogen monotherapy products: Transdermal
Preferred
Climara
Lyllana
Menostar
Minivelle
Vivelle-dot
Dotti
-17B estradiol
Put patch on: continuous delivery of estrogen
Bypassing GI tract: avoid first pass, lower incidence of stroke, clots, dyslipidemia etc.
Estrogen monotherapy products: intravaginal
Vaginal cream (Estrace, Premarin)
Vaginal Insert (Imvexxy)
Vaginal tablet (Vagifem, Yuvafem)
Vaginal Ring (Estring, Femring)
EXCEPTION:
Estring - does not have high amount of systemic absorption (localized)
Femring: Delivers appropriate amount for symptoms
Ring is bigger than string
Topical vaginal products should be prescribed for women
Exclusively experiencing vulvovaginal atrophy (Local)
Women with an intact uterus: When to use estrogen?
Should be prescribed a progestin IN ADDITION TO estrogen in order to decrease the risk of endometrial hyperplasia and endometrial cancer
Women’s Health initiative study:
15 yr research program
Address most common causes of death, disability and poor quality of life in postmenopausal women
Clinical trials + observational study
Effects of hormone therapy, diet modification and Calcium/vitamin D
With uterus:
Conj. estrogen: 0.635 mg/day + medroxyprogesterone 2.5mg/day
W/o uterus:
Conj. estrogen 0.625
Major clinical outcomes of WHI study: Estrogen and Progesterone
Increase:
CV: heart attacks, stroke and venous thromboembolism
Invasive breast cancers
Decrease:
Colorectal cancers
Hip fractures
Major clinical outcomes of WHI study: Estrogen alone
Increase:
Strokes
Venous thromboembolism
Decrease:
Hip fractures
No difference
CHD
Invasive breast cancers
Colorectal disease
Estrogen only: Age groups
-50-59 years favorable risk benefit profile
-60-69 increase risk of CHD and stroke
-70-79 highest risk of CHD and stroke
Estrogen and Progestin age groups
-50-59: lowest risk
-60-69: Increasing risk
-70-79: Highest risk
The women’s health initiative showed estrogen + progestin increased the risk of all of the following EXCEPT
Fracture (decreases)
The WHI showed estrogen alone increased all of the following except:
Heart attack (age <60 within 10 years of menopause)
Fractures
Risk of breast cancer