Hormonal Replacement Therapy

Question 1

When does menopause officially begin?

Answer 1

12 months after the last menstrual period

Question 2

What happens to FSH and LH in menopause?

Answer 2

INCREASE

Question 3

What are the 4 indications approved by the FDA for hormone replacement?

Answer 3

1. Vasomotor symptoms**
2. Preventing bone loss
3. Hypoestrogenism caused by hypogonadism, castration, or primary ovarian insufficiency
4. Genitourinary symptoms*

Question 4

What is the difference in hormone therapy if your patient has a uterus or not?

Answer 4

Uterus - combination of estrogen + progesterone

(this is for endometrial protection)

No uterus - unopposed estrogen

Question 5

Risk of breast cancer with menopause hormone therapy is associated with which hormone?

Answer 5

progesterone with estrogen

estrogen alone doesn’t increase risk

Question 6

When can you consider using HRT (systemic estrogen therapy) in a recent postmenopausal patient at increased risk of bone fracture?

Answer 6

If alternative therapies are contraindicated or cause excessive ADE

Question 7

Which two types of symptoms is Hormone replacement therapy best for?

Answer 7

1. Vasomotor symptoms

2. Genitourinary symptoms

Question 8

Describe how time after menopause effects risk with HRT?

Answer 8

• If <10 years after menopause, pros out weight the cons
• If >10 years after menopause, don’t initiate therapy because more risk for coronary heart disease, stroke, venous thromboembolism, and dementia

Question 9

Absolute contraindications for HRT?

Answer 9

1. Abnormal genital bleeding
2. Breast cancer (hx, known, suspected)
3. Estrogen/Progesterone dependent neoplasia
4. VTE (stroke, MI)
5. Liver dysfunction

Question 10

If a menopausal patient has vasomotor symptoms but has a contraindication to HRT what is the therapy of choice?

Answer 10

• SNRI
• SSRI
• Clonidine
• Gabapentin

Question 11

Vasomotor symptoms: Non-pharmacologic treatment

Answer 11

• wearing layered clothing
• lowering room temperature
• decreasing hot spicy foods, caffeine, and hot beverages
• exercise

Question 12

If a patient has liver function problems what type of estrogen should they receive?

Answer 12

NOT oral

• patch
• topical
• transdermal spray
• vaginal
• implantable pellet

Question 13

What is important to educate your patient about their use of HRT?

Answer 13

HRT doesn’t provide adequate contraception

Question 14

Alternative medications to Estrogen for the treatment of hot flushes

Answer 14

1. Venlafaxine (SNRI) [Effexor]
2. Desvenlafaxine (SNRI) [Pristiq]
3. Paroxetine* -only one that is not considered off-label
4. Megestrol acetate
5. Clonidine
6. Gabapentin

Question 15

Gabapentin: ADEs

Answer 15

• Somnolence
• Dizziness
• Ataxia

**increase dose gradually

Question 16

Androgen insufficiency: Signs and symptoms

Answer 16

• diminished sense of well being
• Persistent fatigue
• Decreased libido

Question 17

Food sources of estrogen

Answer 17

• soybean
• cereals
• flaxseed
• alfalfa sprouts

Question 18

Black Cohosh: overview

Answer 18

• herbal supplement
• possible benefit for vasomotor symptoms
• ADE: hepatotoxicity

Question 19

How long should HRT last?

Answer 19

Shortest time possible (2-3 years typically)

breast cancer risk increases after 5 years of combined hormone therapy

Question 20

After starting a patient on HRT, when do they follow up?

Answer 20

6 weeks

Question 21

If a patient is having breast tenderness how should you adjust the estrogen dose?

Answer 21

• decrease

- switch to transdermal

Question 22

What should you look out for with a patient on Progestogen?

Answer 22

• bloating
• pre-menstrual symptoms (PMS)

Solution: switch to another progestogen

Question 23

Should you use bioidentical hormones?

Answer 23

NO