Menopause therapy Dr. Flores Flashcards
What is the most effective treatment for Vasomotor symptoms (VMS)?
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
What is the most effective treatment for genitourinary symptoms (GMS)?
low dose vaginal estrogen (topical) therapy
Symptoms of Menopause
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
What are the bioidentical hormones?
-similar to the hormones produced by the human body
-17ß-estradiol
-Estrone
-Estriol
-Progesterone - micronized with peanut oil -> PEANUT ALLERGY
Why is Progesterone (bioidentical) micronized with peanut oil?
-it improves absorption
-poorly absorbed and rapidly, metabolized
When to consider topical vaginal menopause therapy?
-the patient has genitourinary symptoms
-minor or no vasomotor symptoms (hot flashes, sweating)
Contraindication for vaginal estrogen
-UNEXPLAINED vaginal bleeding
-breast cancer (consult with oncologist, may be able to use a topical formulation)
-endometrial cancer
-other hormone-sensitive cancer
ADE of Vaginal estrogens
-Headache (6-13%)
-burning, itching, pain, bacterial vaginosis, candidiasis, UTIs
Topical vaginal products
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
Which drug is indicated for severe dyspareunia?
Intrarosa (prasterone)
-synthetic steroid (DHEA) -> metabolite is estrogen and progesterone -> CAUTION: estrogen causes risk for breast cancer
-CI: unexplained vaginal bleeding
Which oral (systemic) drug is indicated for moderate to severe dyspareunia?
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
When to use systemic menopausal hormone therapy?
-use if no CI and the patient desires for vasomotor symptoms
-may help with mood and genitourinary symptoms
What to use if a patient has a moderate cardiovascular risk?
-may use a transdermal instead of nothing at all
highest risk: oral estrogen > trasndermal estrogen > vaginal estrogen
When is progesterone needed in menopausal therapy?
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
ABSOLUTE Contraindications for systemic estrogen therapy
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
Relative CI for systemic estrogen therapy
-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
Reasons to choose transdermal over ORAL
-CVD risk 5-10%
-gallbladder disease
-elevated triglycerides (>400 mg/dl)
Transdermal examples ET
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)
Transdermal combi products
-ClimaraPro
-Combipatch
Oral menopausal therapy
ADMINISTRATION
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)
Oral menopausal therapy
EXAMPLES
ET = estrogen only
-Premarin (CEE)
-Estrace (Estradiol)
EPT = estrogen and progestegon
-Activella
-Prempro: CEE + MDA (stable)
-Premphase CEE + MDA (cyclic progestogen)
Oral Progestogen-only products
daily or cyclic
-Provera
-Prometrium (progesterone) - with peanut oil
Oral bioidentical product for vasomotor symptoms
Bijuva
-for women with intact uterus
-CI: hormone related
Duavee + bazedoxifen (SERM)
-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
