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BCPS > Menopause and Osteoporosis > Flashcards

Menopause and Osteoporosis Flashcards

1
Q

Absolute contrainidcations to hormone therapy

A

Breast or endometrial cancer
CV disease
Active liver disease
Undiagnosed vaginal bleeding

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2
Q

Genitourinary syndrome of menopause (GSM)

A

Common symptom of menopause -
Genital symptoms: dryness, burning, irritation
Urinary symptoms: dysuria, urgency, recurrent UTI
Sexual symptoms: pain, dryness

Loss of estrogen leads to pruritis and pain

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3
Q

Vasomotor symptoms

A

Hot flashes - most common reason for HT due to impact to quality of life

Increased skin temperature, nausea, dizziness, headache, palpitations, sweats

Usually occurs within 12-24 months after last period

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4
Q

Recommend HT for these postmenopausal women

A

<60 y/o
Menopause onset within 10 years
Low risk of breast cancer and CV disease

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5
Q

Avoid HT for these postmenopausal women

A

High risk of breast cancer or CV disease
Age >60
Menopause onset >10 years ago

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6
Q

HT for postmenopausal women with high risk of VTE

A

Non-oral route
Lowest possible dose

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7
Q

HT for postmenopausal women with high risk of CVD

A

Known MI
CVD
PAD
Abdominal aortic aneurysm
DM
CKD
ASCVD >10%

Nonhormonal therapy

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8
Q

HT for postmenopausal with moderate risk of CVD

A

Transdermal estradiol with progestogen

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9
Q

Benefits of estrogen

A

Relieves genitourinary atrophy
Relieves vasomotor instability (improves sleep)
Reduces hip fractures & vertebral fractures
Reduces rate of bone resorption (does not reverse bone loss)

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10
Q

Risks of estrogen

A

AE: bloating, HA, breast tenderness
Endometrial cancer
Breast cancer
CHD
Gallbladder effects (gallstones, cholecystitis, cholecystectomy)

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11
Q

Endometrial cancer & estrogen

A

Increased risk if UNOPPOSED estrogen in women with intact uterus

Avoid if history of endometrial cancer

a progestogen is recommended in all people with an intact uterus using estrogen

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12
Q

Breast cancer & estrogen

A

Uncertain risk but avoid in women with history of breast cancer

Risk increases with use of progestogen .
Risk is related to length of use (>5 yr)

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13
Q

Benefits of progestogen

A

Decrease risk of estrogen-induced irregular bleeding
Decrease risk of endometrial hyperplasia and carcinoma

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14
Q

Risks of progestogen

A

AE: bloating, weight gain, irritability, depression

Unpredictable endometrial bleeding w/ continuous estrogen-progestin during first 8-12 months

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15
Q

Is Conjugated estrogen + medroxyprogesterone acetate appropriate for secondary CHD prevention?

A

No - not indicated for secondary prevention

Long-term use may be associated with decreased MI/ CHD death but increased risk of VTE and gallbladder disease

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16
Q

HT and stroke

A

EPT & ET have increased risk of stoke

50-59 y/o, EPT group had no significant increase in stroke
50-59 y/o ET group had double risk of stroke

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17
Q

HT therapy duration for postmenopausal women

A

-Lowest dose for least amount of time
-Reassess in 3 months to 1 year.
-D/C if asymptomatic.
-Treat for additional 3 months if symptoms recur.
-Limit to < 5 years

18
Q

Menostar patch

A

Lowest-dose patch available
Indicated ONLY for prevention of postmenopausal osteoporosis

19
Q

Benefit of SERM

A

Endometrial protection, so no need for progestogen

20
Q

SERMs for postmenopausal patients

A

Ospemifene (Osphena) - indicated for vaginal dryness or severe dyspareunia

Duavee: mod-severe vasomotor symptoms & prevention of osteoporosis

Similar ADE, contraindications as estrogen

21
Q

Alternatives to HT

A

Vasomotor symptoms:
Fezolinetant (veozah) - neurokinin 3 receptor antagonist
SSRI/SNRI paroxetine 7.5mg (briselle) is only SSRi with indication for vasomotor symptoms

No FDA approval:
soy isoflavones, evening primrose oil, black cohosh (liver tox)
Clonidine, gabapentin/pregabalin, acupuncture, hypnosis, lifestyle changes

22
Q

Low bone mass definition (osteopenia)

A

T score between -1 and -2.5

23
Q

Osteoporosis

A

T score < -2.5

24
Q

Severe/established osteoporosis

A

T score < -2.5 + fragility fracture

25
Q

Osteoporosis in postmenopausal women diagnosis

A

T score <-2.5 OR
Low-trauma spine or hip fracture, regardless of BMD
OR
Osteopenia + fragility fracture (proximal humerus, pelvis, distal forearm)
OR
Osteopenia + high FRAX fracture probability

26
Q

Calcium & vitamin D recs

A

At least 1000mg calcium/day
Avoid doses >2500mg/day (increased risk of constipation, kidney stones, inhibited absorption zinc, iron)

Vitamin D 800-1000 units
(<70 y/o = 600 units; >=70 y/o = 800 units)
Goal level = 30 ng/mL

27
Q

Gold standard for BMD

A

Dual-energy x-ray absorptiometry (DXA)

Measures hip, lumbar spine BMD

28
Q

Drugs that can cause osteoporosis/fractures

A

Antineoplastics
Anticonvulsants
Glucocorticoids
GnRH agonists
Heparin
Levothyroxine (excessive)
Lithium
PPIs
SGLT2i
SSRI

29
Q

FRAX

A

Fracture Risk Assessment Tool

Estimates fracture risk
Useful if pt has osteopenia, to determine need for pharmacologic treatment

Not validated for pts on drug therapy for osteoporosis

30
Q

When to initiate drug therapy for osteoporosis

A
  1. Hip or spine fracture
  2. T score <-2.5 at spine, hip, or femoral neck
  3. T score -1 to -2.5 at femoral neck or spine AND FRAX 10 year probability is >=3% OR FRAX probabiltiy >=20%
31
Q

Length of osteoporosis drug therapy

A

Reassess at 5 years (PO), 3 years (IV)

High risk of fracture: continue max of 10 years (PO) or 6 years (IV)

If fracture risk decreased, then drug holiday for 2-3 years

32
Q

Bisphosphonate General ADRs

A

GI irritation (do not lay for 30 min)

Decrease in serum Ca, Phos in first month

Osteonecrosis of jaw (if high dose IV prolonged therapy - usually in patients with cancer)

A fib possible but not sure.

33
Q

Bisphosphonate shown to decrease mortality

A

Zoledronic acid

Decreases mortality in high risk patients w/ hip fracture

34
Q

Bisphosphonates

A

First line therapy for osteoporosis

Alendronate
Risedronate
Ibrandronate (second line therapy) (women only)
Zoledronic acid

35
Q

Renal adjustment for bisphosphonates

A

Not recommended:

CrCl <35: alendronate, zoledronic acid
CrCl <30: risedronate, ibandronate

36
Q

IV bisphosphonate options

A

Ibandronate (PO & IV)
Zoledronic acid (IV only)

37
Q

Denosumab (Prolia)

A

Inhibits activation of RANKL - cytokine essential for formation, function, survival of osteoclasts

Preferred alternative to first line therapy
-Intolerant to bisphosphonates
-Poor renal function

First line if patient has very high risk or previous fractures

Must take calcium, vitamin D as it can cause hypocalcemia

38
Q

Raloxifene (Evista)

A

SERM

Prevention & treatment of osteoporosis in postmenopausal women PLUS
risk reduction for invasive breast cancer

Decreases resorption in bone
Decreases overall bone turnover

Risk of VTE- avoid if pt history. Highest risk first 4 months.

Interacts with warfarin, levothyroxine (separate by 12 hours)

39
Q

Conjugated estrogens & bazedoxifene (Duavee)

A

SERM + estrogen
HT. Indicated for prevention of osteoporosis - mainly in patients with persistent menopausal symptoms who cannot tolerate other drugs

CI: VTE, hepatic impairment, similar to estrogen

40
Q

Parathyroid hormone related peptide analogs

A

Teriparatide (Forteo) & Abaloparatide (Tymlos)
Both SC daily

Indicated for treatment of osteoporosis in postmenopausal women
Forteo can also be used in men

Recommended first line therapy if very high risk or prior fractures (use x2 yrs)

Do not use longer than 2 years (possible osteosarcoma)

Increases risk of digoxin toxicity

41
Q

Romosozumab (evenity)

A

Sclerostin inhibitor, builds bone, decreases bone resorption

SC monthly x12 months

Recommended first line therapy if very high risk or prior fractures

Do not use if MI or stroke in past year

No renal adjustments, but may be at higher risk for hypocalcemia

42
Q

Calcitonin-salmon (miacalcin)

A

Nasal spray. Inhibits bone resorption

Typically not recommended b/c weak effect on BMD but can be used short-term for bone pain

Higher chance for malignancies

BCPS (27 decks)

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