Menopause

Question 1

Menopause symptoms

Answer 1

Hot flashes, mood lability, insomnia, vaginal atrophy

Question 2

Non pharm therapy for menopause

Answer 2

Limited or no evidence but can try: smoking cessation, healthy diet, cooling techniques, exercise, yoga, CBT, weight loss, etc

Question 3

Osteoporosis prevention and menopause

Answer 3

Screen everyone for fracture risk.
Vitamin D 400-800IU and Calcium 1000-1200mg daily
Nonpharm: exercise, stop smoking, diet

Question 4

Non Hormonal Pharm therapy for GSM

Answer 4

Sx: dryness, itchy, irritation, dyspareunia

Potentially useful: lubricant at HS 3x/week or PRN

Question 5

Non Hormonal Pharm therapy for VMS

Answer 5

SSRIs/SNRIs: reduces sx by 25-69%. May also help with mood. Paroxetine best studied and low doses often effective, allow 2-4 weeks for benefit
Gabapentin/Pregabalin: may also help with insomnia and neuropathic pain, relieves VMS better than placebo (54%), but not better than estrogen
Clonidine: least effective option and anticholinergic

Question 6

Herbal products for menopause

Answer 6

Insufficient evidence for all. Probably wont harm but not great either.
Options: black cohosh, chasteberry, dong quai, evening primrose oil, fennel, red clover, soy, wild yam, valerian

Question 7

Hormonal therapy for menopause pearls

Answer 7

Consider HT for <60yrs or <10yrs from MP as benefits>risks
Use shortest duration possible at lowest effective dose
Highly effective for VMS and/or GSM, decreases vasomotor by 50-100%
Increases CV harm when started late vs <6yrs
Add progest to estrogen if intact uterus to prevent endometrial cancer
Consider topical agents if increased CVD risk, smoking, HTN, DM, etc
If last menstrual cycle was < 1 year ago, use 10-14 day progesterone/month, otherwise continuous to avoid monthly withdrawal bleed

Question 8

A/Es, CIs, DIs of hormonal therapy

Answer 8

A/Es: breast tenderness, HA, mood
CIs: breast, endometrial and other hormone dependent cancer, undiagnosed vaginal bleeding, liver dysf, VTE
DIs: 3A4 substrate, 1A2 inhibitor

Question 9

Combo E and P for menopause

Benefits and Harms

Answer 9

Benefits: 
↓total fracture risk (Hip, vertebral…)
?↓colorectal ca
CHD: expected reduction in CHD not seen;
rather trend toward
Harms:
↑stroke  ↑probable dementia
↑DVT 12, ↑ MI 
↑pulmonary embolism  & ↑gallbladder dx
↑incontinence urinary/stress  ?asthma case
↑invasive breast ca ;↑lung ca death

Question 10

Estrogen only Benefits vs Harms

Answer 10

Benefits:
↓total fracture risk (Hip & vertebr…)
↓invasive breast ca
↓breast ca mortality

Harms:
↑stroke; ↑DVT
↑gallbladder dx
↑urinary incontinence

Question 11

If VMS intolerable, consider systemic hormonal therapy, evaluate in 3-5 years and yearly thereafter if continue therapy beyond_____

Answer 11

5 years

*A/E and harms increase as age increases

Question 12

Low vaginal estrogen does not require______

Answer 12

progesterone

Question 13

When is progesterone required

Answer 13

If intact uterus and on systemic estrogen