Menopause Flashcards
Natural menopause
The time of a person’s final menstrual period
* Diagnosed after no periods for 12 consecutive months
Induced menopause
Experience (before natural menopause) with bilateral oophorectomy (removal of both ovaries) ablation of ovarian function with chemotherapy or pelvic radiation
Perimenopause
- Most often begins between 45 and 55
- Starts at onset of menstrual irregularity and ends 12 months after final menstrual period
- Abnormal uterine bleeding
Abnormal Uterine Bleeding
- Characterized by a deviation of regularity, frequency, duration, or volume of menstrual fluid
- Most often caused by the increased frequency of anovulatory cycles
What are some vasomotor symptoms?
- Hot flashes
- Night sweats
What are some symptoms of genitourinary syndrome of menopause?
- Vaginal atrophy leading to dryness, burning, irritation
- Dyspareunia (sexual discomfort or pain)
- Urinary urgency, dysuria, incontinence, and recurrent UTIs
What are some psychological symptoms?
- Depression and anxiety
- Sleep disturbance
What are postmenopausal women at an increased risk for?
- Osteoporosis
- Bone fractures
- CHD
- Increased memory loss
- Other cognitive difficulties
How do you diagnosis menopause?
- Elevated FSH level is NOT required
- In patients with uterus/ovaries under age 45, rule out other causes of menstrual cycle dysfunction
- In patients with hysterectomy without bilateral oophorectomy, elevated FSH and low estradiol concentrations may support diagnosis
What are some non-pharmacological treatments?
- Smoking cessation
- Exercise
- Avoid hot, spicy foods
- Avoid caffeine
- Layer clothes
Menopausal Hormone Therapy
- Estrogen replacement therapy
- Effective for vulvovaginal symptoms
- Effective for moderate to severe vasomotor symptoms
What MHT are you using if the patient had a hysterectomy?
- Estrogen + Progesterone
- Estrogen + Bazedoxifene
- Low-dose vaginal estrogen
Intravaginal estrogen products are preferred when?
In patient with only genitourinary symptoms
* No need to give with progestogen
* Local action, except with Femring, which achieves systemic levels
What are the adverse effects of estrogen?
- Nausea
- Breast tenderness
- Increased risk of migraine
- Headache
- Thromboembolic events
- Gallbladder disease
- Hypertriglyceridemia
- HTN
- Increased the risk of endometrial cancer
- Small increase in risk of breast cancer and cardiovascular events
Progestin
- Prevent estrogen-induced endometrial hyperplasia and cancer when co-administered when estrogen
- Can be used continuously or cyclically
- At least 12-14 days of progestogen therapy per month is required
Conjugated equine estrogen (CEE)
- Administer 21 days on and 7 days off
- Vaginal estrogen
Estradiol cream (Estrace)
- Vaginal estrogen
- 2-4 g daily for 2 weeks, then half-dose daily for 2 weeks; maintenance 1 g 1-3 times per week
Estradiol tablets (Vagifem)
- Once weekly for 2 weeks, then twice weekly
Estring (intravaginal ring)-estradiol
- Intravaginal estrogen
- 90 days
Femring (intravaginal ring)
- Intravaginal estrogen
- 90 days
Topical emulsion (Estrasorb)
Apply to legs
* topical estradiol
Topical gel (EstroGel metered-dose pump)
- Apply from wrist to shoulder
- Topical estradiol
Topical gel (Elestrin metered-dose pump)
Apply to upper arm
* Topical estradiol
Topical gel (Divigel)
- Apply to upper thigh
- Topical estradiol
Transdermal spray
- Apply to inner forearm
- Topical estradiol
Does cyclic regmines of progestins cause withdrawal bleeding?
Yes
What are the common adverse effects of progestin?
- Breast soreness
- Some experience “premenstrual-like” symptoms such as mood swings and bloating
- Vaginal bleeding iwth cyclic progestin and in the early months of continuous estrogen-progestin (if newly menopausal)
- Risk of CHD with MPA use
What are the contraindications of MHT?
- Unexplained vaginal bleeding
- Active liver disease, liver failure
- Prior estrogen-sensitive breast or endometrial cancer
- History of CHD or stroke
- History of or high risk for VTE
- Untreated HTN
When is transdermal estrogen preferred over oral estrogen?
- Hypertriglyceridemia
- Active gallbladder disease
- Thrombophilia such as factor V Leiden
- Migraine headaches with aura
What is the risk vs benefits of having cardiovascular disease when taking MHT?
- Reduced when estrogen-only used in newly menopausal patient
- No increase if estrogen + progestin therapy initiated within 10 years of menopause
- Increased risk if initiated more than 10 years since menopause
What is the risk vs benefits of having breast cancer when taking MHT?
- Increased risk when estrogen + progestin therapy if used > 10 years
- Use of estrogen alone may decrease risk
What is the risk vs benefits of having osteoporosis when taking MHT?
- Estrogen therapy reduces bone turnover and increases bone density
- Standard-dose MHT reduces postmenopausal osteoporotic fractures
What is the risk vs benefits of having ischemic when taking MHT?
Increased risk with estrogen only and estrogen + progestin
What is the risk vs benefits of having VTE when taking MHT?
- Increased risk of with personal risk factors including obesity, previous history of VTE, presence of Factor V Leiden mutation
Bazedoxifene
- FDA-approved for use in severe vasomotor symptoms and prevention of osteoporosis
- Antagonist in breast and uterus
- Must be used with estrogen
What are the side effects of Bazedoxifene?
- Muscle spasms
- Nausea
- Diarrhea
- Dyspepsia
Ospemifene
- FDA-approved for the treatment of moderate-to-severe dyspareunia from menopausal vulvar and vaginal atrophy
- Nearly full estrogen agonist effect in the vaginal epithelium; antagonist in breast and uterus
What is the side effect of ospemifene?
- Hot flashes
- Vaginal discharge
- Muscle spasms
Prasterone (Intrarosa)
- Once daily vaginal insert
- DHEA
- FDA-approved for treatment of moderate-to-severe dyspareunia
- Local effect = decrease vaginal dryness
- Does NOT carry boxed warning for VTE or endometrial hyperplasia like other estrogen-containing products
What are some side effects of Prasterone (Intrarosa)?
- Vaginal discharge and abnormal Pap smear (atypical squamous cells of undetermined significance)
