menopause Flashcards
what are indications for HRT
- moderate to severe vasomotor symptoms
contraindications to systemic HRT
- pregnancy
- estrogen responsive tumor (EMCA or breast)
- history of VTE
- active severe liver disease
- unexplained vaginal bleeding
- coronary artery disease
- stroke
- dementia
what was primary outcome and primary adverse outcome of WHI? what were groups being compared?
- primary outcome: ASCVD (MI, acute coronary death_
- 3 arms: placebo vs combination HRT (CEE 0.625 mg + MPA 2.5 mg/day) vs CEE 0.625 mg daily
what was the primary outcome of the WHI trial?
no increase in overall mortality in the HRT or ERT groups compared to placebo (i.e. it is not indicated for primary prevention of ASCVD)
what were the primary/secondary outcomes of combination HRT
risks:
- 30% increased risk of coronary heart disease
- 25% increased risk of breast cancer
- 40% increased risk of stroke/PE
(all into 7-8 more cases/10,000 women year)
benefits:
- 33% reduction in bone fracture
- 33% reduction in colon cancer
(5-6 fewer cases/10,000 women years)
what are the current risks of combination HRT
- VTE
- breast cancer
- biliary issues
Starting cHRT >60 years (NAMS 2017 guidelines) - MI, stroke, dementia
what were the primary/secondary outcomes of estrogen alone therapy in WHI?
risk:
- increased VTE/stroke
- NO DIFFERENCE IN CHD, BREAST CANCER
benefit:
- decreased fractures (38-39%)
- NO DIFFERENCE IN CRC RATES
what is the caveat to WHI findings
mean age was 63 years. HERS study and subsequent analyses found no CV risk in age under 60 years
okay to use HRT in women who undergo ppx BSO for BRCA?
limited observational studies say okay to age 52
okay to use HRT in family hx of breast cancer?
HRT does not appear to increase risk
endometrial and breast cancer survivors?
- try non-hormonal first
- level II that it does not increase risk, and has minimal systemic absorption
key concepts in treatment
- lowest dose possible of HRT
- only for VSM or GSM
- not hard and fast rule to dc at age 65
- consider transdermal for pts with
what are doses/options for estrogen component and progesterone component?
standard dose
- conjugated estrogen: 0.625 mg/day
- micronized estradiol 17B 1 mg/day
- transdermal estradiol 0.0375-0.05 mg/day
low dose
- conjugated estrogen: 0.3-0.45 mg/day
- micronized estradiol 17B 0.5 mg/day
- transdermal estradiol 0.025 mg/day
progestins - only for uterine protection
- MPA 2.5 mg/day or 5 mg x 12 days cycled (starting day 1 or 16)
- micronized progestin 100 mg/day or 200 mg/day x 12 days
possible to use estrogen agonist/antagonist with estrogen
- conjugated estrogen 0.45 mg + bazedoxipene 20 mg/day combination tablet
what are treatment options for GSM?
- estradiol 17B ring: releases 7.5 mcg/day; replace q3 months
- estradiol ring: 0.05 mg/day
- estradiol 17B cream: 0.05 mg/day (estrace)
- CEE cream: 2/gday (premarin)
- vaginal estradiol tablet 10 mcg tabs (estrace)
- vaginal inserts (4 nanogram or 10 nanogram) - vagifem
all creams/tabs - daily x 2 weeks, then twice weekly
what are non-hormonal options for VSM/GSM?
non-pharmacologic:
- sleeping in cool area
- dress in layers
- avoid hot foods, beverages, spicy food, ETOH, caffine
- Consume soy products
- increase H2O
all more effective than placebo but less than HRT
SSRIs/SNRIS:
- paroxetine (brisdelle) - only FDA approved at 7.5 mg/day
- fluoxetine (prozac)
- venlafaxine (effexor)
-AVOID PAROXETINE AND FLUOXETINE WITH TAMOXIFEN, CYP2D6 inhibitor (may dampen tamoxifen’s effect)
Clonidine
- 0.1 mg/day, watch hypotensoin
Gabapentin (600-900 mg/day)
- similar efficacy to venlafaxine, pts prefer venlafaxine
SERM
- Ospemifene 60 mg/day
- FDA approved for GSM with dsyapruenia
- no increased risk of EMCA/hyperplasia
- risks of muscle spasm, vaginal discharge, VSM
Vaginal lubricants: water or silicone based
