Menopause/Hormonal Contraception Flashcards
1
Q
Premenopausal Phase
A
- Reproductive phase
- Cyclic
- Predictabe hormones
2
Q
Perimenopausal Phase
A
- Includes menopause transition and ends at 12 months after FMP
- Acyclic
- Fluctuating hormones
- Hot flashes increase as stages progress
3
Q
Postmenopausal Phase
A
- Phase following FMP
- Ovarian cessation
- Low hormones
4
Q
Menopause Signs
A
- Low estrogen levels
- Vaginal wall thinning
- Irregular menses
- Decreased libido
- Erratic levels of estrogen and progesterone
5
Q
Menopause Symptoms
A
- Vasomotor symptoms
- Sleep disturbances
- Mood changes
- Problems with concentration/memory
- Vaginal dryness and dyspareunia
- Arthralgia
- Cessation of menses
6
Q
Vasomotor Symptoms
A
- Hot flashes (hot flashes, night sweats)
- 75-85% of women
- Erythema and perspiration
- Skin (face, head, neck) may become red/warm
- Episodic flush (30 seconds to 5 minutes)
- Chills
- Night Sweats
7
Q
Genitourinary Symptoms of Menopause (GSM) - Signs
A
- Decreased labia size
- Loss of elasticity with constriction
- Thin vaginal epithelial lining
- Petechiae, ulcerations, or tears
- Recurrent UTI
8
Q
GSM - Symptoms
A
- Atrophy of vaginal mucosa
- Genital dryness, burning, irritation
- Impaired sexual function
- Spotting/bleeding post intercourse
- Urinary urgency
- Dysuria
9
Q
Menopause Lab Tests
A
- Perimenopause: FSH on day 2/3 of menstrual cycle >10-12 IU/L (variable)
- Menopause: FSH > 40 IU/L
- Other relevant tests: thyroid function tests, iron stores, lipid profile
10
Q
Goals of Menopause Therapy
A
- Natural process, not a disease
- Relieve symptoms and improve quality of life
- Minimize adverse SE
11
Q
Pharmacologic Algorithm
A
- Assess their symptoms
- Assess the severity of their symptoms
- Assess if estrogen therapy is CI
- Select appropriate therapy
12
Q
Vasomotor Non-pharmacologic Therapy
A
- Wearing layered clothing
- Lowering room temperatures
- Avoid triggers: spicy foods, caffeine, hot drinks
- Weight management
- Exercise
- Avoid alcohol
- Smoking cessation
13
Q
GSM Non-pharmacologic Therapy
A
- Moisturizers/lubricants
- Kegel exercises
- Oxybutynin or tolterodine for urge incontinence
14
Q
Vasomotor Hormone Therapy
A
-Oral/transdermal estrogen therapy is the most effective
Intact Uterus Options: -Combination of estrogen + progesterone -Continuous cycle -Continuous combined -Continuous long cycle -Intermittent combined EX: Duavee (conjugated estrogen + bazedoxifene)
15
Q
GSM Hormone Therapy
A
- Low dose vaginal estrogen populations
- EX: premarin vaginal cream, estring, vagifem
- Non-estrogen Rx Therapies: Osphena
16
Q
Hormone Replacement Therapy Uses
A
- Systemic: moderate to severe vasomotor symtpoms
- Intravaginal: moderate to severe vulvar/vaginal atrophy (EX: vaginal dryness, dyspareunia, atrophic vaginitis)
17
Q
Absolute CI of MHT
A
- Undiagnosed vaginal bleeding
- Known or suspected pregnancy
- Estrogen dependent neoplasm
- History of breast cancer
- Active/history of DVT or PE
- Active/history of arterial thromboembolic disease (stroke/MI)
- Liver dysfunction
18
Q
Relative CI of MHT
A
- Elevated BP
- Hypertriglyceridemia
- Impaired liver function
- Hypothyroidism
- Fluid retention
- Severe hypocalcemia
- Ovarian cancer
- Diabetes
- Migraines with aura (oral estrogen therapy)
- Intermediate risk for breast cancer
19
Q
MHT Box Warning
A
- Endometrial cancer
- CV disease (increased risk of strokes/MI)
- Venous thromboembolism
- Breast Cancer
- Risk v.s. Benefit: estrogen only should be used at the lowest doses for the shortest durations possible
20
Q
Duavee
A
- Conjugated estrogen/bazedoxifene
- Indication: women with intact uterus for menopause or prevention or post menopausal osteoporosis
- AE: dizziness, muscle spasm, oropharyngeal pain
- Agonst: Bone
- Antagonist: Endometrium
- Neutral: breast
21
Q
Estrogen AE
A
- Nausea, headache, breast tenderness, heavy bleeding
- Serious: increased risk for CHD, stroke, venous thromboemolism, breast cancer, gallbaldder disease
- Elevation of TG
- *Transdermal estrogen has lower incidence of breast tenderness, DVTs, and increased TG
22
Q
Progesterone AE
A
- Irritability, weight gain, irritability, bloating, headache
- Pre-menstual-like symptoms: mood changes, bloating, fluid retention, sleep disturbances
23
Q
Vaginal Products Risks
A
- Not statistically acting
- Inadequate relief for VM symptoms
- Endometrial cancer with long term use
24
Q
Vaginal Products Benefits
A
- Long acting
- Restore blood flow
- Improves thickness of walls (increases it)
- Quicker response than systemic
25
Q
Paroxetine
A
- Brisdelle
- Alternative
- Indication: moderate to severe VM symptoms with menopause
- Dose: 7.5 mg
- AE: headache, fatigue, N/V
26
Q
Other Non-Hormonal Options
A
- Catapres
- Effexor
- Neurontin
27
Q
Black Cohost
A
- NOT RECOMMENDED
- Treat hot flashes and night sweats
- Monitoring: liver function
- Long term safety data is unknown
28
Q
Compounded Estrogen
A
- Bioidentical
- Compounded therapies
- May combine multiple hormones: estradiol, estriol, estrone, DHEA, testosterone, progesterone
- Untested, unapproved combinations or formulations
- Prescribed or dosed on bases of salivary hormone testing (unreliable)
29
Q
Alternatives Durations
A
- Estrogen: shortest duration possible
- SSRI/SNRI: 8-24 weeks in most trials
- Lack of long term use data
30
Q
Alternatives Monitoring
A
- Resolution of symptoms
- Specific AE
- 6 mo. after initiation of therapy, followed by annually re-assessment of therapy
31
Q
Conclusion
A
- Hormone therapy is most effective for VM and vaginal symptoms
- Intact uterus: estrogen + progesterone
- No Uterus: estrogen only
- Treatment should be individualized based on benefits and risks and reevaluating when determining continuation of hormone therapy
- In women <60 y.o. or are within 10 years of menopause that have no CI, hormone therapy is favorable
