Hormone Replacement Therapy Flashcards
T or F. Women who initiate HRT within 10 yrs of menopause are at a significantly lower risk of all-cause mortality
T. Even 3-6 yrs of therapy has been shown to reduce the risk of CHD, osteoporosis, and new onset diabetes
Overview of HT use
HT remains appropriate for management of moderate to severe menopausal symptoms in early menopause, but current evidence does not support the use of either estrogen-progestin or estrogen alone for long-term chronic disease prevention (such as osteoporosis)
When should HT be used to prevent osteoporosis?
Tx should be limited to women at high risk for fracture who cannot tolerate alternative therapies
How should the decision to start HT or not begin?
The pts. should have significant symptoms of menopause (hot flashes, night sweats, etc.) If not, avoid
What needs to be considered next if a pt. does have the appropriate symptoms for tx?
Determine whether the pt. is free of contraindications: I.e. has no Hx of CHD, stroke, or TA, and will not be placed at an increased risk of stroke
The steps needed to decide whether systemic HT is safe or not should be re-assessed how often?
every 6-12 months
T or F. Women at high risk of osteoporotic fracture but unable to tolerate alternative preventive meds also may be reasonable candidates for systemic HT even if they do not have moderate to severe vasomotor symptoms
What are the traditional contraindications to all types of HT?
unexplained vaginal bleeding
active liver disease
Hx of venous TE due to pregnancy or blood clotting disorder
oral contraceptive use
Hx of breast or endometrial cancer
What are the traditional contraindications to systemic HT (thus transdermal HT may be an option)?
high TAGs (400+), active gallbladder disease
Hx of venous TE due to past immobility, surgery, or bone fracture
Why is transdermal estrogen safer than oral?
It avoids first-pass hepatic metabolism which promotes prothrombotic changes in factor IX, activated protein C resistance, and tissue-plasminogen activator
What are vasomotor symptoms?
Vasomotor symptoms are usually described as night sweats, hot flashes, and flushes.
When do vasomotor symptoms peak?
late perimenopausal and early postmenopausal years lasting an average of 7.4 yrs
What race is most likely to have vasomotor symptoms?
AA
What are some non-pharm approaches to managing vasomotor symptoms?
weight loss, mindfulness-based stress reduction
S-equol derivatives of soy isoflavones
stellate ganglion block
What are some non-pharm approaches that should NOT be recommended for managing vasomotor symptoms?
cooling techniques
acupuncture
calibration of neural oscillation
avoidance of triggers, exercise, yoga, and paced respiration
What are some pharm options for HT?
Paroxetine and Flouxetine
Escitalopram
Venlafaxine
Clonidine
Gabapentin
These are all FDA approved off-label at lower doses than for primary indications. Effects of the antidepressants are more rapid for VMS alleviation than tradiitional use
What are some options for oral estrogen?
17B-estradiol
Ethinyl estradiol
Conjugated estrogen
What are some options for oral progestogen?
Medroxyprogesterone acetate
Norethindrone acetate
Drospirenone
Micronized progesterone
What is the most effective tx for VMS and urogenital atrophy?
Estrogen +/ progestogen. Relief occurs within one month
Common AEs of estrogen +- progestogen
breast tenderness and uterine bleeding
Vomiting, HA, weight change, rash and pruritis, and cholecystitis
What is Bazedoxifene?
A combo of estrogens and selective estrogen receptor modifier (SERM) that acts as an agonist on some estrogen-sensitive tissues and an antagonist in others (e.g. uterus). In postemenopausal women taking estrogens, this drug helps reduce endometrial overgrowth
VMS have an approx ____ chance of recurring when MHT is discontinued, independent of age or duration of use
50%
More notes on oral vs. transdermal estrogen
Bypassing hepatic metabolism appears to result in more stable serum estradiol levels without supraphysiologic concentrations in the liver. By avoiding first pass, transdermal hormone therapy may have less pronounced effects on hepatic protein synthesis, such as inflammatory markers, markers of coag and fibrinolysis, and steroid binding proteins, while oral hormone therapy promotes a hyper-coaguable state and increases synthesis of CRP and fibrinolytic markers
T or F. Both oral and transdermal delivery systems have beenficial effects on HDL: LDL ratios (oral better than transdermal though), while the transdermal approach has more favorable effects on TAGs
T. AND, the incidence of metabolic syndrome and weight gain appears to be slightly lower with a trandermal delivery system
How would oral estrogen affect libido?
Oral estrogen significantly increases hepatic sex hormone binding globulin production which lowers testosterone availability compared to transdermal delivery, reducing libido
