Menopause

Question 1

Recommended dose of Vitamin D in

< 50 yo and no RF

> 50 yo or RF

RF= osteoporosis, multiple #, malabsorption

Answer 1

< 50 yo: 400 - 1000 U daily

> 50 yo: 800 - 1000 daily

Question 2

What is the recommended daily dose of Calcium

Answer 2

Age: 19 - 50: 1000 mg daily

Age over 50: 1200 mg daily

Question 3

What are the values of LDL at which you need to treat?

Answer 3

Low risk, treat if LDL >/= 5.0 mmol/L

Intermediate risk, treat if LDL >/= 3.5 mmol/L

High risk, treat regardless of cholesterol level but AIM to have cholesterol = 2.0 mmol/L or a decrease > 50%

Question 4

What is the highest normals waist circumference in women

Answer 4

88 cm

Question 5

What are the parameters of metabolic syndrome (

Answer 5

Over 3 of the following criteria:

Obesity

HTN

Glucose status

HDL

Triglycerides

Question 6

With regards to ER/PR and HER2, do they have a positive or negative impact

Answer 6

ER/PR : improved survical

HER-2 : negative impact

Question 7

What is the most potent naturally occuring etrogen?

And # 2, #3?

Answer 7

1: 17-Beta estradiol

Question 8

What is the objective of “micronized” estrogen / progesterone?

Answer 8

Enhances oral bioavailability (absorption) and prevents degradation

Question 9

What are the estrogens preparation for HRT (3)?

Answer 9

Conjugagted estrogen (Premarin)

17-beta-estradiol (Estrace)

Esterified estrogens (Estragyn)

Question 10

In HRT, what is the minimum dose of estrogen required for vasomotor symptom relief and bone benefit?

Answer 10

5 ug

N.B. Much lower than the 20-30 ug in OCP (hence reason why continuous OCP is not an ideal option)

Question 11

In which women should HRT be provided by transdermal route (4 +3) ?

Answer 11

High risk of VTE **

Malabsorption **

Hypertriglyceridemia (spontaneous or estrogen induced)**

Obese with metabolic syndrome **

Smokers

HTN

Sexual dysfunction

** Evidence for adverse effects vs advantage of transdermal

Question 12

How do you follow a patient only on estrogen therapy?

Answer 12

Yearly endometrial biopsy

If progesterone added, continue yearly endometrial biopsies as effect of estrogen does not dissapear right away

OR use a SERM

Question 13

Through which mecanisms are obese women exposed to excess estrogen (2)?

Answer 13

Peripheral convertion of androstenedione → estrone in adipose tissue (aromatase)

Reduced serum concentration of SHBG → increase free estrogen

Question 14

What are the progesterone preparations for HRT (2 x 3 + 1)?

Answer 14

17-alpha-hydroxyprogesterone derivatives

• MPA
• Megestrol (Megace)
• Micronised progesterone (Prometrium)

19-nortestosterone derivatives

• Norethindrone
• Norethindrone acetate
• Levonorgestrel – Only as mirena

Spironolactone derivative

• Drospirenone – Only in combination with estradiol

Question 15

What is the name of the SERM approved for HRT?

Answer 15

Bazedoxifene

To be used with conjugated estrogen only

Question 16

What is the effect of menopause (natural and surgical) on estradiol and testosterone levels?

Answer 16

Natural

• Estradiol decreases by > 80 %
• Testosterone decreases by 25 %

Surgical

Testosterone decreases by 40 - 50 %

Question 17

Name the contraindications to estrogen replacement therapy (6)

Answer 17

Previous stroke

Coronary heart disease

Active thromboembolic disease

Acute liver dysfunction

Unexplained vaginal bleeding

Estrogen dependant cancer (endometrial/ breast)

Question 18

What are the contra-indications to progesterone therapy (2+1)?

Answer 18

Breast cancer

Unexplained vaginal bleeding

Peanut allergy ? (micronized progesterone)

Question 19

What are the non-hormonal Rx to treat VMS and which one is the most effective?

Answer 19

SSRI (Venlafaxine, paroxetine, fluoxetine)

Gabapentin

Clonidine

Bellergal

SSRI most effective

Question 20

What is the most common complain of post menopausal women?

Answer 20

Vasomotor symptoms

Sleep disturbance

Question 21

What is the most effective way of reducing cardiovascular risk in post menopausal patients?

Answer 21

Reduction of modifiable RF

DM

HTN

Abdominal obesity

Smoking

Psychological stress

Question 22

With regars to HRT and VTE

What factors increase the risk of VTE beyound the baseline risk (4)?

Answer 22

Oral route (vs transdermal)

Estrogen-Progesterone therapy (vs estrogen alone)

Older

Obese

Question 23

With regards to HRT and cardiovacular health

Which factors increase the risk of CVD (2)?

Answer 23

HRT initiated > 10 y post menopause

Combined estrogen-progesterone therapy (vs estrogen alone)

Question 24

Does HRT increase the risk of stroke and in which population?

Answer 24

Standard doses : YES

Low dose: low to absent risk

Question 25

If a cardiovascular event would happen to women on HRT, when is it moore likely to happen?

Answer 25

Within the first years of use

Question 26

What is pre-menopause surgical oophorectomy associated with?

Answer 26

↑ Risk of CAD

↑ Risk of stroke

Question 27

What are the metabolic effect of HRT in women without DM?

Answer 27

HRT reduces …. In women without DM

Abdominal obesity

Insulin resistance

New onset DM

Lipid levels

Blood pressure

Question 28

What are the metabolic effect of HRT in women with DM?

Answer 28

HRT reduces….in women with DM

Insulin resistance

Fasting glucose

Question 29

List the risk factors for DVT in post-menopausal women (4)

What is the best way to administer HRT?

Answer 29

Age

Obesity

Factor V Lieden

Hx of prior DVT

Use TRANSDERMAL therapy