Menopause Therapeutics Flashcards
What is systemic and local estrogen for?
Systemic (oral, transdermal): vasomotor symptoms
Local: for vulvovaginal atrophy
What are risks of using the first pass effect in systemic estrogen (oral pill instead of transdermal)
Increases:
- HDL cholesterol
- Triglycerides
- Coagulation factors
When are transdermal products used?
When at risk of:
- Hypertriglyceridemia
- High risk of VTE
- Malabsorption
- Obese women with metabolic syndrome
- Smokers
- history of gallstones
What are contraindications to estrogen therapy
- unexplained vaginal bleeding after 1 year of amenorrhea
- liver disease
- history of thromboembolic disease
- Estrogen-dependent cancer
- Pregnancy
- Coronary heart disease
- Previous stroke
When is follow up for estrogen
4-6 weeks
When is progestogen HT indicated?
Women with a uterus taking systemic ET
- prevents endometrial hyperplasia
- hyperplasia occurs within 6 months of ET if they do not take progesterone
What are CI of progestogens
- unexplained vaginal bleeding
- breast cancer
- pregnancy
- peanut allergy
- soy allergy
When do we give progestogen IUD
Estrogen + levonorgestrel
- if patients experiencing s/e to oral progestogen
- if they want contraception
What is the dosing like when using progestogen?
Cyclic for 5 years pre-menopause and 2 years post-menopause
- 2 weeks on, 2 weeks off
- to prevent BTB - although common
After 2 years post-menopause: continuous dosing
When are combo products used?
When patients are stabilized on a dose
- more difficult to taper
- daily pills
When to use COC in menopause?
Perimenopausal women if
- they need contraception
- useful when needing to control irregular or heavy bleeding
When is vaginal estrogen used?
For symptoms of vulvovaginal atrophy
- including dyspareunia
- urinary urge incontinence
- Recurrent UTIs
Must try systemic first
What are the CI of vaginal estrogen?
Not CI in women with CI to oral
- avoid in women with breast cancer and aromatase inhibitors
Which therapies are more risker for side effects
EPT vs ET
Oral vs transdermal
Risks:
EPT > ET
Oral > transdermal
When to treat or avoid HT in breast cancer? When does risk of breast cancer decrease?
Treat: risk of breast cancer
AVOID: if they had breast cancer
Risk decreases 3 years after stopping HRT
What to give if patient has GSM symptoms but no vasomotor symptoms?
Use vaginal lubricants/moisturizers
If inadequate response
- start low dose vaginal estrogen
When do you avoid HT if patient has vasomotor symptoms?
- 10+ years of menopause
- CVD risk over 10%
When to choose transdermal patches if patient has vasomotor symptoms?
If patient has moderate risk of CVD 5-10%
Explain what tibolone is an alternative for?
Activity?
Who should use?
Efficacy?
When to start?
Tibolone: alternate therapy for vasomotor symtpoms
Activity:
- all 3 types: estrogenic, progestogenic, androgen
Who should use
- patients with uterus
- patients who don’t tolerate EPT
Efficacy
- more effective than EPT at improving vaginal symptoms
- Less effective in reducing vasomotor symptoms
When to start?
- wait at least 1 year after LMP to avoid worsening BTB
What is bazedoxifine used for (symptoms)?
Drug class?
Benefit?
Class: SERM
Used for vasomotor symptoms, vulvovaginal symptoms, osteoporosis
Benefit
- does not require a progestogen
- less bleeding, less breast tenderness
What symptoms are antidepressants used for?
Who should use it?
For vasomotor symptoms
Who should use:
- EPT is CI
- if pt has anxiety/depression symptoms
What are some lifestyle changes to offer relief of vasomotor symptoms?
Reduce core temp
Regular exercise
Weight management
Smoking cessation
Avoiding hot drinks, alcohol
Cognitive behavioural therapy
What symptom is ospemifene used for?
Drug class?
Who should use?
Efficacy?
Benefit?
Side effects?
Used for genitourinary syndrome symptoms
Only SERM with agonist on vaginal epithelium
Who should use
- 2nd line for atrophic vagina symptoms
Efficacy: similar to ET
Benefit: no need for progesterone
Side effects
- increases vasomotor symptoms
What symptoms are dehydroepiandrosterone used for?
MOA
GSM symptoms
- insert vaginally
MOA: inactive sex hormone that is converted to estrogen + androgen in vaginal cells
