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BPH P&T > Menopause > Flashcards

Menopause Flashcards

1
Q

What is the brand name of Ospemifene?

A

Osphena

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2
Q

What is the only ORAL agent for Vulvovaginal Atrophy/Uregenital systems?

A

Ospemifene

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3
Q

Why Ospemifene controversial?

A

Controversial whether a progestin should be used

Its dose is 60mg daily

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4
Q

Name are the treatments for Vulvovaginal Atrophy/Urogenital symptoms?

Estrogens

A 
Premarin (Conjugated equine estrogen cream)
Estrace
Vagifem
Estring
Femring
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5
Q

What are some comments for Vulvovaginal Atrophy/Urogenital symptoms?

A

DOC for patients with vaginal symptoms only

With low dose (LD) , no progestin necessary

Moderate to hight dose requires 10 days of progestin q12 weeks to protect the endometrium.

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6
Q

Name Non-estrogen therapies for menopause?

A

SSRI’s

  • Paroxetine
  • Brisdelle
  • Fluoxetine (Prozac)
  • Ecitialopram (Lexapro)

SNRI’s
Venlafaxine (Effexor), desvenlafaxine (Pristiq)

Clonidine and Gabapentin

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7
Q

Whats the efficacy of Non-estrogen therapies (VMS)?

A

SSRI’s, SNRI, Clonidine, and gabapentin;

All more effect than placebo in reducing hot flashes but less effective than estrogen

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8
Q

What’s Non-estrogen’s place in therapy?

A

Contraindication to MHT

Patient prefers not to use MHT or cannot tolerate MHT

Use after 5 yrs and pts still experience VMS

Mood changes in addintion to menopause symptoms.

–These groups may benefit

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9
Q

Dietary supplements for Menopause: Which Supplement i has a precaution with patients with aspirin or salicylate allergy?

A

Black Cohosh

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10
Q

Dietary supplements for Menopause: Which Supplement does not have estrogenic activity but may effect serotonin?

A

Black Cohosh

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11
Q

Dietary supplements for Menopause:
Pytoestrogens (compounds with week estrogen resceptor properties)

Name all the classes?

A

Pytoestrogens

Isoflavones (soy): (active) genisteiin, daidzein

Lignans:Flaxseed

Coumestans: Alpha sprouts

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12
Q

What are the precautions for Phytoestrogens?

A

Individual or family of hx of breast, endometrial or ovarian Cancer

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13
Q

How should MHT be monitored?

A

Breast exams, and periodic mammograms, assess menopausal symptoms q 3-6 months

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14
Q

Does MHT caused increased Dementia?

A

Yes, EPT therapy show increased risk of dementia (Alzhiemers disease) in post menopause women >65yrs.

Womens Health Initiative Memory Study

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15
Q

How should MHT be discounted?

A

Do not discontiune in all women at age 65.

Discontinuing may cause recurrent VMS in 50% of women.

Tapering or abrupt (no evidence support one or the other)

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16
Q

Which drug was approved for moderate to severe VMS and prevention of osteoporosis in women with intact uterus?

A

Duavee: 0.45mg - conjugated estrogen/20mg bazedoxifene PO Daily

only recommend for Shortest duration possible

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17
Q

EPT (Estrogen + Progestin): what are the Transdermal combo?

A

Combipatch and Climara Pro

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18
Q

EPT (Estrogen + Progestin): what are the continuous oral combo?

A

Prempro, femhrt, Activella, Angeliq, or Activella and Mimvey

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19
Q

EPT (Estrogen + Progestin): what are the intermittent oral combo?

A

Prefest

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20
Q

EPT (Estrogen + Progestin): what are the oral continuous Cyclic combo?

A

Premphase

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21
Q

How do we managed the AE of progestins?

A

Change to another progestin

Change the dosing regimen (Cyclic to continuous)

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22
Q

Progestin: name the oral agents?

A

Provera(common), Aygestin(common), Prometrium

Progestin dose for continous regimen is typically half of cyclic regimens

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23
Q

Progestin: name the intrauterine system?

A

Mirena

Contraceptive used for endometrial protection

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24
Q

What is the brand name of Medroprogesterone acetate?

A

Provera

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25
Q

What is the brand name of Norethindrone?

A

Aygestin

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26
Q

What is the brand name Levonorgestral (intrauterine)?

A

Mirena

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27
Q

What is the brand name of micronized Progesterone?

A

Prometrium

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28
Q

What are the AE of estrogens?

A

Breast tenderness and Heavy Bleeding?

29
Q

How do we managed estrogens AE?

A
  1. Decrease dose of estrogen
  2. Switch the dose (oral ->transdermal),
  3. If breast tenderness, don’t switch from transdermal to oral
  4. Change to different type (women respond differently)
30
Q

Name the “early” symptoms of Menopausal Transition?

A

Abnormal Bleeding

31
Q

Name the “late” menopausal transition and “early” Post-menopause symptoms?

A

Vasomotor (VMS): Hotflash/flashes, Night sweats

Genitourinary (VVA):Vaginal dryness,itching, Dyspareunia

Cognitive: Sleep disturbances and mood changes

32
Q

At what stages is hot flahses most limey to occur?

A

late” menopausal transition and “early” Post-menopause”

33
Q

What is menopause?

A

12 months after FMP (Final menstrual period)

34
Q

Mentrual cycle: describe early menopausal transition?

A

Variale cycle length

> 7 days different from normal

35
Q

Mentrual cycle: describe late menopausal transition?

A

> 2 skipped cycles and an interval of amenorreha of > 60 days

36
Q

what are the cause of premature menopause?

A

Chemotherapy/radiation or Surgery

37
Q

When does FMP (Final mental period occur)?

A

After Late menopausal transition*

38
Q

Why do women seek medical care for menopause?

A

Hot-flashes/flashes and night sweat

39
Q

What aggravates or causes hotflahses to occur more frequently in women who have menopause?

A

Smoking, caffeine, alcohol,spicy foods, Obesity, less physical activity

40
Q

What is Vulvovaginal atrophy (VVA)?

A

Vaginal dryness and Dysareunia -Painful intercourse

Related to estrogen deficency

41
Q

What are the psychologic effects of menopause?

A

Sleep disturbance (may not be related to night sweats)

Mood disturbances

Cognitive disturbance

42
Q

Treatment: what are some lifestyle changes which will aid menopause symptoms?

A
  1. Smoking cessation
  2. decrease alcohol intake
  3. Excercise (mixed results may increase VMS)
  4. Avoid: caffeine,spicy food, hot drinks
  5. Dress in layer (take it off baby **)
  6. Keep cool
43
Q

What does MHT mean?

A

Menopaual Hormone Therapy

44
Q

What MHT is suggest for women WITHOUT uterus?

A

ESTROGEN

45
Q

What MHT is suggest for women WITH uterus?

A

Estrogen + PROGESTIN

46
Q

Why is EPT (Estrogen + PROGESTIN) suggest at MHT for women with uterus?

A

Progestin is added for endometrial protection

Long version: progestin is added to prevent the endometrial lining building up and causing hyperlasia. Want to prevention endometrial hyperplasia and endometrial cancer.

47
Q

When is it “ok” to treat VMS with MHT?

Hotflash/flashes, Night sweats

A

Moderate to severe VMS - its most effective for vasomotor and vaginal symptoms

only recommneed for < 5 years

48
Q

How is vagninal symptoms VVA treated?

Vaginal dryness,itching, Dyspareunia

(whats more effective systemic or local)?

A

Local Hormone therapy is more effective than systemic in reliving these symptoms

49
Q

What extra benefit does MHT have ?

A

Osteoporosis prevention and Cardiovascuar health

  • Osterporoisis increses in women who lose estrogen
  • many MHT agents are indicated for osteoporosis
50
Q

What were the results of the Women’s Health initiative study? (WHI)

A

Study shows increase risk for Stroke, MI, Breast Cancer, thromboembolism for EPT (Estrogen + PROGESTIN)
–Benefit for colorectal cancer and osteoporosis/hip fracture

Study shows increase in stroke and thromboembolism, no benefit in MI,Breast cancer, Colorectal caner.
–Benefit for osteoporosis/hip fracture

Mean age 63 years

51
Q

Meanwhile in Demark, RCT has conflicting results with WHI? What was it and Why?

A
  1. Younger patients (do not use HRT in older women)

Mean age 49.7 years

52
Q

What are the contraindication ins MHT (Absolute)?

A
  1. Untreated endometrial hyperlasia
  2. Current/past/suspect Breast cancer
  3. Arterial thromboembolic disease (MI/Stroke)
  4. venous thromboembolic disease
  5. (untreated HTN)

Smoking is OK (just not advised)

53
Q

timing hypothesis: Whats the suggested Duration of therapy when using ET?

A

7 years

54
Q

timing hypothesis: Whats the suggested Duration of therapy when using EPT?

A

3-5 years

55
Q

timing hypothesis: what is it?

A

MHT will have less CV risk when started 5 years within POST-menopause

The average window you can use HRT, when the risk would not increase , the time has to be correct*

56
Q

What should be considered before staring MHT?

A

Severity of symptoms:moderate or severe (only)

Timing (Time hypotheisis )

Risk: VTE, Breast CA, Gallbadder disease, CVD: MI/CAD, PVD,stroke

57
Q

Whats the golden rule for hormonal therapy for menopause? (take home)

A

MHT should be prescribed for the shortest period of time and at the lowest effective dose.

58
Q

Methods of administration: Intermittent Combined EPT (“Pulsed-Progestin”)

A

Three days of estrogen alone, then 3 days EPT continuously

i. Estrogen everyday, but days 3-6 progestin is added along with the estroge, then days 9-12 we give progestin

o Lower dose of progestin results in fewer side effects

59
Q

Methods of administration:Continuous Long Cycle

A

convenient – 6 periods per year

Daily estrogen + 12-14 days of progestin every other month

i. We have continuous estrogen, then progestin the last 14 days. However in the second month we have continuous estrogen and no progestin. Therefore you will be able to skip a period every other month.

o Bleeding every other month (convenient – 6 periods per year**

60
Q

Methods of administration: Continuous Cyclic (“Sequential”)

A

Note: women will have predictable monthly bleeding with continuous cyclic regimens (every month)** _make sure she now when to use what drug**

Estrogen continuously (estrogen always stays the same in all cycle), minimum of 12 days of progestin 
(at the end of the cycle)

-Withdrawal bleeding 1-2 days after last progestin dose (so the women will get
what looks like a period every month)

61
Q

Methods of administration: Continuous Combined

A 
EPT continuously (same thing, no change in dose)
o Unpredictable bleeding/spotting for the first 6-12 months

o If used, this regimen is preferred for women who are at least 2 yrs

postmenopause as they are less likely to have unpredictable bleeding (if they use it within the first 6 months-12 months more likely to have bleeding)

o Continuous combined EPT is not recommended in the AACE 2011 guidelines. Their rationale: continuous progestin exposure is linked to adverse breast outcomes in recent studies. We need to have a certain amount of progestin for endometrium support but they belive that the EPT combo poses a greater risk to adverse breast outcomes.

62
Q

VMS (ET) menopause therapy: Transdurmal?

A

Evamist,

Estrasorb [thigh]

Estrogel, Elestrin, Divigel [ARM]

Vivelle-Dot, Alora, Menostar, Estraderm [lower abs]

63
Q

menopause therapy: Transdurmal what are some comments made?

A
64
Q

menopause therapy: ORAL what are some comments made?

A
65
Q

VMS (ET) menopause therapy: ORal?

NO (EE)

A

Premarin, Estrace, Femtrace, Enjuvia,Cenestin, Orth-Est, and Ogen

66
Q

What are some serious AE of estrogens?

A

STROKE

VTE

CVD

Breast Cancer

67
Q

Whats another AE of estrogen not mentioned, but is mentioned by mancono’s topics?

A

Hypothyroidism; can increase T4 requirements (for function??)

68
Q

what are some AE for Progestins?

A

Irritability, Depression, headache, “Premenstrual like” symptoms.

69
Q

Whats the deal with Bioidentical for menopause treatment?

A

Plant derived hormones which are said to have identical structure to endogenous hormones.

claim improve safety,

  • some contain commercial products
  • custom compounding
  • salivary hormone concentration

Safety and efficacy is not supported by clinical trials

BPH P&T (8 decks)

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