Hormone Replacement Therapy

Question 1

Peak occurences and ethnic disparity for vasomotor symptoms in menopause

Answer 1

• • late perimenopause and early postmenopause

- - greater severity and frequency in African Americans

Question 2

Non pharmacologic approaches to post menopausal management

Answer 2

• avoid smoking
• moderate alcohol consumption
• dress in layers/cool drinks/maintain low ambient temp
• aerobic exercise (indirect effect on mood/perceived stress/body image)
• paced respiration/clinical hypnosis/behavioral therapy

Question 3

17-Beta-Estradiol, Ethinyl Estradiol, Conjugated Estrogen

Answer 3

Oral estrogen replacement therapies,

Question 4

Bazeedoxifene (conjugated estrogen)

Answer 4

combination estrogen + SERM (selective estrogen receptor modifier) – acts as agonist to some estrogen receptors and antagonist to others (uterus),

reducing endometrial outgrowth!

Question 5

Transdermal estrogen advantages

Answer 5

17-Beta-Estradiol patch/gel/spray/emulsion

– avoids 1st pass metabolism = decreases prothrombotic hemostatic changes

Question 6

Targets for Prothrombotic hemostatic changes instigated by oral estradiol

Answer 6

• • Factor IX
• • Protein C Resistance
• • TPA (tissue plasminogen activator)

Question 7

How long after initiating hormone replacement will patients feel symptom relief?

Answer 7

1 month

Question 8

Most effective treatment for vasomotor symptoms and urogenital atrophy?

Answer 8

estrogen + progesterone

Question 9

3 mechanisms of administration for estrogen, 2 for progestogen

Answer 9

Estrogen:
Oral,
transdermal (17B-estradiol patch/gel/spray/emulsion)
Vaginal (17B-estradiol cream/tablet/emulsion)

Progestogen:
Oral
Transdermal

Question 10

Oral progesterones? Transdermal?

Answer 10

oral: Medroxyprgosesterone acetate, Norethindrone acetate, draspirenone, Micronized progesterone
transdermal: norethindrone acetate, levonorgestril

Question 11

most common dose related adverse effects?

Answer 11

breast tenderness, uterine bleeding, (+ HAs, vomiting, weight change, rash/pruritis, cholecystitis)

Question 12

consequences of stopping MHT?

Answer 12

• 50% chance of VMS recurring
• bone resorption accelerates
• vulvovaginal atrophy
• risks/benefits return relatively rapidly to baseline w/ exception of breast cancer risk which persists a few years

Question 13

Non hormonal medications for VMS? + common side effects?

Answer 13

Paroxetine, Fluoxetine, Escitalopram – nausea, HA, insomnia, sexual dysfunction

Venlafaxine — nausea, vomit, dry mouth, anorexia, sexual dysfunction

Clonidine – dry mouth, insomnia, drowsiness, skin reaction with transdermal patch

Gabapentin – dizziness, unsteadiness, drowsiness

Question 14

Clonidine MOA in VMS

Answer 14

lowers peripheral vascular reactivity, raises sweat threshold,

Question 15

Gabapentin MOA?, use?

Answer 15

VMS in menopause, MOA unknown

Question 16

Increased/Decreaseed Risks for CEE (combined equine estrogen) + MPA (Medroxyprgosesterone acetate)?

Answer 16

increased: CVD, invasive Breast ca, stroke, pulm embolism, gallbladder disease, dementia, urinary incontinence
decreased: hip fracture, diabetes, VMS

Question 17

breast cancer risks for CEE alone vs. CEE + MPA?

Answer 17

decreased risk w/ CEE alone

Question 18

age and time since menopause influence on risk of adverse event with CEE + MPA?

Answer 18

• • influence findings of absolute risk and risk of adverse event
• • younger women = much lower risk