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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
Q

Topical estrogen monotherapy products

-less used bc absorption varies and kids can get into it

A

-Estrogel
-Divigel
-Elestrin
-Evamist (spray)

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26
Q

Vaginal estrogen monotherapy products

A

-cream (estrace, premarin)
-insert (Imvexxy)
-tablet (vagifem, yuvafem)
-ring (estring, femring)

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27
Q

IM estrogen monotherapy injections

-more used for gender care
-try the other ones first

A

-estradiol cypionate (depo-estradiol)
-estradiol valerate (deletrogen)

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28
Q

Topical ESTROGEN vaginal products should be prescribed for:

A

-women EXCLUSIVELY experiencing vulvovaginal atrophy

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29
Q

PROGESTIN should be prescribed to

A

-women WITH uterus
-in addition to estrogen to dec risk of endometrial cancer

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30
Q

Concerns w hormone use

A

-women’s health initiative study

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31
Q

WHI purpose

A

-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

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32
Q

WHI estrogen and progesterone therapy effects

A

-inc CV disease (esp thromboembolism)
-inc some cancer
-dec colorectal cancer
-dec hip fractures

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33
Q

WHI estrogen monotherapy effects

A

-inc CV but not really CHD
-no difference in cancer
-dec in hip fractures

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34
Q

Critical factors in determining whether hormone therapy reduces or inc risk of CHD

A

-time since menopause
-age of initiation

-no effect on cancer risk tho

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35
Q

risk of estrogen monotherapy for women <60 within 10 years of menopause

A

-no evidence of CHD

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36
Q

risk of estrogen monotherapy for women >10 years of menopause

A

-inc risk of CHD within the first 2 years

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37
Q

Highest risk group for CHD from estrogen monotherapy

A

-women 70-79 and >20 years of menopause

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38
Q

Risk of estrogen monotherapy on women w CHD

A

-no additional benefits

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39
Q

estrogen w progestin therapy age group risks

A

-lowkey same as estrogen monotherapy?

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40
Q

risk of breast cancer in women with a uterus

A

-increase
-no difference in mortality

41
Q

risk of breast cancer in women w hysterectomy

A

-decreased
-no change in mortality

42
Q

MHT current recommendations

A

-women UNDER 60
-OR
-within 10 years of last period

43
Q

Methods of estrogen/progestin admin

A

-continuous cyclic therapy
-continuous long cycle
-continuous combined

44
Q

Continuous CYCLIC therapy (e+p)

A

-sequential treatment
-estrogen daily
-progesterone 12-14 days out of a 28 day cycle
-mimic cycle
-scheduled withdrawal bleeding

45
Q

Continuous CYCLIC therapy preferred in

A

-recently menopausal women

46
Q

Continuous CYCLIC therapy products (e+p)

A

-Premphase
-Combipatch

47
Q

Premphase

A

-Continuous CYCLIC
-oral
-conjugated ESTROGENS
-medroxyPROGESTERONE acetate

48
Q

Combipatch

A

-continuous CYCLIC
-Transdermal
-Estradiol
-norethindrone acetate (progestin)

49
Q

Continuous LONG cycle therapy (e+p)

A

-RARE
-“cyclic withdrawal”
-estrogen daily
-progesterone + estrogen for 12-14 days every OTHER month
-6 bleedings per year
-limited safety data

50
Q

Continuous COMBINED therapy (e+p)

A

-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
Q

Continuous COMBINED therapy recommended for

A

-women >2 years post-final menstrual period
-best long term endometrial protection

52
Q

Continuous Combined products

A

-slide 32

53
Q

Progestin for endometrial protection

A

-medroxyprogesterone (oral) Provera
-norethindrone acetate (oral) Aygestin
-micronized progestin (oral) (preferred) PROmetrium (peanut oil warning)
-levonorgestrel (vaginal) Mirena IUD
-progesterone gel (vaginal) Crinone

54
Q

Estrogen and SERM

A

-tissue-selective estrogen complex (TSEC)
-treat menopausal symptoms
-prevent bone loss in women w uterus

55
Q

Selective estrogen receptor modulator (SERM)

A

-non-hormonal
-bone agonist
-breast and uterus antagonist
-dec risk of endometrial cancer
-stroke risk?
-overweight women might not work on

56
Q

Estrogen and SERM side effects

A

-GI disorders
-muscle spasm
-neck pain
-dizzines
-oropharyngeal pain

57
Q

Estrogen and SERM product

A

-Duavee
-oral
-conjugated estrogen
-bazedoxifene (SERM)

58
Q

Preferred MHT regimen

A

-transdermal estrogen +/- progestin

59
Q

Why is transdermal estrogen +/- progetin preferred

A

-less thromboembolic risk, stroke, heart attack
-less headache
-less breast tenderness
-good for GI intolerance bc it not oral

60
Q

transdermal estrogen +/- progestin considerations

A

-hypertiglyceridemia
-liver disease
-gall bladder disease

61
Q

side effects of transdermal estrogen

A

-skin irritation
-skin transfer possible (topical)

62
Q

Alternative MHT regimen

A

-bazedoxifene + estrogen

63
Q

bazedoxifene + estrogen pros

A

-avoid vaginal bleeding
-less breast tenderness
-less altered mood

64
Q

Alternative MHT regimen

A

-oral estrogen +/- progestin
-systemic vaginal estrogen +/- progestin

65
Q

Recommended treatment duration of MHT

A

-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
Q

Alternatives for vasomotor symptoms that are NOT recommended

A

-black cohosh (liver toxicity)
-dong quai (inc risk of bleed w warfarin)

67
Q

Recommended alternatives for vasomotor symptoms

A

-gabapentin
-oxybutynin
-SSRI/SNRI
-fezolinetant

68
Q

SSRI/SSNRI use for

A

-hot flashes (vasomotor)
-drug of choice if NO estrogen treatment

69
Q

Avoid paroxetine with

A

Tamoxifen (breast cancer drug)

70
Q

Strong CYP2D6 (paroxetine) inhibitors reduce efficacy of

A

Tamoxifen (breast cancer drug)

71
Q

SSRIs

A

-Paroxetine (Brisdelle, Paxil, Pexeva) (7-15mg) (FDA) approved for menopause)
-Citalopram (10-30mg)
-Escitalopram (10-20mg)

72
Q

SNRIs (serotonin and norepinephrine reuptake inhibitors)

A

-venlafaxine (Effexor) 37.5mg-150mg/day
-desvenlafaxine (Pristiq) 50-100
-duloxetine (Cymbalta) 60

73
Q

side effects of SNRIs

A

-dry mouth
-anorexia
-nausea
-constipation

74
Q

Fezolinetant (Veozah)

A

-NK3R ANTAgonist
-mod-severe vasomotor symptoms
-take w CYP1A2 inhibitors
-45mg PO qd

75
Q

KDNY neurons

A

-innervate thermoreg center in hypothalamus
-stimulated by neurokinin B (NKB)
-inhibited by estrogen

76
Q

Inc vasomotor symptoms caused by

A

-dec estrogen in menopause leads to unopposed NKB stimulation

77
Q

Fezolinetant (Veozah) contraindications

A

-known cirrhosis
-severe renal probs

-must check liver function before starting at 3/6/9 months

78
Q

Fezolinetant (veozah) side effects

A

-inc LFT
-ab pain
-diarrhea
-insomnia
-back pain
-hot flash
-expensive

79
Q

Fezolinetant (veozah) contraindicated if LFT is greater than or equal to

A

2
-checked annually

80
Q

Bio-identical hormone replacement therapy

A

-compounds w unique mix of estradiol, estrone, estriol, progesterone
-minimal insurance coverage
-only 1 FDA approved
-lack of data

81
Q

Bio-identical hormone replacement therapy product

A

-Bijuva
-oral
-estradiol 0.5-1mg
-micronized progestin 100mg

82
Q

Recommended menopausal symptom management for women within 10 years of menopause and low CVD

A

-may use MHT
-oral or transdermal

83
Q

Recommended menopausal symptom management for women within 10 years of menopause w moderate CVD risk

A

-transdermal estrogen
-avoid oral

84
Q

Recommended menopausal symptom management for women w high CVD risk

A

-avoid oral MHT
-if genitourinary symptoms: low dose vaginal estrogen

85
Q

AVOID systemic MHT for women with

A

-high CV risk
-mod-high risk breast cancer risk

86
Q

Genitourinary Syndrome of Menopause (GSM) first line treatments (nonhormonal)

A

-lubricants
-vaginal moisturizers (2-3/week)

87
Q

Genitourinary Syndrome of Menopause (GSM) second line treatments (estrogen)

A

-topical cream/ring/tablet
-low dose oral contraceptive

88
Q

Drugs for mod-severe Dyspareunia (painful intercourse)

A

-Ospemifene (oral)
-Prasterone (vaginal)

89
Q

Ospemifene (osphena)

A

-treat dyspareunia
-SERM
-vagina and uterus agonist
-60mg PO wf

90
Q

Ospemifene (osphena) recommended for

A

-POSTmenopausal women

91
Q

Ospemifene (osphena) black box warning

A

-endometrial cancer
-stroke
-VTE

92
Q

Ospemifene (Osphena) side effects

A

-vaginal discharge
-endometrial hyperplasia
-hot flashes (7-12%)

-similar precautions to estrogen therapies

93
Q

Prasterone (Intrarosa)

A

-inactive Dehydroepiandrosterone (DHEA) converted to active estrogens and androgens
-intravaginal qd at bedtime
-no black box warning
-POST menopausal women

94
Q

Prasterone (intrarosa) contraindications

A

-undiagnosed vaginal bleeding
-avoid if history of breast cancer

95
Q

Which is first line for GSM??

A

idk man

96
Q

Genitourinary syndrome of menopause

A

-vulvovaginal atrophy
-urinary tract dysfunction
-sexual dysfunction
-urinary freq/urgency

97
Q

USPSTF graded estrogen D in PREVENTION of chronic conditions in postmenopausal women

A

-NO BENEFIT of estrogen + progesterone in women w INTACT uterus
-NO BENEFIT of estrogen alone in hysterectomy

98
Q

eSTRING vs femRING***

A

-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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