Menopause therapy Dr. Flores

Question 1

What is the most effective treatment for Vasomotor symptoms (VMS)?

Answer 1

systemic menopause hormone therapy -> oral and patches

also when the woman is close to menopause (within 5 -10 years of transition, less than 60) and does not have a risk for breast cancer or cardiovascular disease

symptoms: hot flashes, night sweats

Question 2

What is the most effective treatment for genitourinary symptoms (GMS)?

Answer 2

low dose vaginal estrogen (topical) therapy

Question 3

Symptoms of Menopause

Answer 3

Vasomotor
-Headache, NV
-hot flashes, night sweating, sleep disturbance
-palpitations
-dizziness

Genitourinary
-vulvovaginal atrophy (dryness, burning, itching, vulvar pruritis; stress incontinence (low urogenital tone), UTI)

Mood
irritability, depression, poor concentration, impaired memory

Question 4

What are the bioidentical hormones?

Answer 4

-similar to the hormones produced by the human body

-17ß-estradiol
-Estrone
-Estriol

-Progesterone - micronized with peanut oil -> PEANUT ALLERGY

Question 5

Why is Progesterone (bioidentical) micronized with peanut oil?

Answer 5

-it improves absorption
-poorly absorbed and rapidly, metabolized

Question 6

When to consider topical vaginal menopause therapy?

Answer 6

-the patient has genitourinary symptoms
-minor or no vasomotor symptoms (hot flashes, sweating)

Question 7

Contraindication for vaginal estrogen

Answer 7

-UNEXPLAINED vaginal bleeding

-breast cancer (consult with oncologist, may be able to use a topical formulation)
-endometrial cancer
-other hormone-sensitive cancer

Question 8

ADE of Vaginal estrogens

Answer 8

-Headache (6-13%)

-burning, itching, pain, bacterial vaginosis, candidiasis, UTIs

Question 9

Topical vaginal products

Answer 9

Cream
-Premarin (CEE, conjugated equine estrogen)
-Estrace (Estradiol, bioidentical)

Vaginal ring
-Estring
-Femring (high dose, may be systemic at high dose, also approved for vasomotor symptoms) -> may need progestin to protect the uterus from endometrial hyperplasia

Vaginal tablet
-Vagifem

Vaginal inserts
-Imvexxy

Question 10

Which drug is indicated for severe dyspareunia?

Answer 10

Intrarosa (prasterone)

-synthetic steroid (DHEA) -> metabolite is estrogen and progesterone -> CAUTION: estrogen causes risk for breast cancer

-CI: unexplained vaginal bleeding

Question 11

Which oral (systemic) drug is indicated for moderate to severe dyspareunia?

Answer 11

Osphena (ospemifene)
-SERM: estrogen agonist on vaginal tissue, antagonist on breast tissue -> no progesterone needed
-don’t use it with other estrogens

ADE: hot flashes, endometrial hyperplasia

CI: undiagnosed genital bleeding, history of DVT or PE, pregnancy

Question 12

When to use systemic menopausal hormone therapy?

Answer 12

-use if no CI and the patient desires for vasomotor symptoms
-may help with mood and genitourinary symptoms

Question 13

What to use if a patient has a moderate cardiovascular risk?

Answer 13

-may use a transdermal instead of nothing at all

highest risk: oral estrogen > trasndermal estrogen > vaginal estrogen

Question 14

When is progesterone needed in menopausal therapy?

Answer 14

When the patient has a uterus and is treated with systemic estrogen

-to reduce the risk of endometrial cancer

-progesterone may be given in 10-14 days of the cycle, estrogen is given every day

Question 15

ABSOLUTE Contraindications for systemic estrogen therapy

Answer 15

vaginal CI: UNEXPLAINED vaginal bleeding and breast cancer, endometrial cancer

+

-liver disease (clot risk)
-h/o or active VTE
-thrombophilic disease
-Cardiovascular disease (MI, CVA; TIA)
-HTN
-hypersensitivity

Question 16

Relative CI for systemic estrogen therapy

Answer 16

-women with 1st-degree relatives with h/o of breast cancer or risk of breast cancer
-age over 60 or 10y beyond menopause onset
-CVD risk > 10%

also REEVALUATE patients who are on menopausal treatment and become 60 or 10y beyond menopause onset or risk for cancer

Question 17

Reasons to choose transdermal over ORAL

Answer 17

-CVD risk 5-10%
-gallbladder disease
-elevated triglycerides (>400 mg/dl)

Question 18

Transdermal examples ET

Answer 18

ET = Estrogen only
-systemic

-Climara
-Vivelle-dot
-Alora
-Divigel

only use ET if they had a hysterectomy, if not add progesterone product to protect from endometrial hyperplasia or use a combi product (estrogen + progesterone)

Question 19

Transdermal combi products

Answer 19

-ClimaraPro
-Combipatch

Question 20

Oral menopausal therapy
ADMINISTRATION

Answer 20

cyclic:
-estrogen daily
-progestogen:1 0-14 days every 1-4 months
->recommended for women who have not yet experienced 12 months without menses

continuous -> daily estrogen and progestogen results in endometrial atrophy (decrease in size)

Question 21

Oral menopausal therapy
EXAMPLES

Answer 21

ET = estrogen only
-Premarin (CEE)
-Estrace (Estradiol)

EPT = estrogen and progestegon
-Activella
-Prempro: CEE + MDA (stable)
-Premphase CEE + MDA (cyclic progestogen)

Question 22

Oral Progestogen-only products

Answer 22

daily or cyclic

-Provera
-Prometrium (progesterone) - with peanut oil

Question 23

Oral bioidentical product for vasomotor symptoms

Answer 23

Bijuva
-for women with intact uterus
-CI: hormone related

Question 24

Duavee + bazedoxifen (SERM)

Answer 24

-CEE + SERM (instead of progestogen)
-for vasomotor symptoms with an intact uterus

SERM part is an antagonist in the endometrium and breast tissue and an agonist in the bone tissue (may be used in the prevention of postmenopausal osteoporosis)

-CI: uterine bleeding, h/o VTE, MI, estrogen-dependent cancer, pregnancy