Hormone Replacement Therapy

Question 1

T or F. Women who initiate HRT within 10 yrs of menopause are at a significantly lower risk of all-cause mortality

Answer 1

T. Even 3-6 yrs of therapy has been shown to reduce the risk of CHD, osteoporosis, and new onset diabetes

Question 2

Overview of HT use

Answer 2

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)

Question 3

When should HT be used to prevent osteoporosis?

Answer 3

Tx should be limited to women at high risk for fracture who cannot tolerate alternative therapies

Question 4

How should the decision to start HT or not begin?

Answer 4

The pts. should have significant symptoms of menopause (hot flashes, night sweats, etc.) If not, avoid

Question 5

What needs to be considered next if a pt. does have the appropriate symptoms for tx?

Answer 5

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

Question 6

The steps needed to decide whether systemic HT is safe or not should be re-assessed how often?

Answer 6

every 6-12 months

Question 7

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

Question 8

What are the traditional contraindications to all types of HT?

Answer 8

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

Question 9

What are the traditional contraindications to systemic HT (thus transdermal HT may be an option)?

Answer 9

high TAGs (400+), active gallbladder disease

Hx of venous TE due to past immobility, surgery, or bone fracture

Question 10

Why is transdermal estrogen safer than oral?

Answer 10

It avoids first-pass hepatic metabolism which promotes prothrombotic changes in factor IX, activated protein C resistance, and tissue-plasminogen activator

Question 11

What are vasomotor symptoms?

Answer 11

Vasomotor symptoms are usually described as night sweats, hot flashes, and flushes.

Question 12

When do vasomotor symptoms peak?

Answer 12

late perimenopausal and early postmenopausal years lasting an average of 7.4 yrs

Question 13

What race is most likely to have vasomotor symptoms?

Answer 13

AA

Question 14

What are some non-pharm approaches to managing vasomotor symptoms?

Answer 14

weight loss, mindfulness-based stress reduction

S-equol derivatives of soy isoflavones

stellate ganglion block

Question 15

What are some non-pharm approaches that should NOT be recommended for managing vasomotor symptoms?

Answer 15

cooling techniques

acupuncture

calibration of neural oscillation

avoidance of triggers, exercise, yoga, and paced respiration

Question 16

What are some pharm options for HT?

Answer 16

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

Question 17

What are some options for oral estrogen?

Answer 17

17B-estradiol

Ethinyl estradiol

Conjugated estrogen

Question 18

What are some options for oral progestogen?

Answer 18

Medroxyprogesterone acetate

Norethindrone acetate

Drospirenone

Micronized progesterone

Question 19

What is the most effective tx for VMS and urogenital atrophy?

Answer 19

Estrogen +/ progestogen. Relief occurs within one month

Question 20

Common AEs of estrogen +- progestogen

Answer 20

breast tenderness and uterine bleeding

Vomiting, HA, weight change, rash and pruritis, and cholecystitis

Question 21

What is Bazedoxifene?

Answer 21

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

Question 22

VMS have an approx ____ chance of recurring when MHT is discontinued, independent of age or duration of use

Answer 22

50%

Question 23

More notes on oral vs. transdermal estrogen

Answer 23

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

Question 24

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

Answer 24

T. AND, the incidence of metabolic syndrome and weight gain appears to be slightly lower with a trandermal delivery system

Question 25

How would oral estrogen affect libido?

Answer 25

Oral estrogen significantly increases hepatic sex hormone binding globulin production which lowers testosterone availability compared to transdermal delivery, reducing libido