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Therapeutics > Lecture 35: Menopausal Hormone Therapy > Flashcards

Lecture 35: Menopausal Hormone Therapy Flashcards

1
Q

Menopause

A

-final menstrual period

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2
Q

Menopause diagnosis confirmed after ___

A

-12 months of amenorrhea

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3
Q

Premenopause

A

-period of endocrine changes BEFORE menstruation stops

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4
Q

Perimenopause (climacteric)

A

-endocrine changes surrounding the menopause

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5
Q

postmenopause

A

-endocrine changes AFTER menstruation stops

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6
Q

Menopause onset age

A

-51 years (40-58)
-40% of woman’s life is postmenopausal

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7
Q

Premature menopause

A

-premature ovarian insufficiency (POI)
-before age 40
-hysterectomy, radiation therapy, chemo
-1%
-inc risk of mortality and morbidity

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8
Q

Worst symptoms of menopause occur

A

within first 1-2 years

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9
Q

menopause symptoms last how long

A

7+ years

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10
Q

Causes of menopause

A

-physiologic
-oophorectomy
-breast cancer chemo
-radiation therapy

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11
Q

Physiologic cause of menopause

A

-deterioration of follicular cells and ova w aging
-dec estrogen and progesterone levels = inc FSH and LH

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12
Q

Clinical presentation of menopause

A

-hot flashes
-night sweats
-irregular menses
-episodic amenorrhea
-sleep disturbance
-mood changes
-fatigue
-vulvovaginal atrophy
-UTI
-dec sex drive
-urinary freq, urgency

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13
Q

Long term consequences of menopause

A

-CV disease (#1 killer of women)
-bone loss
-osteoarthritis
-body comp
-skin changes
-balance

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14
Q

Treatment of Menopausal symptoms

A

-nonpharmacologic therapy
-MHT
-nonhormonal alterntatives

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15
Q

vasomotor symptoms

A

-hot flashes
-night sweats

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16
Q

Recomended nonpharmacologic treatment of menopause

A

-weight loss
-CBT
-clinical hypnosis
-stellate ganglion block (pain management injection)

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17
Q

Scam therapies for menopause

A

-lifestyle changes
-????
this slide ??? 12

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18
Q

Indications for Menopausal Hormone Therapy

A

-Vasomotor symptoms
-Vulvovaginal atrophy
-osteoporosis prevention

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19
Q

ABSOLUTE contraindications to MHT

A

-random vaginal bleeding
-pregnany
-endometrial/breast cancer
-stroke
-thromboembolic disorder
-active liver disease

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20
Q

RELATIVE contraindications to MHT

A

-uterine leiomyoma
-migraine w aura
-seizure disorders
-diabetes
-hypertriglyceridemia
-active gallbladder disease
-high heart disease risk
-family history of breast cancer

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21
Q

Estrogen monotherapy is only to be used on

A

women WITHOUT a uterus

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22
Q

Estrogen monotherapy dosage forms

A

-oral
-transdermal
-topical
-intravaginal
-IM injections

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23
Q

Oral estrogen monotherapy products

-more side effects

A

-Premarin (conjugated)
-Menest (esterified)
-Estrace (micronized)

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24
Q

Transdermal Estrogen monotherapy produts

-preferred

A

-Climara
-Lyllana
-Menostar
-Minivelle
-Vivelle-dot
-Dotti

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25
Topical estrogen monotherapy products -less used bc absorption varies and kids can get into it
-Estrogel -Divigel -Elestrin -Evamist (spray)
26
Vaginal estrogen monotherapy products
-cream (estrace, premarin) -insert (Imvexxy) -tablet (vagifem, yuvafem) -ring (estring, femring)
27
IM estrogen monotherapy injections -more used for gender care -try the other ones first
-estradiol cypionate (depo-estradiol) -estradiol valerate (deletrogen)
28
Topical ESTROGEN vaginal products should be prescribed for:
-women EXCLUSIVELY experiencing vulvovaginal atrophy
29
PROGESTIN should be prescribed to
-women WITH uterus -in addition to estrogen to dec risk of endometrial cancer
30
Concerns w hormone use
-women's health initiative study
31
WHI purpose
-address common causes of death and poor quality of life for postmenopausal women -15 year trials and studies -effects of hormone therapy, diet, and calcium/vit D
32
WHI estrogen and progesterone therapy effects
-inc CV disease (esp thromboembolism) -inc some cancer -dec colorectal cancer -dec hip fractures
33
WHI estrogen monotherapy effects
-inc CV but not really CHD -no difference in cancer -dec in hip fractures
34
Critical factors in determining whether hormone therapy reduces or inc risk of CHD
-time since menopause -age of initiation -no effect on cancer risk tho
35
risk of estrogen monotherapy for women <60 within 10 years of menopause
-no evidence of CHD
36
risk of estrogen monotherapy for women >10 years of menopause
-inc risk of CHD within the first 2 years
37
Highest risk group for CHD from estrogen monotherapy
-women 70-79 and >20 years of menopause
38
Risk of estrogen monotherapy on women w CHD
-no additional benefits
39
estrogen w progestin therapy age group risks
-lowkey same as estrogen monotherapy?
40
risk of breast cancer in women with a uterus
-increase -no difference in mortality
41
risk of breast cancer in women w hysterectomy
-decreased -no change in mortality
42
MHT current recommendations
-women UNDER 60 -OR -within 10 years of last period
43
Methods of estrogen/progestin admin
-continuous cyclic therapy -continuous long cycle -continuous combined
44
Continuous CYCLIC therapy (e+p)
-sequential treatment -estrogen daily -progesterone 12-14 days out of a 28 day cycle -mimic cycle -scheduled withdrawal bleeding
45
Continuous CYCLIC therapy preferred in
-recently menopausal women
46
Continuous CYCLIC therapy products (e+p)
-Premphase -Combipatch
47
Premphase
-Continuous CYCLIC -oral -conjugated ESTROGENS -medroxyPROGESTERONE acetate
48
Combipatch
-continuous CYCLIC -Transdermal -Estradiol -norethindrone acetate (progestin)
49
Continuous LONG cycle therapy (e+p)
-RARE -"cyclic withdrawal" -estrogen daily -progesterone + estrogen for 12-14 days every OTHER month -6 bleedings per year -limited safety data
50
Continuous COMBINED therapy (e+p)
-estrogen AND progesterone daily -endometrial atrophy = no bleeding -unpredictable spotting that goes away 6-12 months -drug free period of 1-2 weeks may help stop bleeding
51
Continuous COMBINED therapy recommended for
-women >2 years post-final menstrual period -best long term endometrial protection
52
Continuous Combined products
-slide 32
53
Progestin for endometrial protection
-medroxyprogesterone (oral) Provera -norethindrone acetate (oral) Aygestin -micronized progestin (oral) (preferred) PROmetrium (peanut oil warning) -levonorgestrel (vaginal) Mirena IUD -progesterone gel (vaginal) Crinone
54
Estrogen and SERM
-tissue-selective estrogen complex (TSEC) -treat menopausal symptoms -prevent bone loss in women w uterus
55
Selective estrogen receptor modulator (SERM)
-non-hormonal -bone agonist -breast and uterus antagonist -dec risk of endometrial cancer -stroke risk? -overweight women might not work on
56
Estrogen and SERM side effects
-GI disorders -muscle spasm -neck pain -dizzines -oropharyngeal pain
57
Estrogen and SERM product
-Duavee -oral -conjugated estrogen -bazedoxifene (SERM)
58
Preferred MHT regimen
-transdermal estrogen +/- progestin
59
Why is transdermal estrogen +/- progetin preferred
-less thromboembolic risk, stroke, heart attack -less headache -less breast tenderness -good for GI intolerance bc it not oral
60
transdermal estrogen +/- progestin considerations
-hypertiglyceridemia -liver disease -gall bladder disease
61
side effects of transdermal estrogen
-skin irritation -skin transfer possible (topical)
62
Alternative MHT regimen
-bazedoxifene + estrogen
63
bazedoxifene + estrogen pros
-avoid vaginal bleeding -less breast tenderness -less altered mood
64
Alternative MHT regimen
-oral estrogen +/- progestin -systemic vaginal estrogen +/- progestin
65
Recommended treatment duration of MHT
-no set duration -suggest to avoid in women over 65 -weigh cost vs benefits -evaluate annually -consider periodic trials of tapering ot changing to lower dose/transdermal route -MHT for 5-7 years did not affect mortality
66
Alternatives for vasomotor symptoms that are NOT recommended
-black cohosh (liver toxicity) -dong quai (inc risk of bleed w warfarin)
67
Recommended alternatives for vasomotor symptoms
-gabapentin -oxybutynin -SSRI/SNRI -fezolinetant
68
SSRI/SSNRI use for
-hot flashes (vasomotor) -drug of choice if NO estrogen treatment
69
Avoid paroxetine with
Tamoxifen (breast cancer drug)
70
Strong CYP2D6 (paroxetine) inhibitors reduce efficacy of
Tamoxifen (breast cancer drug)
71
SSRIs
-Paroxetine (Brisdelle, Paxil, Pexeva) (7-15mg) (FDA) approved for menopause) -Citalopram (10-30mg) -Escitalopram (10-20mg)
72
SNRIs (serotonin and norepinephrine reuptake inhibitors)
-venlafaxine (Effexor) 37.5mg-150mg/day -desvenlafaxine (Pristiq) 50-100 -duloxetine (Cymbalta) 60
73
side effects of SNRIs
-dry mouth -anorexia -nausea -constipation
74
Fezolinetant (Veozah)
-NK3R ANTAgonist -mod-severe vasomotor symptoms -take w CYP1A2 inhibitors -45mg PO qd
75
KDNY neurons
-innervate thermoreg center in hypothalamus -stimulated by neurokinin B (NKB) -inhibited by estrogen
76
Inc vasomotor symptoms caused by
-dec estrogen in menopause leads to unopposed NKB stimulation
77
Fezolinetant (Veozah) contraindications
-known cirrhosis -severe renal probs -must check liver function before starting at 3/6/9 months
78
Fezolinetant (veozah) side effects
-inc LFT -ab pain -diarrhea -insomnia -back pain -hot flash -expensive
79
Fezolinetant (veozah) contraindicated if LFT is greater than or equal to
2 -checked annually
80
Bio-identical hormone replacement therapy
-compounds w unique mix of estradiol, estrone, estriol, progesterone -minimal insurance coverage -only 1 FDA approved -lack of data
81
Bio-identical hormone replacement therapy product
-Bijuva -oral -estradiol 0.5-1mg -micronized progestin 100mg
82
Recommended menopausal symptom management for women within 10 years of menopause and low CVD
-may use MHT -oral or transdermal
83
Recommended menopausal symptom management for women within 10 years of menopause w moderate CVD risk
-transdermal estrogen -avoid oral
84
Recommended menopausal symptom management for women w high CVD risk
-avoid oral MHT -if genitourinary symptoms: low dose vaginal estrogen
85
AVOID systemic MHT for women with
-high CV risk -mod-high risk breast cancer risk
86
Genitourinary Syndrome of Menopause (GSM) first line treatments (nonhormonal)
-lubricants -vaginal moisturizers (2-3/week)
87
Genitourinary Syndrome of Menopause (GSM) second line treatments (estrogen)
-topical cream/ring/tablet -low dose oral contraceptive
88
Drugs for mod-severe Dyspareunia (painful intercourse)
-Ospemifene (oral) -Prasterone (vaginal)
89
Ospemifene (osphena)
-treat dyspareunia -SERM -vagina and uterus agonist -60mg PO wf
90
Ospemifene (osphena) recommended for
-POSTmenopausal women
91
Ospemifene (osphena) black box warning
-endometrial cancer -stroke -VTE
92
Ospemifene (Osphena) side effects
-vaginal discharge -endometrial hyperplasia -hot flashes (7-12%) -similar precautions to estrogen therapies
93
Prasterone (Intrarosa)
-inactive Dehydroepiandrosterone (DHEA) converted to active estrogens and androgens -intravaginal qd at bedtime -no black box warning -POST menopausal women
94
Prasterone (intrarosa) contraindications
-undiagnosed vaginal bleeding -avoid if history of breast cancer
95
Which is first line for GSM??
idk man
96
Genitourinary syndrome of menopause
-vulvovaginal atrophy -urinary tract dysfunction -sexual dysfunction -urinary freq/urgency
97
USPSTF graded estrogen D in PREVENTION of chronic conditions in postmenopausal women
-NO BENEFIT of estrogen + progesterone in women w INTACT uterus -NO BENEFIT of estrogen alone in hysterectomy
98
eSTRING vs femRING***
-RING is bigger than STRING -femRING has bigger systemic absorption =can relieve vasomotor symptoms -gotta put a girlie on progesterone w this one

Therapeutics (78 decks)

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