Menopause

Question 1

Describe vasomotor sx for menopause

Answer 1

• Hormone therapy most effective for moderate to severe sx

- Typically, last 7-8 years

Question 2

Describe genitourinary sx for menopause

Answer 2

• Vaginal estrogen is best option b/c less systemic effect
• • Can still use even if breast cancer hx (if failed non-hormonal tx)
• Non-hormonal tx = vaginal moisturizers

Question 3

Describe HRT (what to use)

Answer 3

• Always use combo estrogen + progestin unless no uterus -> then use estrogen + SERM (bazedoxifene) (combo used to prevent endometrial cancer)
• Always use lowest possible dose for shortest period of time!
• If last menstrual period < 1 year ago -> cyclic timed to endogenous cycle (minimizes risk of breakthrough bleeding)
• If last menstrual period > 1 year ago -> continuous to avoid monthly withdrawal bleeding
• Topical/transdermal if increased CVD risk, HTN, DM, smoking, obesity, and/or gallstones

Question 4

Describe risks and AE of HRT

Answer 4

• Risks -> increased risk of breast cancer after 5 years of use, coronary heart disease (if risk factors such as > 60 y/o, menopause > 10 years), thromboembolic events, and stroke
• AE = breast tenderness, headache, mood changes (risk increases w/ increased age)
• SE (progestin) = mood swings, bloating

Question 5

Describe CI to HRT

Answer 5

• Unexplained vaginal bleeding
• Acute liver dysfunction
• Estrogen-dependent cancer
• Coronary heart disease
• Previous stroke
• Active thromboembolic disease

Question 6

Describe antidepressant use for menopause

Answer 6

• Used off-label and appear less effective than hormone therapy
• Reduce vasomotor sx by 25-69%
• Paroxetine is most well studied
• Low doses often effective
• AE = GI, headache, insomnia, sexual dysfunction, weight gain

Question 7

Describe anticonvulsant use for menopause

Answer 7

• Used off-label and appear less effective than hormone therapy
• Initiate at low dose (ex: gabapentin 300 mg HS or pregabalin 50 mg HS)
• AE = dizziness, somnolence, headache, weight gain, rash

Question 8

Drug interactions w/ menopause drugs

Answer 8

• Estrogen -> levels increased by 3A4 inhibitors

- Paroxetine = CYP 2D6 inhibitor

Question 9

Red flags for menopause

Answer 9

Unexplained vaginal bleeding

Question 10

Case specific assessment questions for menopause

Answer 10

• Any changes in your periods? *
• Are you having any hot flashes? *
• Any vaginal dryness or pain or sexual concerns? *
• Any bladder issues or incontinence? *
• How is your sleep?
• How is your mood?
• If yes to any of the first 4 questions -> may be a candidate for tx

Question 11

Non-pharms for menopause (general)

Answer 11

• Vaginal moisturizers for urogenital sx applied HS 3 times/week
• Weight loss, CBT
• Smoking cessation, healthy diet, exercise, yoga, avoidance of triggers

Question 12

General monitoring for menopause

Answer 12

• Pt monitor sx -> may take up to 6-8 weeks before modifying regimen
• If experiencing SE from progestin -> decrease dose by ½ or decrease duration by 7-10 days
• If bleeding heavy or erratic on cyclic regimen -> increase progestin dose

Question 13

General follow up for menopause

Answer 13

• Follow-up in 6 weeks when starting new medication
• Re-assess hormone therapy annually
• Likely recommend tapering off hormone therapy to prevent worsening of VMS
• Useful to screen all menopause px for fracture risk

Question 14

Describe monitoring for menopause for a new hormone therapy

Answer 14

• Monitor for sx improvement and SE of medication weekly

- Common SE = breast tenderness, headache, mood changes

Question 15

Describe when to go to a Dr for menopause for a new hormone therapy

Answer 15

• Go to doctor if no sx improvement after 4-8 week trial?

- Any changes in frequency/severity of sx or if new sx occur

Question 16

Describe when to go to emergency for menopause for a new hormone therapy

Answer 16

• Go to emergency if dramatic mood changes or if sx worsen; severe AE to medication

Question 17

Describe non pharms for menopause for a new hormone therapy

Answer 17

• Vaginal moisturizer (Replens)
• Weight loss (if overweight)
• CBT, mindfulness-based stress reduction
• Smoking cessation, healthy diet, cooling techniques (carry a fan w/ you, wear loose and light clothing), yoga

Question 18

Describe follow up for menopause for a new hormone therapy

Answer 18

• I will follow up with you 1 week to discuss adherence, SE management, and sx improvement
• We will be in constant communication because we want you to be on this drug for the shortest possible amount of time

Question 19

Describe monitoring for menopause for a new non-hormonal therapy

Answer 19

• Monitor for sx improvement weekly and SE of medication daily
• Common SE of antidepressants = GI, headache, insomnia, sexual dysfunction
• Common SE of anticonvulsants = dizziness, somnolence, headache, weight gain, rash; dose HS

Question 20

Describe when to go to a Dr for menopause for a new non-hormonal therapy

Answer 20

Go to doctor if no sx improvement after 4-week trial; any changes in frequency/severity of sx or new sx occur

Question 21

Describe when to go to emergency for menopause for a new non-hormonal therapy

Answer 21

Go to emergency if sx worsen, dramatic mood changes

Question 22

Describe non pharms for menopause for a new non-hormonal therapy

Answer 22

• Vaginal moisturizer (Replens)
• Weight loss (if overweight)
• CBT, mindfulness-based stress reduction
• Smoking cessation, healthy diet, cooling techniques (carry a fan w/ you, wear loose and light clothing), yoga

Question 23

Describe follow up for menopause for a new non-hormonal therapy

Answer 23

• I will follow up with you 1 week to discuss SE management and adherence
• It takes about 2-4 weeks for this drug (antidepressant) to start working, so after 4 weeks I will follow up with you again and we can reassess if this medication should be continued or stopped.