Hormone replacement therapy Flashcards
What is perimenopause
Onset of menstrual irregularity-12 months after LMP
What is menopause
permanent cessation of menses caused by loss of ovarian follicular activity
In menopausal women, bleeding is
cancer until proves otherwise
What happens when ovarian function ceases
Ovaries no longer are primary site of estradiol and progesterone synthesis
Serum FSH reaches >40
Menopause is characterized by
10-15x increase in circulating FSH
4-5x increase in LH
>90% decrease in estrogen and progesterone
Perimenopause is characterized by
FSH fluctuates between normal and postmenopausal ranges (so don’t use FSH to Dx perimenopause!)
-You can still get pregnant in perimenopause!
Leading up to menopause, most women have
4-8 years of heavy, irregular cycle changes which is mostly caused by anovulatory cycles (can also be 2/2 thyroid abn, hyperPRL, or PCOS)
What are symptoms of menopause
Vasomotor Sx (hot flashes, night sweats) slep disturbances mood changes problems with concentrating and memory vaginal dryness and dyspareunia
What lab tests can you get to diagnose menopause and perimenopause
Peri: FSH on day 2 or 3 of cycle >10-12 IU
Meno: FSH >40 IU
-Can also get thyroid tests, iron stores, and a lipid profile
FDA approved therapy for these 4 indications
Vasomotor symptoms (hormonal Tx is A1)
Prevention of bone loss
Hypoestrogenism
GU Sx
How can estrogen be given to postmenopausal women
W/ a uterus: estrogen + progesterone (or estrogen agonist-antagonist)
Had a hysterectomy: unopposed estrogen
What is MHT
menopause hormone therapy
individualized based on severity of Sx and risk of CVD, breast cancer, osteoporotic Fx, and VTE
DO NOT use to reduce risk of CVD
In what way does MHT increase the risk of breast cancer
With progesterone added to estrogen therapy!
Breast cancer risk is not higher in women taking unopposed estrogen
Recently postmenopausal women are at an increased risk for
fracture!
May use systemic estrogen to prevent osteoporotic Fx when alternate Tx are CI or have excess ADE
Per USPSTF, should post menopausal women use hormone therapy as primary prevention for chronic diseases
No! It is a grade D recommendation that if with a uterus you NOT use estrogen+progesterone, and if without a uterus you NOT use estrogen
Absolute contraindications to using MHT are
undiagnosed genital bleeding known or suspected Hx of breast cancer Known or suspected E/P dependent neoplasia Active or Hx of DVT or PE Active or recent MI or CVA Liver dysfunction or disease
What lifestyle modifications can help relieve vasomotor symptoms
Wear layered clothing
lower room temperature
decrease intake of spicy food, caffeine, or hot beverages
exercise
Does HRT provide contraception?
NO
What is the estrogen transdermal patch
17 b-estradiol
Different formulations of estrogen include
topical emulsion, gel topical transdermal spray implanted vaginal ring intravaginal products (to Tx urogenital Sx)
What are the oral types of progsterone
Medroxyprogesterone acetate
Micronized progesterone
Norethindrone acetate
Why do women typically not like progesterone
Because it messes with your menses, and can cause your periods to return
Commonly used oral hormone replacements are
Conjugated equine estrogen + MPA
Ethinyl estradiol + Norethindrone acetate
Commonly used topical hormone replacements are
Estradiol + Norethindrone acetate patch
Estradiol + Levonorgestrel patch
What can you use other than estrogen to treat hot flashes
- Venlafaxine: may cause nausea, HA, dizzy, constipation, HTN
- Desvenlafaxine: may cause same as above but no HTN
- Paroxetine: may cause same as above but no HTN
- Megestrol acetate: progesterone can be linked to breast cancer
- Clonidine: may cause drowsiness, dizzy, hypotension, dry mouth
- Gabapentin: may cause dizzy, mental confusion, ataxia
What therapy is becoming more widespread
therapeutic use of testosterone (androgens)
even though it is unclear if there is a true androgen deficiency!
What effects do androgens have in women
Act directly via androgen receptors in bone, skin, hair follicles, and sebaceous glands
Act indirectly via aromatization of T-to-E in ovaries, bone, brain, adipose, and other tissues
Symptoms of androgen insufficiency include
diminished well being
persistent, unexplained fatigue
decreased libido, sexual receptivity, and pleasure
What androgen treatments are available
Methyltestosterone + Esterfied estrogens
Testosterone pellets
Transdermal testosterone system
Oral tablet Flibanserin (came out for women)
What are phytoestrogens
Plant compounds with bioactivity like estrogen (but weak estrogen receptor binding) that have a physiologic effect in humans
What are the 3 main classes of phytoestrogens
Isoflavones: Genistein and Daidzein (active components)- found in soybeans
Lignans- found in cereal, oilseeds, flaxseeds
Coumestans- found in alfaalfa sprouts
What is Black Cohosh
an herbal supplement that acts through the serotonergic system, but does not have strong estrogenic properties
Relatively safe but has been linked to hepatotoxicity
May not offer a lot of relief of hot flashes
Never put transdermal products on
The breasts!!
After prescribing HRT, follow up
in 6 weeks to discuss patient concerns, and evaluate Sx relief, ADE, and patterns of withdrawal bleeding
How long should hormone therapy be used
only as long as Sx control is necessary; usually 2-3 years
ADE of estrogen are
Breast tenderness!
Reduce the estrogen dose, or switch to transdermal
(If hot flashed persist, raise estrogen dose)
ADE of progesterone are
Bloating
PMS-like Sx
-switch to a different progesterone
What does ACCE NOT recommend
Use of bioidentical hormone therapy
Part of the general statement on HRT put out by NAMS
- Benefits >risks for women <60, w/in 10 years of menopause
- HRT should be individualized
- VMS and GSM prevent bone loss and fracture
What are bioidentical hormones
Natural forms of estrogen, progesterone, and testosterone
carry the same risks as traditional hormone therapy!
If women only have vulvovaginal Sx, how do you treat
Mild: vaginal moisturizer/lube
Mod-Severe: vaginal estrogen at lowest dose
If women have only vasomotor Sx, how do you treat
Mild: Non-pharm therapy
Mod-severe: If not CI, use estrogen +/- progesterone. If CI, use SNRI, SSRI, clonidien, or gabapentin
If a woman has vasomotor and vulvovaginal Sx, how do you treat
Basically combine the two !
