Lecture 7 - Menopause Flashcards by Patryk Lasiuk

Definition of Menopause

permanent cessation of menses resulting from loss of ovarian follicular activity

12 consecutive months of amenorrhea (w/o menstruation)

avg age 51, premature if before 40

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menopausal transition

period of gradually declining ovarian function

cyce irregularity

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Perimenopausal

immediately prior to and 1 year after menopause

start to experience symptoms

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Hormonal changes menopause

Estradiol 90% dec = dec estrogen, progesterone, androgens

FSH = 10-15X inc

LH = 4-5X inc

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3 main categories of Perimenopausal changes

CNS = headache, sleep and mood swings/depression anxiety
Vasomotor symptoms
Genitourinary syndrome of menopause (GSM)

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Can you use estrogen of migraine with aura?

nah dont wanna use

if no aura, transdermal estrogen would be preferred

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medication related causes of hot flashes?

Tamoxifen = cancer
Raloxifene = osteoporosis
Androgen derivative therapy = prostate cancer

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Hot flash risk factors

Early/surgical menopause
High BMI, sedentary lifestyle
Smoking
Stress, Anxiety, depression

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Pathophysiology of GSM?

Dec vag secretions
inc vag pH

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Symptoms of GSM

Genital dryness, burning, irritation
sexual lack of lub, impaired function
Inc urgency and frequency, UTI

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Mild Vasomotor symptoms….Life style medications

Avoid triggers = Spicy foods**
reduce tobacco and alc
Dress in layers
Drink cold water
Dec room temp
Relaxation/stress reduction

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If Moderate/Severe Vasomotor symptoms….MHT

reduce freq by 75% and severity by 87%

Limit txm to time of symptoms at lowest dose needed**

Benefits dissipate quickly once stopping txm, gradually dec or lengthen dose interval

consider d/c after 5 yrs or >60

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CI for Estrogen MHT

Breast cancner
DVT/PE
Stroke/MI w/I 1yr
Liver dysfunction
Migraine with aura

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Continuous MHT oral

cycle = Premarin
content = estrogen every day
Comment = only for women who had hysterectomy

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Contiuous cyclic MHT oral

cycle = Premphase
content = estrogen every day, progesterone every 12-14 days
Comments = scheduled withdrawal bleeding, 1-2 after stop progesterone

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Continuous combined MHT oral

Cycle = prempro
Content = estrogen and progesterone every day
Comments = unpredictable bleeding or spotting for 6-12 months, then stop

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Continuous/EAA MHT oral

Cycle = Duavee
Content = Estrogen + Estrogen agonist/antagonist every day
Comment = vasomotor symptoms and osteoporosis prevention

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Situation where transdermal patch might be preferred

used where you want lower DVT/CVD risk, lower TG

preferred pts who have migraines w/o aura

Note on Estrogen only patch

must be combined with oral progestogen if uterus intact

important info about creams and rings?

High dose and low dose formulations and directions

For vag creams, if vasomotor symptoms then use….

high dose formulations
progestogen if uterus intact

For vag ring/cream/gels, if vag symptoms then use…

low dose formulations
dont need progestogen

Duavee (Estrogen/Bazedoxifine) indication

moderate/severe hot flashes
Prevention of osteoporosis

Duavee CI

Breast cancer
thromboembolism
Abrnomal uterine bleeding

Duavee warnings

Dont take additional estrogens Cancer ( endometrial, breast, ovarian) Gallbladder disease D/c if vision changes, jaundice or high TGs

Paroxetine mesylate (Brisdelle) Indications and interactions

moderate/severe hot flashes CYP2D6 inhib = dec conversion of tamoxifen to active metabolite only FDA approved

Paroxetine mesylate (Brisdelle) warnings

box warning = suicidal thoughts Hyponatremia bleeding bone fractures manic symptoms

Paroxetine mesylate SE

anticholinergic effects sweating, dec libido, Headache, dizziness, Nausea,tiredness

Black Cohosh MOA

mixed competitive agonist activity at serotonin receptor possible estrogenic activity

Black Cohosh Efficacy

questionable

Black Cohosh Efficacy

questionable may reduce freq compared to baseline but not placebo

Black Cohosh Safety

CI = breast cancer Recommend periodic LFT due to contamination

Soy for hotflash

Protein >> Supplements mod dec severity and frequency Takes 1-2 months to see effect not effective in photoflash related to Breast cancer treatment ** women with estrogen-dependent cancers should avoid soy supplements**

Bioidenticals

not really recommended or FDA approved

GSM mild symptoms non-pharm

pelvic floor exercises vag dilator therapy vag activity inc bood flow to vag

GSM mild symptoms, things that provide symptomatic relief

Apply lube before sex apply moisturizers 2-3 times per week to vag ** Avoid natural oils due to inc risk of infections **

GSM moderate/severe symptom treatmetns

Low dose vag estrogen takes 1-2weeks for improvement, 3-4 months full effect Progestogen not indicated, efficacy similar among products avoid women h/o breast cancer until talk with oncologist

When can vag creams for GSM be preferred

if atrophy of vulva in addition to vagina can be messier, but more flexible with dosing and admin freq

When are Vag rings indicated GSM?

indicated for LUTS as well as vag symptoms placed by provider

Ospemifene (Osphena) used specifically for

painful sex or dry vag

Ospemifene CI

Endometrial cancer CVD, H/o of MI/stroke H/o of DVT/PE breast cancer

Ospemifene SE

Hot flash endometrial hyperplasia muscle spasm vag discharge hyperhidrosis stroke/DVT Endometrial cancer

Prasterone (Intrarosa)

insert used for pain during sex DHEA = converted into estrogen and androgen in vag tissue Oral is not equal