HRT, BPH, ED Flashcards
What are the Stages of Menopause?
- Perimenopause
- Menopause
- Post Menopause
Stages of Menopause:
Perimenopause
- When?
- What?
- Few years before last period
- 1-2 years of fluctuating hormones and irregular cyclez
Stages of Menopause:
Menopause
- When?
- Causes?
- Date of last period
- Causes
- Natural depletion of eggs
- Surgical menopause
Stages of Menopause:
Post Menopause
- When?
- What?
- 12 months after last period
- No more bleeding
- Effects of lack of estrogen in body
What are the Effects of Low Levels of Oestrogen?
- Headaches and hot flushes and night sweats
- Increased risk of CVD
- Incontinence
- Mood Swings
- Aches and pains
- Vaginal dryness, itching and shrinking
- Bone loss
Effects of Low Levels of Oestrogen: Increased risk of CVD
- What are Oestrogen’s known effects?
- What happens in menopause?
- Oestrogen’s known effects:
- Increases HDL
- Decreases LDL
- Promotes blood clot formation
- Relaxes, smooths and dilates blood vessels so blood flow increases
- In menopause:
- Changes in the walls of the blood vessels, making it more likely for plaque and blood clots to form
- Changes in the level of lipids in the blood
- Increase in fibrinogen – increase risk of heart disease and stroke
Effects of Low Levels of Oestrogen: Bone loss
- What does oestrogen inhibit?
- What is the role of osteoclasts and what happens in menopause?
- IL-6 - Stimulator for bone resorption
- In menopause, decreased oestrogen levels
- IL-6 starts being active and starts to actively resorb bone
- Osteoclasts – Eats away at bone
- In menopause, decreased oestrogen levels
- Osteoclasts live longer and therefore active in bone resorption
- In menopause, decreased oestrogen levels
What are Preventive Measures in Post-Menopausal Women?
What should be screened?
For CVD what should be evaluated?
- Avoid or quit smoking
- Lose weight
- Exercise for 30-40 mins 3-5 days per week
- Follow a diet low in saturated fat, low in trans-fat and high in fibre, fish and folate rich foods
- Treat and control comorbidities e.g. diabetes, HTN, dyslipidaemia
- Avoid alcohol
- Screen for Breast, colon, ovary and uterus cancer
- Evaluate bone mass
- For CVD
- Family hx
- Risk factors: BP, Smoking, Diabetes, Cholesterol
What is HRT used for?
How is it initiated?
Does it provide contraceptive cover?
- Used to reduce frequency and severity of hot flushes
- Initiated at a low or ultra-low dose to reduce the incidence of adverse effects of oestrogen such as breast tenderness and nausea
- DOES NOT provide contraceptive cover
What are symptoms of Progestin Intolerance?
- Bloating and flatus
- Irritability
- Depression
- Breast tenderness
What are the Management Options for Progestin Intolerance?
- Alternative oral progestin
- Reducing progestin dose (keep in mind the need for endometrial protection)
- Trying a different route of administration e.g. transdermal
What are the Indications for Non-Oral Route in HRT?
- Patient preference
- Poor symptom control with oral treatment
- Adverse effects
- History of, or risk of VTE
- Poorly controlled HTN
- Hypertriglyceridemia
- Current hepatic enzyme inducing agent
- Poor absorption of oral therapy
- History of migraine
- History of gall stones
What are the Goals of Therapy in HRT?
- Trying to treat 3 main symptoms
- Vasomotor symptoms
- Psychological symptoms
- Urogenital atrophy
Goals of HRT:
What are the Treatment options for Vasomotor Symptoms?
- FIRST LINE: HRT
- 2nd Line: SSRIs, SNRIs and clonidine
- Venlafaxine = no HTN effects
- Paroxetine = avoid in women taking tamoxifen
Goals of HRT:
What are the Treatment options for Psychological Symptoms?
Consider HRT, CBT to alleviate low mood/anxiety
Goals of HRT:
What are the Treatment options for Urogenital Atrophy?
- Vaginal oestrogen
- PLUS vaginal moisturisers and lubricants
What are the Benefits of HRT?
- Controls vasomotor symptoms
- Reduces risk of Osteoporosis by protecting BMD
- Protects and stops symptoms of vaginal atrophy
What are the risks of HRT?
- Thromboembolitic disease
- Oral HRT > transdermal
- Consider transdermal for those with risk of VTE
- Breast Cancer
- Risk is high in both women on oestrogen alone and women on oestrogen and progestogen
- Endometrial cancer
- Cardiovascular disease
- Increased risk of MI
- Oral HRT associated with small increase in risk of stroke
- Hypertriglyceridemia
- Oestrogen alone increases triglycerides
What are Contraindications to HRT?
- History of hormone-dependent cancer or active hormone-dependent cancer → Explore other options in these individuals
- History of thromboembolic disease for oral HRT → Safer to use transdermal oestrogen
- Patients with CV and cerebrovascular disease
HRT in Older Women (10 years post menopause)
How is it treated?
Are there any adverse effects?
- Ultra-low dose of oestrogen that’s slowly increased as adverse effects (breast pain and tenderness) resolve or are tolerated
- Initiating, but not continuing, combined HRT in older women is associated with an increase in CV events
- If an older women needs HRT, other CV risks should be addressed concurrently
Cessation of HRT
- Is HRT abruptly ceased?
- What is suggested?
- An abrupt cessation is more likely to be followed by a return of symptoms, especially in women who had severe symptoms before treatment
- Suggest gradual tapering of the HRT dose
- Over 6 weeks (for mild symptoms)
- 6 months (for severe symptoms)
- Unless for medical reasons it has to be stopped abruptly e.g. breast cancer
Are Alternative Therapies good for HRT?
Little evidence to support the use of alternative therapies
What are essential for BPH?
Normally functional testes are essential for BPH
What 3 components contribute to symptoms of BPH?
- Mechanical obstruction by the enlarged prostate
- Dynamic obstruction caused by the tone of the prostatic smooth muscle
- Reaction of the bladder to the obstruction
What are the 2 Groups of Symptoms in BPH?
What are the Symptoms of Each?
- Voiding symptoms
- Hesitancy
- Straining
- Weak or intermittent flow
- Sensation of incomplete emptying
- Bladder storage symptoms
- Urgency
- Frequency
- Nocturia
Before Starting Treatment for BPH, what is done?
- Assess symptom severity using IPSS
- Assess prostate size
- Look for aggravating factors (constipation, diuretics, drugs with anticholinergic effects)
- Non-Pharmacological
- Reduce caffeine and alcohol intake
- Bladder training
- Reducing fluid intake at times when urinary frequency is inconvenient
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Decreases prostate size?
- Alpha adrenergic antagonists: No
- 5-alpha reductase inhibitors: Yes
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Halts Disease Progression?
- Alpha adrenergic antagonists: No
- 5-alpha reductase inhibitors: Yes
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Peak Onset?
- Alpha adrenergic antagonists: 1-6 Weeks
- 5-alpha reductase inhibitors: 3-6 Months
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Efficacy?
- Alpha adrenergic antagonists: ++
- 5-alpha reductase inhibitors: ++ (enlarged prostate)
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Dosing Frequency?
- Alpha adrenergic antagonists: Once Daily
- 5-alpha reductase inhibitors: Once Daily
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Decreases PSA?
- Alpha adrenergic antagonists: No
- 5-alpha reductase inhibitors: Yes
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
Sexual Dysfunction?
- Alpha adrenergic antagonists: +
- 5-alpha reductase inhibitors: ++
Compare and contrast the indications and effects of Alpha adrenergic antagonists and 5-alpha reductase inhibitors
CVS adverse effects?
- Alpha adrenergic antagonists: Yes
- 5-alpha reductase inhibitors: No
What is Erectile Dysfunction?
- Consistent or recurrent inability of a man to attain and/or maintain a penile erection adequate for sexual intercourse
What are the Causes of Erectile Dysfunction?
- Psychogenic (mind)
- Organic
- Neurogenic
- Hormonal
- Vasculogenic
- Drug-induced
What drugs and medical conditions can be associated with ED?
- Diabetes
- HTN
- Depression
- Hyperlipidaemia
- Erectile dysfunction is a risk marker for CVD
