Menopause

Question 1

Standard estrogen dose equivalencies between

• Oral conjugated equine estrogen
• Oral estradiol
• Transdermal estradiol
• Oral ethinyl estradiol

Answer 1

• Oral conjugated equine estrogen 0.625mg
• Oral estradiol 1mg
• Transdermal estradiol 0.05mg
• Oral ethinyl estradiol 0.005mg

Question 2

Menopause definition

Answer 2

Menopause is the date of the final menstrual period

Question 3

Average age of menopause in caucasian women living in the US

Answer 3

51.3

Question 4

Definition of Primary ovarian insufficiency

Answer 4

menopause < 40yo

Question 5

Menstrual transition common symptoms

Answer 5

• menstrual irregularity (90%)
• Hot flushes/night sweats (80%)
• Insomnia (45%)
• Mood changes/depression (30%)
• Cognitive changes (45%)
• Musculoskeletal (50%)
• Diminished libido (60%)
• Dyspareunia (20%)

Question 6

Menopause physiology, hormonal changes of LH, FSH, estradiol, progesterone, GnRH, inhibin, AMH?

Answer 6

Ovarian aging –> decreased antral count –> decreased (inhibins + AMH) and decreased (estradiol + progesterone) –> hypothalamus –> increased GnRH –> pituitary –> increased LH + FSH

Kisspeptin, neurokinin B, and dynorphin (KNDy) neurons are neurons in the hypothalamus of the brain that are central to the hormonal control of reproduction. KNDy neurons control GnRH pulse generation by through release of three known peptides.

Question 7

TSEC?

Answer 7

TSEC = Bazedoxidene 20mg + 0.45 conjugated equine estrogen 0.45mg

Bazedoxifene = an estrogen agonist/antagonist

• Approved by the FDA for treatment of vasomotor symptoms and to prevent osteoporosis in postmenopausal women with a uterus

Question 8

Some guiding principles for postmenopausal hormone therapy

Answer 8

• Age <60
• Least amount of progestin possible
• Low dose estradiol
• transdermal
• Local therapy for local problem

Question 9

Some examples of low dose estradiol and progesterone

Answer 9

• Low dose estradiol + micronized progesterone vaginal 200mg/day or norethindone acetate 5mg/d x 14 days/month every 2 months
• If you do ultra low dose of estradiol (<0.0125mg), you don’t have give progesterone/

Need TVUS annually for 2-3 years for long cycles or unopposed ET. Annual follow up visit for bleeding

Question 10

Is bioidentical hormone therapy better?

Answer 10

There is data supporting variable purity, mislabeling with unclear potency and lack of efficacy and safety data

Question 11

Estradiol level for menstruation and menopausal?

Answer 11

Menstruation: >200pg/mL
menopause: <50pg.mL

Question 12

FSH for postmenopausal range

Answer 12

FSH > 20pg/mL

Question 13

Clinical effects of premature ovarian insufficiency or surgical menopause?

Answer 13

Increased osteoporosis, cardiovascular disease, dementia, Parkinson’s

Question 14

Ideal estrogen dose for premature ovarian insufficiency for osteoporosis prevention?

Answer 14

• 0.05 - 0.1mg Transdermal estradiol
• 2mg oral estradiol?
• 0.01 -0.02mg Ethinyl Estradiol

Question 15

Why does smoking increase your VTE risk?

Answer 15

Smoking causes premature aging of your cardiovascular system