Hormone Replacement Therapy Flashcards
T or F: Women who initiate Hormone Replacement therapy within 10 years of menopause are at a significantly lower risk of all-cause mortality.
True, original studies showing increased health risk of CV events was performed on women greater than 10 years out from menopause and gave screwed results.
Aside from improved quality of life, what are the benefits of estrogen therapy in women who are less than 10 years out from menopause?
- Prevention of CHD (chronic heart dz)
- Decreased Fracture risk
**NOTE: this tx doesn’t have to be long term. Even patients that use it for 3-6 years show benefits
How long do vasomotor symptoms often persist in women with menopause?
- What causes of vasomotor symptoms should be excluded to assure that menopause is the cause?
7.4 years, but these symptoms tend to last longer in AA women
DDx:
Emotional Flushing
Autonomic Epilepsy
Hyperthyroidism
Medications (like CCBs)
EtOH related Flushing
Pheochromocytoma
Carcinoid Syndrome
What is the 1st step in management of post-menopausal symptoms?
- Cognitive-behavioral therapy (and hypnosis)
- Mindfulness-based stress reduction, S-equol derivatives (of soy isoflavones), and stellate ganglion block
- DO NOT RECOMMEND: avoidance of triggers, yoga, excercise, paced respiration, relaxation, OTCs and herbals, acupuncture, calibration of neural oscillations, chiropractic interventions.
What non-hormonal medications are used to control vasomotor symptoms in menopause?
**Which is/are FDA approved?
Paroxetine
Fluoxetine
Escitalopram
Venlafaxine
Clonidine
Gabapentin
**Only Paroxetine is FDA approved for treatment of vasomotor symptoms of menopause**
Compare the dosage of antidepressant used in non-hormonal treatment of vasomotor symptoms compared to use as antidepressant?
- compare onset of action?
Much Lower doses of antidepressant are required to achieve the vasomotor relief
Onset of action for vasomotor relief is much faster than for anti-depressants
What drugs used in the non-hormonal treatment of post-menopausal vasomotor symptoms may cause sexual dysfunction.
- note any differences in side effects among these drugs.
Paroxetine, Fluoxetine, and Escitalopram:
N/HA, insomnia, sexual dysfunction.
Venalafaxine:
N/V, DRY MOUTH, ANOREXIA, and sexual dysfunction
What drugs used in the non-hormonal treatment of postmenopausal vasomotor symptoms can cause dry mouth?
- list other side effects of these drugs
Venlafaxine:
N/V, Dry mouth, Anorexia, sexual dysfunction
Clonidine:
Dry mouth, insomnia, drowsiness, skin reaction to transdermal patch
What drugs used in the non-hormonal treatment of post-menopausal vasomotor symptoms are known to cause dizziness, and drowsiness?
Clonidine and Gabapentin
Clonidine:
Dry mouth, insomina, drowsiness, skin reactions to transdermal patch
Gabapentin:
Dizziness, unsteadiness, drowsiness
What is the MOST EFFECTIVE treatment for post-menopausal vasomotor symptoms?
- how long must therapy be used before there is relief of symptoms?
Estrogen +/- Progesterone
Typically 1 month of therapy is required before symptoms get better
What adverse effects are common to estrogen as a hormonal treatment of post-menopausal vasomotor symptoms?
Dose-related:
Cholecystitis, Pruritus, Rash, Weight Change, V/HA
Why are transdermal estrogen patches preferred over PO therapy in the treatment of post-menopausal vasomotor symptoms?
Transdermal Patches avoid 1st pass metabolism, which is responsible for many of the thromboembolitic effects of oral estrogen therapy in older women. Hemostatic changes in oral therapy the promote thrombosis are caused by:
- Changes in factor IX
- Activated Protein C resistance
- tPA
What oral estrogen therapies are used to treat post-menopausal vasomotor symptoms in patients?
- 17Beta-estradiol
- Ethinyl Estradiol
- Conjugated Estrogen
What types of estrogen are used in the transdermal (patch, gel, spray, emulsion) estrogen patch?
17 beta-estradiol
What estrogen type is used in vaginal (cream, tablet, ring) estrogen administration?
17 beta-estradiol
What oral progesterone therapies are used in the treatment of post-menopausal vasomotor symptoms?
- Medroxyprogesterone
- Norethindrone acetate
- Drospirenone
- Microioized Progesterone
What transdermal estrogens are used in progesterones can be used in the treatment of post-menopausal vasomotor symptoms?
Norethindrone
Levonorgestril
- *Bazedoxifene**
- how does it differ from other estrogen therapies used in the treatment of post-menopausal vasomotor symptoms?
Bazedoxifene is a combination of estrogens and SERMs that can act as an agonist in some estrogen tissue and an antogonist in others (e.g. Uterus).
This prevents endometrial growth in older women taking this drug.
What is the chance that vasomotor symptoms of menopause will recur after discontinued use of estrogen therapy?
- what about other symptoms of menopause?
50% chance that vasomotor symptoms will return.
Bone atrophy and vulvovaginal atrophy occur as expected following discontinuation of estrogen
Risk (reduction?) of breast cancer perisists for longer
Compare oral and transdermal estrogen with effects on:
- Clotting/Inflammation
- Cholesterol/Triglycerides
- Libido
Oral Therapy does not avoid 1st pass and therefore more hyper-coagulability is seen and more C-reactive protein is produced.
Cholesterol and Triglycerides are lowered by both methods, however ORAL therapy lowers CHOLESTEROL more while TRANDERMAL therapy lowers TRIGLYCERIDES more
Transdermal therapy does not lead to increases in Sex Hormone Binding Globulin and therefore does not decrease testosterone. For this reason TRANSDERMAL ESTROGEN has less impact on decreasing libido.
