HRT Flashcards
Perimenopausal cycles are associated with
Elevated and irregular follicle-stimulating hormone
Decreased inhibin
Normal luteinizing hormone
Slightly elevated estradiol levels
Menopause is considered to have occurred when there is no menses for
12 months
The average age of menopause is
51 years of age (95% between ages of 45 and 55 years).
Vasomotor symptoms are caused by
fluctuations in estrogen levels
Vaginal changes are caused by
low estrogen levels
Primary goal of MHT
relieve hot flashes but can help with sleep disturbances, mood lability/depression, and in some cases, joint aches and pains
Hot flashes require
systemic estrogen, GU syndrome of menopause (GSM) – treat with low-dose vaginal estrogen
Exogenous estrogens work like endogenous estrogens - Examples
Estradiol
Equine estrogen
Esterified and micronized estrogen
Exogenous progestins work like endogenous progestins - Examples
Medroxyprogesterone
Norethindrome
Micronized progesterone
HRT: Goals of Treatment
Provide relief from symptoms associated with menopause. Prevent or reduce vasomotor symptoms. Prevent or reduce vaginal atrophy. Reduce risk for osteoporosis. Ensure benefits of HRT outweigh risks.
Guidelines for indvidual approach
Based upon calculating women’s baseline CV and baseline risk prior to initializing therapy
Menopausal hormonal therapy (MHT) indicated for management of menopausal symptoms but not the prevention of CVD, osteoporosis, or dementia
Benefits outweigh risk for most symptomatic women who are either under age 60 y.o. or less than 10 years from menopause
Cardiac disease:
HRT not recommended
Breast cancer:
HRT may promote it; inconclusive evidence in younger women, but definite in older adults
Colon cancer:
HRT decreases risk
Osteoporosis:
HRT reduces risk but is not primary reason
Vasomotor symptoms and vaginal atrophy
HRT improves symptoms
Cognitive performance, sleep disturbances, and skin changes - HRT
inconsistent data
HRT: Rational Drug Selection
Use lowest dose that relieves symptoms for shortest time (up to 5 years in menopause; longer with surgical menopause).
Extended use of MHT should be individualized and not based solely on age (North American Menopause Society and the American college of Obstetrics and Gynecology).
Individualize the drug choice and dose based on patient’s risk profile.
Monitor patient annually.
Tapering versus abrupt stopping
Estrogen Therapy - Relief of
Relief of peri-menopausal/post-menopausal symptoms
Estrogen Therapy all types of
All types of estrogen are effective for relieving hot flashes
Estrogen Therapy - Route
Route – oral, transdermal, topical gels and lotions, and vaginal rings
Estrogen Therapy started on
Started on lowest dose (typically oral or transdermal).
Lower doses are associated with less vaginal bleeding, breast tenderness, fewer effects on coagulation and inflammatory markers, and a possible lower risk of stroke and VTE than standard-dose therapy
Estrogen Therapy NO
NO unopposed estrogen to women with intact uterus
Estrogen Therapy avoid in women with
Avoid in women with hypertriglyceridemia, active gallbladder disease, or known thrombophilia
Estrogen Therapy transdermanl
Transdermal estrogen preferred in women with migraine headaches with auras.
Estrogen Therapy symptoms start
Symptoms start to improve in 2 weeks, reach maximal effect in 8 weeks
Estrogen Therapy phytoestrongens
Phytoestrogens
Red clover, soy, and black cohosh have inconsistent results.
Estrogen Therapy Botanicals/herbals
Botanicals/herbals
Black cohosh and chaste tree fruit have inconsistent results.
Estrogen Therapy can be used to treat
Vulvovaginal atrophy and dryness
Low-dose estrogen (0.3 to 0.625 mg daily) alleviates symptoms.
Vaginal application of estrogen (ring or cream form) can improve symptoms in as little as 2 weeks.
Topical application is preferred because of lower overall estrogen dose and no systemic effect.
Estrogen Therapy - Increased risk for
Increased risk for endometrial cancer with unopposed oral estrogen
Estrogen Therapy increase in risk for coronary heart disease with
Increase in risk for coronary heart disease risk with combination HRT
May be related to onset and length of therapy
Estrogen Therapy increased risk of strok and
Increased risk of stroke and thromboembolic events
Progestin Therapy - All women with an
intact uterus need a progestin to be added to their estrogen to prevent endometrial hyperplasia, which can occur after as little as six months of unopposed estrogen (KNOW)
Progestin-alone is used for
contraception or menorrhagia
Progestin Combined with estrogen
to treat perimenopausal or postmenopausal women
Combined Estrogen/Progestin Therapy options
Multiple combinations are available.
Cyclical or sequential therapy is used if breakthrough bleeding is a problem.
Estrogen is taken daily.
Medroxyprogesterone is taken for part of the cycle (10 to 12 days, 14 days, or Monday through Friday).
Estrogen is started at low dose (0.3 mg) every other day for 2 months and then daily for 2 months before increasing dose.
Testosterone Therapy
If hot flashes do not improve with HRT/estrogen therapy, then adding testosterone may help
Testosterone Therapy is combined with
is combined with estrogen
Testosterone Therapy alone may cause
Testosterone-alone may cause masculinizing.
Testosterone Therapy - what is an issue
Acne is an issue.
Menopausal Hormone Therapy Risks
Cardiovascular events: Myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis Endometrial cancer Breast cancer Ovarian cancer Gallbladder disease Dementia Urinary incontinence
HRT - Use for Approved Indications
Treatment of moderate to severe vasomotor symptoms associated with menopause
Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with menopause
Prevention of postmenopausal osteoporosis
IMPORTANT note when Treating Menopause with Hormones - Check
Check lab work along with pt. history and exam to verify pt. IS in menopause
Hormone levels consistent with menopause
Menopausal symptoms – sleep disturbances, hot flashes, mood swings, headaches in combination
Amenorrhea for greater than 12 months or menstrual irregularity with periods of amenorrhea (peri-menopause)
IMPORTANT note when Treating Menopause with Hormones - if patient has
HAS uterus - use combined estrogens for treatment
This protects against endometrial hyperplasia and cancer
IMPORTANT note when Treating Menopause with Hormones - if patient does not have
DOES NOT have a uterus – estrogen alone therapy is recommended hormone treatment
IMPORTANT note when Treating Menopause with Hormones - KEE in mind
we can also treat menopause symptoms with NON-hormonal therapies such as antidepressants, herbals and other alternative therapies if pts choose to treat menopause without hormones.
HRT Monitoring - Annual complete
history and physical, including pelvic examination (Papanicolaou test per other guidelines)
HRT Monitoring - Annual
Annual mammography
HRT Monitoring - Liver
Liver function tests at baseline
HRT Monitoring Lipid
Lipid profile at baseline
HRT Monitoring women older than 45
Women older than age 45 years should be screened for type 2 diabetes mellitus.
HRT Monitoring - Abnormal uterine
bleeding requires uterine biopsy.
