MHT, SERMs & TSECs (Segars)

Question 1

Symptoms of Menopause (only reasons to prescribe MHTs)

Answer 1

Hot flashes
Night sweats
Vaginal dryness/Painful intercourse/Sexual dysfxn
Sleep disturbances
Mood/Cognitive issues
Urinary incontinence

Question 2

What is the primary therapy for menopausal symptoms?

Answer 2

Estrogen; still have uterus - progestin as well

Question 3

Primary therapy for menopausal patients with a uterus still intact?

Answer 3

Estrogen AND progestin (unless it says they surgically removed their uterus)

***unopposed estrogen increased risk for endometrial hyperplasia/carcinoma

Question 4

What are the 4 available estrogenic forms for MHT?

Answer 4

1. Estradiol
2. Conjugated Estrogens (CE)
3. Esterified Estrogens (EE)
4. Estropipate

Question 5

What are the 3 available progestinic components?

Answer 5

1. Medroxyprogesterone (MPA)
2. Methyltesterone
3. Progesterone

Question 6

What things will be decreased once estrogen therapy is started?

Answer 6

Cholesterol (TC/LDL-C)
Anti-thrombin III
Osteoclastic activity (bone turnover)

Question 7

What things will be increased once estrogen therapy is started?

Answer 7

Triglycerides & HDL-C
Clotting factors (can be bad- cautious w/ pts with history of coagulative events (stroke, DVT, PE etc)
Platelet aggregation
Na+/fluid retention
Thyroid Binding Globulin (TBG)

Question 8

Harms of combined estrogen and progestin therapy

Answer 8

Breast cancer (combined only)
Coronary heart disease (combined only)
Dementia
Gallbladder disease
Stroke
Venous thromboembolism
Urinary incontinence

Question 9

Benefits of combined estrogen and progestin therapy

Answer 9

Diabetes
Fractures (stronger bones)
Colorectal cancer

Question 10

Harms of estrogen therapy alone

Answer 10

Dementia
Gallbladder disease
Stroke
Venous thromboembolism
Urinary incontinence

Question 11

Benefits of estrogen therapy alone

Answer 11

Breast cancer
Fractures
Diabetes

Question 12

What is the only harm associated with combine estrogen/progestin therapy that is a benefit for estrogen therapy alone?

Answer 12

Breast cancer (invasive)

Question 13

5 Major Points of Agreement

Answer 13

1. MHT is acceptable for treating menopausal symptoms
2. women with vaginal symptoms only are preferred to use low doses of topical vaginal estrogen
3. women with uterus - protesting along with estrogen and women w/o uterus - estrogen alone
4. MHT increases risk for blood clots and strokes
5. MHT increases risk of breast cancer

Question 14

What are two comorbidities that increase during menopause?

Answer 14

Bone effects (osteopenia/osteoporosis/fractures)
Cardiovascular effects (ACS/MI/CVD)

Question 15

What is a benefit associated with combine estrogen and progestin therapy that is not associated with estrogen use alone?

Answer 15

Colorectal cancer

Question 16

What are the two harms that are associated with combine estrogen and progestin therapy that is not associated with estrogen use alone?

Answer 16

Breast cancer and coronary heart disease

Question 17

Selective Estrogen Receptor Modulators (SERMS) goals

Answer 17

pro-estrogenic agonist actions in select tissues (bone, vagina and vasomotor) and anti-estrogenic antagonist actions in other tissues such as breast and endometrium

Question 18

Tissue Selective Estrogen Complexes (TSECS)

Answer 18

combines SERM with estrogen compound

Question 19

What are the two SERM agents

Answer 19

Ospemifene
Clomiphene

Question 20

What is the only TSEC and when is it used?

Answer 20

Bazedoxifene; women with intact uterus; only used the replacing progestin therapy in patient who absolutely cannot tolerate that medication in a combined therapy; MOA destroy HER2 malignant cells

Question 21

Ospemifene

Answer 21

indicated for dyspareunia (painful intercourse) due to vulvar & vaginal atrophy (VVA) or vaginal dryness; MOA agoist on vagina and anti-estrogenic on breast; can have worsening menopausal symptoms

Question 22

Clomiphene

Answer 22

indicated in infertility when patient is trying to get pregnant; irregular ovulation, luteal phase defects, PCOS

Question 23

MOA of clomiphene

Answer 23

blocks inhibitory (neg feedback) actions of estrogen on hypothalamus, preventing estrogen from lower GnRH and pituitary gonadotropin release; side effects ovarian cysts; luteal phase dysfunction