Menopause Flashcards
menopause
physiologic event that occurs one year after having menses
FSH>/ 40 IU, decline or cessation in ovarian function
peri menopause
immediately prior to menopause after 1st year after menopause begins, characterized by annovulatory bleeding
menopause patho
aging-> decrease in ovulatory ufnction
no estradiol or progesterone, just testosterone
cause rise in FSH and LH
clinical presentation
vasomotor symptoms(hot flashes, night sweats. occurs 12-14 months after stopped period)
genitourinary syndome menopause
a.genital: dryness, burning, irritation (vulvovaginal atrophy)
urinary sexual symptoms: dysuria, urgency, recurrentUTI
other. menstrual irregularity sleep disturbances mood changes difficulty with concentration and memory osteoporosis
FDA indications for hormone therapy
systemic (oral) HT: treatment of moderate to severe VMS +/- GSM
intravaginal HT: moderate to severe GSM
absolute CI to HT
undx abnormal bleeding
known, suspected, or hx of breast cancer
known or suspected estrogen or progesterone neoplasia
active history of VTE
active or recent arterial thromboembolic disease( MI or stroke)
liver function or disease
non pharm menopause therapy for VMS and GSM
VMS: CBT, hypnosis, weightloss
GSM: non hormonal vag lubricants and moisturizers
two types of HT
estrogen alone
E+P
estrogen in HT pearls
- use lowest effective dose for symptom control
- ae: start low and change formulation if AE
- types: systemic: for mod-severe VMS +/-GSM
vaginal/local: for mod -severe GSM
progesterone in VT perasl
- must be given to every woman wit intact uterus due to risk of estrogen induced endometrial hyperplasia
- dose: given a min. of 12-24 days per month
preparations: systemic/oral
can be used continuously (results in endometrial atrophy ) or cyclically (resulting in atrophy and monthly withdrawal bleeding)
diff type of progesterone regimens
continuous cyclic
E daily,, P given last 12-14 days of every cycle
diff type of progesterone regimens
continuous combines
MOST common
E+p daily
reserve for woman 2 years post menopause cause less than tht can have increased risk for spotting and bleeding
when is HT indicated
has indication, no CI, <60 y.o, within 10 years of onset of menopause
diff type of progesterone regimens
continuous long cycle
E daily, P given last 12-14 days of every OTHER cycle. 6 periods a year
diff type of progesterone regimens
intermittent combined
3 days of Ealone, followed by 3 days of combined E+P
women health initiative
found risksincreased risk of BC/ heart disease and stroke and vte
found benefits, relieved VMS, GSM, decreased hip fracture and osteoporosis, decreased risk of colorectal cancer
HT for VMS
goals/duration
duration should be <5 years
HT for GSM
loe dose vaginalle E does not require progestin
if using long term, may require intermittent p
pt counseling for ht
systemic HT is highly effective in alleviating VMS+/-GSM
limit therapy for < 5 years
D/C of HT
should be tapered over 3-6 mo after 4-5 years of therapy
how to determine whether to treat
- determine if thwyhave an indication
a. systemic : mod-severe VSM+/- GSM
b. local: mod-severe GSM only
- determine if CI
hx of undx abnormal bleeding
known, suspected, or hx of breast cancer
known or suspected estrogen or progesterone neoplasia
active history of VTE
active or recent arterial thromboembolic disease( MI or stroke)
liver function or disease
- decision to initiate
a. are they less than 60?
b. are they within 10 years f the start of menopause
c. do they have risk fo abc or cvd
HT therapy algorithm for VMS only
- VMS
mild: non pharm
mod-determine if they have CI - do they hav CI?
a.yes: non hormonal like SNRI (venlafaxine), SSRI (paroxetine), clonidine, gabapentin/pregabalin
b.no: do they hace a prior hysterechtomy?
I. yes: estradiol acetate IV ring ot systemic estrogen
II. no: oral or transdermal estrogen or estradiol acetate IV ring +progestin OR conjugated estrogen/ bazedoxifene
HT therapy algorithm for VSM + GSM
- VSM + GSM
mild: non pharm
mod-determine if they have CI - do they hav CI?
a.yes: non hormonal like SNRI (venlafaxine), SSRI (paroxetine), clonidine, gabapentin/pregabalin
AND vaginal moisturizers and lubricants
b.no: do they hace a prior hysterechtomy?
I. yes: estradiol acetate IV ring oR systemic estrogen
II. no: oral or transdermal estrogen or estradiol acetate IV ring +progestin OR conjugated estrogen/ bazedoxifene
HT algorithm for GSM symptoms
- GSM
mild: vaginal moisturizers and lubricants
moderate-severe: vaginal estrogen preparations with low estrogen systemic exposure or ospemifene or prasterone
additional therapies for treatment of menopause
Androgens: could possibly increase sex drive
SERMS
a. raloxifene: OP. not VSM
B.OSPEMIFENE dyspaurenia
c.CEE + bazedoxifine: OP and VMS
SSRIs-vasomotor symptoms
SNRI’s: VMS
clonidine: VSM
Gabapentin: VSM
Prasterone (intrarosa): dyspareunia due to menopause
risk and clinical benefits of alternative options
general
estradiol only one that increases risk of breast cancer
all have bone benefits, increase lipid liver,
