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MFSRH Part 2 (2023) > Menopause > Flashcards

Menopause Flashcards

1
Q

Name some vaginal estrogens that are ESTRIOL, and how they are taken

A

Estriol
- Creams (Ovestin 0.1%, Gynest 0.01%) taken nightly for 2 weeks and then twice weekly
- Pessary (Imvaggis 0.03mg) taken nightly for 3 weeks and then twice weekly
- Gel (Blissel 50ug) taken nightly for 3 weeks and then twice weekly

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2
Q

Name some vaginal estrogens that are ESTRADIOL, and how they are taken

A

Estradiol
- Vaginal tablet (vagifem 10 ug) taken nightly for 2 weeks and then twice weekly
- Vaginal ring (Estring 7.5ug) changed every 3 months

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3
Q

What forms, brand names and doses does estradiol come in? Excluding vaginal estradiol

A

Oral
- 0.5mg (combined only)
- 1mg
- 2mg

Patches
- 25ug, 37.5ug, 40ug, 50ug, 75ug, 80ug, 100ug
- Evorel, estradot, estraderm, femseven mono, progynova TS

Gel
- 0.06% estrogel 75mg
- 500ug, 1mg Sandrena gel

Sprays
- 1-3 sprays Lenzetto

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4
Q

What non-estrogens are available?

A
  • Tibolone (2.5mg oral tablet for systemic symptoms)
  • DHEA Prasterone (6.5mg pessary for genitourinary symptoms)
  • SERM Ospemifene (60mg oral tablet for genitourinary symptoms)
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5
Q

What common side effects are complained about with estrogen HRT? And what can be done about them?

A

Side effects
- Fluid retention
- Breast tenderness
- Bloating
- Nausea / dyspepsia
- Headaches

Action
- Reduce dose
- Change route
- Change type

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6
Q

What common side effects are complained about with progestogens in HRT? And what can be done about them?

A

Side effects
- Fluid retention
- Breast tenderness
- Headaches
- Mood swings
- PMT-like symptoms

Action
- Change type
- Reduce dose if available
- Change route
- Alter duration

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7
Q

The local pharmacy has ran out of Evorel Sequi patches (transdermal estradiol with sequential norethisterone) - what alternatives could the patient try?

A

Can take estrogen and progestogen separately

Other TD estrogens
- Evorel 50 patches
- Estradot 50 patches
- Estraderm 50 patches
- Femseven mono 50 patches
- Progynova TS 50 patches
- Oestrogel one measure twice a day = Evorel Sequi
- Sandrena 1mg sachet OD = Evorel Sequi
- Lenzetto 3x sprays = Evorel Sequi

Progestogens
- Utrogestan 200mg orally for 12 days a month at night
- Provera 10mg orally for 12 days a month
- Norethisterone 5mg orally for 12 days a month
- 52mg IUS

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8
Q

The local pharmacy has ran out of Evorel Conti patches (TD estrodiol with continuous norethisterone), what alternatives could the patient try?

A

Can consider TD estrogen with alternate progestogen

Femseven Coni patches contain TD estradiol with continuous levonorgestrel

Other TD estrogens
- Evorel 50 patches
- Estradot 50 patches
- Estraderm 50 patches
- Femseven 50 mono patches
- Estrogel one measure BD = Evorel Conti
- Sandrena 1mg sachet OD = evorel conti
- Lenzetto 3x sprays = evorel conti

Progestogens
- Utrogestan 100mg orally at night continuously
- Provera 5mg orally continuous
- Norethisterone 5mg orally continuous
- Off-licence use of norethisterone in a POP (Noriday) = 3x tablets of 350 micrograms
- 52mg IUS

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9
Q

How do you switch from Evorel patches to Oestrogel?

A
  • Evorel 25 = oestrogel one measure OD
  • Evorel 50 = oestrogel one measure BD
  • Evorel 75 = oestrogel TDS
  • Evorel 100 = oestrogel QDS
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10
Q

Oral combined sequential
- What options will give 1mg estradiol?

A
  • Femoston 1/10 1mg estradiol + 10mg dydrogesterone
  • Elleste Duet 1mg estradiol + 1mg norethisterone
  • Novofem estradiol + 1mg norethisterone

OR take them separately with 1mg oral estradiol, and either utrogestan/provera/norethisterone sequentially or Mirena IUS

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11
Q

Oral combined sequential
- What options will give 2mg estradiol?

A
  • Femoston 2/10 2mg estradiol + 10mg dydrogesterone
  • Elleste Duet 2mg estradiol + 1mg norethisterone
  • Trisequens 2mg/2mg/1mg estradiol + 1mg norethisterone

Or take them separately, with 2mg estradiol orally and sequential progestogen with utrogestan/provera/norethisterone or Mirena IUS

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12
Q

Continuous combined oral HRT
- Which give 1mg estradiol?

A
  • Bijuve 1mg estradiol + 100mg progesterone
  • Femoston conti 1mg estradiol + 5mg dydrogesterone
  • Kliovance 1mg estradiol + 0.5mg norethisterone
  • Indivina 1mg estradiol + 2.5mg MPA
  • Indivina 1mg estradiol + 5mg MPA

Or take separately

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13
Q

Oral continuous combined HRT - which will give 2mg estradiol?

A
  • Elleste Duet Conti 2mg estradiol + 1mg norethisterone
  • Kliofem 2mg estradiol + 1mg norethisterone
  • Indivina 2mg estradiol + 5mg MPA

Or take separately

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14
Q

Oral estrogen only HRT - what options are there?

A
  • Elleste solo 1mg or 2mg estradiol tablets
  • Zumenon 1mg or 2mg estradiol tablets
  • Progynova 1mg or 2mg estradiol tablets
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15
Q

How long would a woman be recommended to be on sequential combined HRT for? (maximum) and why?

A

Long term use of sequential combined HRT for >5 years may be associated with increased risk of endometrial hyperplasia / cancer

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16
Q

How many days minimum per month is recommended to take progestogen for endometrial protection?

A

12-14 minimum, and studies suggest if taking for <10 days per month women would be at higher risk of endometrial hyperplasia / cancer

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17
Q

How could you modify someone’s progestogen if they are experiencing unscheduled bleeding on continuous combined HRT?

A

For continuous combined HRT
- The dose of progestogen could be increased (i.e. increase utrogestan from 100mg to 200mg)
- Switch to a different progestogen
- If IUS already in-situ, could have utrogestan / MPA / norethisterone added
- Can trial switching back to sequential if doesn’t work

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18
Q

How could you modify someone’s progestogen if they are experiencing unscheduled bleeding on cyclical HRT?

A

For cyclical regimens
- the dose of progestogen could be increased (i.e. utrogestan 300mg for 12 days / month rather than 200mg), or switched to a different progestogen
- the progestogen could be taken for more days i.e. 14 or 21 days

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19
Q

How would you counsel a patient on the risk of breast cancer and being on HRT?

A
  • In women who are low risk, the benefits of HRT up to 5 years will exceed potential harm
  • In women with POI, exposure to HRT should be counted from age 50 (not from when they actually started)
  • Risk is not further increased in overweight or obese women who use HRT
  • Unopposed estrogen is associated with little or no change in risk
  • Risk is not increased with vaginal estrogens
  • Combined HRT is associated with duration-dependent increased risk
  • Absolute excess risk is small (10 additional per 1000 women aged 50-59 with up to 14 years of use)
  • Consider weighing this against the risk of endometrial cancer, which is significantly reduced
  • Risk is similar to being obese and to drinking 4-6 units ETOH a day
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20
Q

What is clonidine and how is it used in menopause?

A
  • Centrally acting alpha adrenoceptor agonist (developed for HTN)
  • May be of help in women with tamoxifen-induced vasomotor symptoms
  • Only non-estrogen based preparation licensed for menopausal flushes (although evidence is limited and conflicting)
  • Adverse effects: dry mouth, sedation, dizziness
  • 50-75ug OD, use with caution in women also on HTN meds
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21
Q

How can SSRIs / SNRIs be used in menopause?

A
  • SSRIs (fluoxetine, paroxetine, citalopram) and SNRIs (venlafaxine, desvenlafaxine) can be used for vasomotor symptoms
  • Most convincing data is for venlafaxine 37.5-75mg OD
  • Adverse effects: GI upset and reduced sexual function
  • Not licensed
  • Women on tamoxifen should not be px paroxetine or fluoxetine as they can inhibit conversion of tamoxifen to its active substance (thereby increased risk of breast cancer recurrence)
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22
Q

How can Gabapentin be used in menopause?

A
  • Gamma-aminobutyric acid analogue used to treat epilepsy, neurogenic pain and migraine
  • Reduces hot flushes at a dose of 900mg by 50%
  • Adverse effects: dry mouth, dizziness, drowsiness
  • NICE says gabapentin can be used in women with previous breast cancer for treatment of postmenopausal hot flushes
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23
Q

Can you give progestogens only for control of vasomotor symptoms (if someone can’t take estrogen)?

A
  • Norethisterone 5mg/day, megestrol acetate 40mg/day, MPA 20mg/day can be effective at controlling hot flushes and night sweats
  • However the higher doses may be associated with increased VTE risk
  • Breast safety is uncertain, particularly ini those with progestogen receptor positive tumours (liaise with breast team)
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24
Q

How can beta blockers be used in menopause?

A
  • Propranolol 80mg OD may be useful for anxiety, panic attacks and palpitations
  • Do not affect psychological symptoms
  • Adverse effects include bradycardia, hypotension, GI disturbance, sexual dysfunction
  • Avoid in asthmatics
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25
Q

What are phytoestrogens?

A
  • Plant substances with similar effects to conventional estrogens
  • Isoflavones (soybeans, chickpeas, red clover, beans and peas) and lignans (flaxseed, cereal bran, vegetables and fruit)
  • Evidence is inconsistence and many supplements are not standardised for content or quality
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26
Q

Describe how black cohosh (actaea racemosa) can be used in menopause

A
  • May have isoflavone effect and directly stimulate estrogen receptors
  • Insufficient evidence
  • Unclear if safe in women with previous breast cancer (women should discontinue if they develop breast ca or liver disease) - a few reports of liver toxicity
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27
Q

Name some other herbal remedies used in menopause

A
  • Ginseng
  • Evening primrose oil
  • Dong quai
  • Gingko biloba
  • Sage
  • Wild yam
  • St John’s Wort, chasteberry, liquorice root, valerian root

Don’t forget to advice re. potential drug interactions

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28
Q

Describe some non-hormonal vaginal therapies

A

Good for women concerned about hormone use and for those with minimal physiological changes

Moisturisers: Replens and Regelle, use every 3 days

Lubricants: Sylk or Yes

Can use together

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29
Q

Name some other therapeutic approaches to menopausal symptoms

A
  • Acupuncture
  • CBT
  • Reflexology
  • Yoga
  • Homeopathy
  • Magnetism
  • Mindfulness
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30
Q

How can you assess a patient’s menopausal symptoms?

A
  • Validated menopause symptom questionnaires: Geene Climacteric Scale, Menopause Rating Scale, Menopause Specific Quality of Life Questionnaire
  • Ask the patient to hone in just three or four ‘worst’ symptoms and the effect these are having on life and work
  • Categories usually vasomotor, psychological and urogenital
31
Q

What relevant risk factors for endometrial cancer should be sought in menopause history consultation?

A
  • Obesity
  • Diabetes
  • Nulliparity
  • History of chronic anovulation (e.g. PCOS)
  • Late menopause
  • Use of unopposed estrogens or tamoxifen
  • Family history of hereditary nonpolyposis colorectal cancer (Lynch syndrome), ovarian or endometrial cancers
32
Q

What family history should be elicited for a menopause consultation?

A
  • Breast, ovarian or bowel cancer
  • Any parents, sisters or brothers had such cancers
  • What age did they develop it
  • Has the patient been tested for BRCA 1 or 2?
    As well as first degree relative VTE risk
  • Provoked or unprovoked
  • Were they treated with any anticoagulants
33
Q

What questions could elicit risk factors for heart disease and stroke?

A
  • Exercise (how often and what type)
  • PMH of heart attack or stroke
  • Parents or siblings had an MI or stroke (and what age)
  • Smoking history
  • PMH of HTN or diabetes
  • Ever had a lipid assessment?
  • BMI
34
Q

What questions could elicit risk factors for osteoporosis?

A
  • Was menopause before age 45?
  • Has she taken systemic corticosteroids for 6 months or longer?
  • PMH anorexia or significant weight loss?
  • FH of osteoporosis? (first degree relatives)
  • Previous/current low calcium or vitamin D, any malabsorptive disorders?
  • PMH any fractures (elicit fragility fracture i.e. from a standing height)
35
Q

Describe when you would check FSH, LH and estradiol as part of menopause assessment

A
  • POI (may need repeating on two or three occasions)
  • Try to do the assays on days 1-5 of menstrual cycle
  • Seldom recommended in women >45 years old (exceptions may include women without menses)
  • Repeat 4-6 weeks apart
36
Q

When would you test for testosterone?

A
  • Women complaining of lack of libido may request testosterone levels
  • 2/3 of testo is bound to SHBG and 1/3 bound to albumin - only about 2% is free/unbound
  • Increase in levels of free testo (free androgen index) is sometimes used
  • FAI = 100 x (total testo / SHBG)

Levels do not correlate with symptoms
Can be used to monitor safety of testo prescribing, but no clear guidelines

37
Q

What investigations could be done if symptoms indicate a secondary health condition?

A
  • FBC
  • TFTs
  • Fasting glucose
  • Autoantibody screen
  • Catecholamines (phaeochromocytoma) and 24-hour urninary 5-hydroxyindoleacetic acid (carcinoid syndrome)
  • Chest xray
38
Q

When would you request a thrombophilia screen?

A
  • Not advocated routinely
    Consider in the following:
  • Women under 40 with unprovoked VTE
  • Recurrent unprovoked VTE
  • VTE in unusual sites (cerebral, mesenteric)
  • FH unexplained VTE in 2+ relatives
  • FH specific thrombophilia
  • Warfarin-induced skin necrosis (paradoxical clotting)
39
Q

How are oral estrogens metabolised differently to TD estrogens?

A
  • Oral follows first-pass liver metabolism pathway
  • Prothrombotic effect on coagulation cascade which affects pro-inflammatory markers (e.g. CRP)
  • Alterations in thrombin generation compared to women not using HRT, and compared to women using TD estrogen
  • However risk could be increased with increased doses of TD estrogen
40
Q

How are micronised progesterones different to synthetic progestogens?

A
  • Micronised progesterones selectively bind to progesterone receptors and have fewer adverse effects on androgenic, mineralocorticoid and glucocorticoid receptors than synthetic progestogens
  • Therefore have a better safety profile
  • Androgenic progestogens partly reverse the beneficial arterial effects of estrogens
41
Q

How can HRT help sexual function?

A
  • Systemic HRT may act on central arousal centres in brain
  • Local HRT has proliferative effect on vulval and vaginal epithelium
  • Testosterone can improve sexual desire and orgasm but should only be considered if HRT alone is not effective (long-term safety data is lacking)
  • Tibolone has a weak androgenic effect = may help sexual function and libido
42
Q

How might fibroids be affected by menopause?

A
  • Symptoms likely to improve or disappear (shrink by up to 40%) and HMB will cease
  • Postmenopausal HRT may increase volume of existing fibroid, but not contribute to development of new fibroids
  • LNG-IUS first-line tx (assuming no distortion of cavity)
  • Can also be treated with GnRH analogues or UPA (liver failure risk)
43
Q

How might a history of PCOS affect your HRT prescribing?

A
  • Higher risk of endometrial hyperplasia and cancer
  • Often have hyperinsulinaemia and obesity
  • Even after menopause, women with PCOS have higher serum androgens and metabolic abnormalities (such as impaired glucose tolerance, raised triglycerides and lower HDL)
  • Higher coronary artery calcium scores

Therefore take the above into account

44
Q

What about prescribing HRT to women with HTN?

A
  • No evidence that estradiol increases BP
  • HRT can be taken alongside HTN meds provided the BP remains well controlled
  • Conjugated estrogens may cause a rise in BP
  • TD estrogen has less effect on the RAS system and so may be a bettre choice
  • Tibolone and raloxifene do not affect BP
45
Q

Describe the effect of HRT on lipid profile

A
  • Oral estrogens reduce LDL / increase HDL
  • Can maintain this effect by adding non-androgenic progestogen or micronised progesterone
  • Androgenic progestogens cause a drop in HDL
  • TD route has less effect than oral route
  • Women at high risk of raised lipids, consider TD
  • Raloxifene and tamoxifen reduce total cholesterone
  • Statins are first-line therapy, not HRT
46
Q

Describe HRT prescribing and VTE considerations

A
  • Oral HRT = 2x VTE risk
  • Risk begins immediately on starting but stopped when ceased HRT
  • TD preferred option as does not increase VTE risk (even in those with thrombogenic mutations)
  • Non-androgenic progestogen or micronised progesterone is preferred
  • In complex high risk women, could consider anticoagulation alongside HRT (rare scenario, discuss with haematologist)
  • Raloxifene and high-dose progestogens can increase risk of VTE (not tibolone)
47
Q

Should you discontinue HRT prior to surgery (like CHC)?

A
  • No need to discontinue TD HRT
  • Individualised risk assessment with surgeon and anaesthetist
  • May be a small increased risk with oral HRT
  • Weigh up VTE risk vs those who may commence LMWH anyway
48
Q

What prescribing considerations are there for HRT and thyroid disease?

A
  • Thyroid hormones increase synthesis of SHBG, testo and androstenedione, reducing clearance of estradiol and estrone
  • Hypothyroidism = epithelial dysfunction, reduced cardiac contractility, elevated LDL
  • Dose of thyroxine may need to be increased with oral estrogens due to liver interactions
  • Don’t worry about TD estrogen
49
Q

What prescribing considerations are there for HRT and migraines?

A
  • Migraines are very common in perimenopause
  • Pre-menstrual migraines improve with TD estradiol
  • However too high an estrogen dose can trigger migraines
  • TD estrogen is preeferred
  • Sequential progesterone can trigger migraines (try natural progesterones or LNG IUS)
  • No evidence of increased risk of ischaemic stroke in women with migraines with aura who take HRT (unlike CHC)
50
Q

Describe estrogen implants

A
  • Crystalline pellets of estradiol subcut and slow release
  • Inserted every 6 months
  • Higher levels of circulating estrogen
  • Tachyphylaxis: recurrence of menopausal symptoms despite adequate levels of estradiol
  • Check estradiol levels pre re-implantation (but no clear guidance on what level it should be)
  • If estrogen suddenly contraindicated, cannot remove the implant easily
51
Q

How would you prescribe HRT in women who have undergone hysterectomy?

A

Subtotal hysterectomy: may have some remnants of endometrial tissue in cervical stump
- Trial sequential HRT and see if bleeding ensues (if it does, will need continuous combined)

Pelvic clearance for endometriosis
- Risk unopposed estrogen can reactivate residual micro-deposits
- Consider giving women combined HRT or tibolone post surgery to reduce this risk

52
Q

What HRT would you give someone who has had endometrial ablation?

A

Combined, don’t assume all of endometrium has been removed

53
Q

What doses of estrogen should you start at when prescribing?

A

Minimum bone-sparing doses:
- Oral 1-2mg
- Patch 25-50mg
- Gel 1-2mg
- Implant 25-50mg
- Conjugated estrogens 0.3-0.625mg

Lower doses may be sufficient to improve vasomotor symptoms

Young women with surgical menopause may need higher doses to alleviate symptoms

54
Q

How can you manage irregular bleeding on HRT?

A

Pelvic pathology should be excluded if problem persists or does not respond to treatment

Consider non-concordance with therapy, drug interactions, GI upset

Otherwise:
- Increasing dose/type of progestogen if HMB/prolonged
- Change type of progestogen with dysmenorrhoea
- Change regimen or increase progestogen with irregular bleedinig

55
Q

What non-hormonal options are there for someone with previous breast cancer?

A
  • Lifestyle advice (smoking cessation, limiting ETOH, losing weight, exercise)
  • Vasomotor control: clonidine, SSRI/SNRI (avoid paroxetine and fluoxetine in those taking tamoxifen) and gabapentin
  • Desvenlafaxine 100mg OD (not available in UK)
  • Psychological support
  • Vaginal moisterisers (vaginal estrogens could be considered low-dose if significant symptoms)
56
Q

What bone conserving options are available for women who have had breast cancer?

A
  • Tamoxifen increases spine and hip BMD in postmenopausal women (but does not reverse the effect chemotherapy may have had)
  • GnRH analogues and aromataze inhibitors increase bone loss and induce osteoporosis
  • May need frequent DXA scans
  • Bisphosphonates are often px whilst on aromatase inhibitors (they also improve breast cancer mortality irrespective of estrogen receptor status)
57
Q

How do you diagnose osteoporosis?

A
  • Presence of fragility fracture, or by BMD assessment in DEXA
  • T score < -2.5 (>2.5 SD below the mean) = osteoporosis
  • T score between -1.0 and -2.5 = osteopenia

Can measure bone turnover markers (such as c-terminal telopeptide type 1 collagen) for a more rapid response

These bone markers are increased after menopause

Quantitative ultrasound of calcaneous (QUS) can be used, but a positive result would have to be confirmed by DEXA anyway

58
Q

How do prevent osteoporosis?

A
  • Diet with adequate protein, calcium and vitamin D exposure
  • Maintaining BMI between 19 and 25
  • Exercise, smoking cessation, alcohol limitation
  • Population screening not cost effective
  • Dose dependent and cumulative effect of glucocorticoid use (start bisphosphonate in someone commencing high dose pred who has T-score < -1.5
59
Q

What are clinical risk factors for osteoporosis?

A
  • Age
  • History of parental hip fracture
  • Low BMI/previous anorexia
  • Previous fragility fracture
  • Current smoking
  • Alcohol intake 3 units/day +
    PMH: RA, hypogonadism, prolonged immobility, organ transplant, T1DM, hyperthyroidism, GI disease, chronic liver disease, COPD
  • Current or past glucocorticoid tx for 3 months or longer
  • Medications: aromatase inhibitors, PPIs, SSRIs, thiazolinediones, anticonvulsants
60
Q

What is a FRAX score?

A
  • Online calculator validated for patients age 40-90
  • Calculates 10 year risk of hip and major osteoporotic fractures
  • Should be undertaken in all postmenopausal women without a fracture but with a clinical risk factor (or BMI <19)
  • Low risk FRAX: reassure, lifestyle advice, reassess in 5 years or sooner
  • Medium risk FRAX: measure BMD and recalculate fracture risk
  • High risk FRAX: consider treatment without need for BMD
61
Q

What tests might you do to assess secondary causes of osteoporosis?

A
  • FBC, ESR, CRP
  • Serum calcium, phosphate
  • Parathyroid hormone
  • Renal function
  • LFTs
  • TFTs
  • 12-hydroxyvitamin D levels
  • If necessary: DEXA, myeloma screen and coeliac screen
62
Q

What calcium and vitamin D supplements should you recommend for a post menopausal woman with osteoporosis?

A
  • Total daily calcium (food + tablets) = 1200mg/day
  • Vitamin D = 800-1000 units / day
63
Q

Describe bisphosphonates

A
  • Alendronate, risedronate, ibandronate
  • Used in fracture prevention and treatment of osteoporosis
  • Alendronate is first-line
  • Zoledronic acid is IV infusion (good for people who cannot tolerate oral absorption)
  • All are poorly absorbed from GI tract - give on empty stomach and remain upright for 30 mins
  • Not advised for women of childbearing age (concerns on effects of fetal skeleton)
  • Risk of osteonecrosis of the jaw - encourage dental examinations
64
Q

Can you use SERMs for osteoporosis management?

A

Sort of

Raloxifene can reduce vertebral fractures only, by 30-50%

Has estrogenic effects in bone and anti-estrogenic effects in endometrium and breast tissue - reducing the risk of breast cancer to the same extent as tamoxifen

65
Q

Name some primary and secondary causes of premature ovarian insufficiency

A

Primary
- Chromosomal and gene abnormalities
- Enzyme deficiencies
- Autoimmune disease

Secondary
- Chemo/radiotherapy
- BSO or surgical menopause
- Hysterectomy without oophorectomy
- Uterine artery embolisation
- Infection

66
Q

Describe the chromosomal and gene abnormalities associated with POI

A
  • Most common are X abnormalities (defects, deletions, translocations and isochromosomes)
  • Turner Syndrome
  • Downs Syndrome
  • Fragile X (FMR1) syndrome
  • Blepharophimosis, ptosis and epicanthus inversus syndrome (BPES)
67
Q

Describe some enzyme deficiencies associated with POI

A
  • Deficiency of galactose-1-phosphate uridyltransference
  • Cholesterol desmolase deficiency
  • 17-alpha-hydroxylase deficiency (CAH)
  • 17-20-desmolase deficiency (like CAH but only ovarian insufficiency occurs, rather than the adrenal stuff)
68
Q

Describe some autoimmune diseases that are associated with POI

A
  • Most commonly found antibodies in POI are thyroid, adrenal and lupus related
  • Myasthenia gravis, rheumatoid arthritis and SLE also reported (but less so)
69
Q

Describe how chemo and radiotherapy can contribute/cause POI

A
  • Radiotherapy results in sterility when total dose exceeds 6Gy
  • Prepubertal girls are more resistant to radiotherapy and chemotherapy
  • Normal menstruation post does not mean ovaries are unaffected
  • Some damage to uterus can occur, so IVF may not even be possible
  • Prepubertal uterus is more vulnerable to irradiation
  • Adverse pregnancy outcomes include early pregnancy loss, preterm birth, SGA / low birth weight
70
Q

What infections are associated with POI?

A
  • TB and mumps most common
  • Multidrug resistant strains of bacili are of concern
  • In most cases, normal ovarian function returns after mumps
  • Malaria, varicella and shigella has also been implicated in POI
71
Q

What counselling and support should be offered to women with a diagnosis of / suspected POI?

A
  • Written info and internet resources such as Daisy Network (support groups)
  • Psychological support with a counsellor
  • Ovulation may occur again and so pregnancy can occur spontaneously - still discuss contraception
  • Discuss fertility issues and tailor to the woman’s desires and wishes
72
Q

What are the HRT recommendations for POI?

A
  • Both to treat symptoms and to prevent adverse effects of estrogen deficiency
  • Continue until average age of menopause
  • HRT more beneficial than COC
  • Doses may be higher than in older women
  • Consider additional testosterone as androgen deficiency is common in women with oophorectomy (but also psychosexual counselling)
73
Q

What advice can you give to someone with POI re. fertility and contraception?

A
  • Ascertain fertility wishes
  • It is a myth that POI is final and infertility definite
  • Chance of spontaneous conception is 5-15%
  • If they do not want children, prescribe contraception
  • For those who need fertility support, donor oocyte IVF or surrogate is treatment of choice
  • With a normal karyotype, IVF success rates are the same as other women
  • Consider embryo freezing prior to treatment with chemo or radiotherapy

MFSRH Part 2 (2023) (22 decks)

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