Menopause

Question 1

menopause

Answer 1

physiologic event that occurs one year after having menses

FSH>/ 40 IU, decline or cessation in ovarian function

Question 2

peri menopause

Answer 2

immediately prior to menopause after 1st year after menopause begins, characterized by annovulatory bleeding

Question 3

menopause patho

Answer 3

aging-> decrease in ovulatory ufnction
no estradiol or progesterone, just testosterone
cause rise in FSH and LH

Question 4

clinical presentation

Answer 4

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

Question 5

FDA indications for hormone therapy

Answer 5

systemic (oral) HT: treatment of moderate to severe VMS +/- GSM

intravaginal HT: moderate to severe GSM

Question 6

absolute CI to HT

Answer 6

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

Question 7

non pharm menopause therapy for VMS and GSM

Answer 7

VMS: CBT, hypnosis, weightloss

GSM: non hormonal vag lubricants and moisturizers

Question 8

two types of HT

Answer 8

estrogen alone

E+P

Question 9

estrogen in HT pearls

Answer 9

1. use lowest effective dose for symptom control
2. ae: start low and change formulation if AE
3. types: systemic: for mod-severe VMS +/-GSM

vaginal/local: for mod -severe GSM

Question 10

progesterone in VT perasl

Answer 10

1. must be given to every woman wit intact uterus due to risk of estrogen induced endometrial hyperplasia
2. 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)

Question 11

diff type of progesterone regimens

continuous cyclic

Answer 11

E daily,, P given last 12-14 days of every cycle

Question 12

diff type of progesterone regimens

continuous combines

Answer 12

MOST common

E+p daily

reserve for woman 2 years post menopause cause less than tht can have increased risk for spotting and bleeding

Question 13

when is HT indicated

Answer 13

has indication, no CI, <60 y.o, within 10 years of onset of menopause

Question 14

diff type of progesterone regimens

continuous long cycle

Answer 14

E daily, P given last 12-14 days of every OTHER cycle. 6 periods a year

Question 15

diff type of progesterone regimens

intermittent combined

Answer 15

3 days of Ealone, followed by 3 days of combined E+P

Question 16

women health initiative

Answer 16

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

Question 17

HT for VMS

goals/duration

Answer 17

duration should be <5 years

Question 18

HT for GSM

Answer 18

loe dose vaginalle E does not require progestin

if using long term, may require intermittent p

Question 19

pt counseling for ht

Answer 19

systemic HT is highly effective in alleviating VMS+/-GSM

limit therapy for < 5 years

Question 20

D/C of HT

Answer 20

should be tapered over 3-6 mo after 4-5 years of therapy

Question 21

how to determine whether to treat

Answer 21

1. determine if thwyhave an indication

a. systemic : mod-severe VSM+/- GSM
b. local: mod-severe GSM only

2. 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

3. 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

Question 22

HT therapy algorithm for VMS only

Answer 22

1. VMS
   mild: non pharm
   mod-determine if they have CI
2. 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

Question 23

HT therapy algorithm for VSM + GSM

Answer 23

1. VSM + GSM
   mild: non pharm
   mod-determine if they have CI
2. 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

Question 24

HT algorithm for GSM symptoms

Answer 24

1. GSM

mild: vaginal moisturizers and lubricants
moderate-severe: vaginal estrogen preparations with low estrogen systemic exposure or ospemifene or prasterone

Question 25

additional therapies for treatment of menopause

Answer 25

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

Question 26

risk and clinical benefits of alternative options

general

Answer 26

estradiol only one that increases risk of breast cancer

all have bone benefits, increase lipid liver,