mod 8. Menstrual concerns + Osteoporosis

Question 1

what vitamins are important in the treatment and prevention of osteoporosis?

Answer 1

calcium
magnesium
vitamin D
Vitamin K

Question 2

Why is vitamin D important for osteoporosis? and where do we get it from?

Answer 2

Vitamin D helps in the absorption of calcium in the small intestine

Question 3

what is the first line treatment for osteoporosis?

Answer 3

Biphosphates such as alendronate and risedronate

They must be taken on an empty stomach with a glass of water

Question 4

what is a Biphosphonate drug holiday?

Answer 4

Prolonged use of biphosphonate can be linked to the development of an aypical femur fracture (doesnt heal properly)

If a patient is not considered high risk for osteoporotic fractures they should stop taking biphosphonate after 5 years of oral therapy or after 3 years of IV therapy

the duration of how long this “holiday” is is TBD

Question 5

for which patients are drug holidays of alendronate, risedronate, and zoledronate not advised?

Answer 5

Drug holidays are not recommended in patients with a history of a previous fracture of spine or hip, as these individuals are at higher risk for recurrent fractures and the benefit of ongoing therapy is greater than potential risks

Question 6

How does calcitonin treat osteoporosis?

Answer 6

Calcitonin reduces pain associated with acute vertebral fractures

Question 7

How does Teriparatide work to treat osteoporosis?

Answer 7

Teriparatide is a parathyroid hormone analoge, it activates bone reabsorption and it in the kidneys it cause calcium to be reabsorbed

it is effective at treating coticosteroid induced osteoporosis

Question 8

for the prevention of osteoporosis in early postmenopause women, what agent can you prescribe?

Answer 8

estrogen or estrogen/progesterone

but it should not be used as a treatment for osteoporosis its just preventative

Question 9

When is it appropriate to start pharmacological treatment for osteoporosis ?

Answer 9

The patient must be considered high risk
(FRAX score is above 20%)
or they have had prior fragility fracture of the hip/spine
or they have had more than one fragility fracture

Question 10

what medication would you prescribe for the prevention and treatment of steroid induced osteoporosis?

Answer 10

same first line, bisphoshonates

Question 11

if an adolescent or premenopausal adult presents with OVULATORY abnormal uterine bleeding what are their first line treatments options and how long should they trial it for?

Answer 11

first line tx for ovulatory abnormal uterine bleeding in premenopausal/adolescent

1. TXA
2. NSAID
3. oral contraceptive
4. levenorgestrel intrauterine device
5. progestin 21 days

re-evaluate @ 3-6months

Question 12

if an adolescent or premenopausal adult presents with ANVULATORY abnormal uterine bleeding what are their first line treatments options and how long should they trial it for?

Answer 12

1. Oral contraceptives
2. levenorgestrel intrauterine device
   3.Depo-Provera
3. Progestin 21

Question 13

What vitamin supplementation would you advise for vasomotor symptoms or menopause?

Answer 13

Calcium 1200mg/day
Vitamin D 800-2000units/day

Question 14

What are the nonpharm treatment options for vasomotor symptoms

Answer 14

cooling techniques, dressing in layers, fans
avoid triggers like spicy food
weight loss
smoking cessation
CBT
exercise 150min/week

Question 15

for women who enter menopause early (before 45) or premature (before 40) what treatment would you prescribe and why?

Answer 15

you would start them on hormone therapy because early menopause is associated with osteoporosis and cardiovascular disease

Continue the treatment till the age of 50

Question 16

In hormone therapy for menopause what is estrogen indicated for and what is progestogen indicated for?

Answer 16

Estrogen reduces the reduction of the frequency and severity of hot flashes in VMS

Progestogen is indicated in patients with an intact uterus using systemic estrogen to reduce the risk of endometrial hyperplasia

Question 17

explain how estrogen progestogen therapy is taken by a patient?

Answer 17

with EPT the estrogen is taken continuously everyday and the progestogen can be taken continuously everyday (continous EPT)

Or cyclically for 12-14 consecutive days in a calendar month

continous EPT is more effective at preventing endometrial hyperplasia

Question 18

in estrogen treatment for vasomotor symptoms what is the benefit of using transdermal (patch) estrogen compared to oral?

Answer 18

the non oral route eliminates its first pass through the liver resulting less of an increase of triglycerides and CRP

it can reduce risk of VTE, has more consistent systemic estrogen levels compared with oral therapy

select this in patient with migraine, high triglycerides, HTN, malabsorption syndrome, low libido, and shift workers

Question 19

what are the absoblute contraindications to estrogen

Answer 19

ABCD

Acute liver disease
undiagnosed vaginal Bleeding
Cancer, Cardiovascular disease
DVT

and pregnancy

Question 20

what are contraindications to progesten?

Answer 20

undiagnosed vaginal bleeding
known or suspected carcinoma of the breast
pregnancy

Question 21

when would you consider starting a patient on hormone therapy?

Answer 21

hormone therapy treats VMS and is used for patients less than 60 years of age OR its been less than 10 years since the start of menopause

there is a “window” of when to start hormone therapy. Cardiovascular risk increases when hormone therapy is started further away from the onset of menopause

AND ITS first line treatment for both osteoporosis and VMS

Question 22

what non-hormonal pharmaceutical treatment can you offer for VMS treatment?

Answer 22

SSRI and SNRI can be used as first line treatment (nonhormonla) in patients with VMS who also have significant perimenopausal/menopausal mood and anxiety concerns.​

also:
gabapentin, pregabalin, clonidine, oxybutin

Question 23

What natural health products can be used to treat VMS?

Answer 23

soy isoflavones may improve hot flash scores and vaginal dryness but not night sweats.​

Black cohosh is dangerous advise against it can cause liver damage

Question 24

why use vaginal estrogen for VMS?

Answer 24

it can treat vaginal atrophy/dryness
reduces UTI incidence
you dont need to use progestogen with it

Question 25

What is the first line treatment for genitouruinary syndrome of menopause (GMS)

recurrent urinary tract infections, dysuria, urinary frequency and urgency and vaginal atrophy

Answer 25

Vaginal estrogen

Question 26

When would you prescribe combined hormonal contraceptives in premenopausal women?

Answer 26

its an option during premenopause for women requiring contraception or control of irregular or heavy bleeding

Question 27

What side effects can a women with continuous EPT therapy expect as side effects during the first year?

Answer 27

During the first year of using continuous EPT, unexpected spotting or vaginal bleeding may occur. With the cyclic EPT, a patient can expect a withdrawal bleed when the progestogen is stopped at the end of the cycle.

Question 28

if a women with an intact uterus is taking estrogen for VMS, can they use topical progesterone for endometrial protection?

Answer 28

no, topical progesterone does not provide enough endometrial protection

Question 29

if your patient has a peanut allergey, what precautions should you take when prescribing progesterone?

Answer 29

Generic progesterone contains peanut oil

Prometrium contains sunflower oil instead of peanut oil, order this instead

Question 30

When and how dod you discontinue menopausal hormone treatment?

Answer 30

there is no good evidence to support when to discontinue, review with your patient on an annual basis.

avoid abrupt discontinuation, taper off

Question 31

What are all of the treatment options for VMS in postmenopausal patients with an intact uterus?

Answer 31

1. Estrogen-progesterone hormone therapy
   2.Tibolone
2. TSEC (tissue selective estrogen complex with bazedoxifene)
3. Nonpharm: CBT, exercise,

The most effective is estrogen progesterone

Question 32

what are some of the pros to taking Tibolone and TSEC over regular HT?

Answer 32

Tibolone is synthetic estrogen, and you dont need progesterone

TSEC contains bazedoxifene which provides endometrial protection and you dont need progesterone

progesterone creates side effects like breast tenderness and uterine bleeding

however EHT is the most effective over these two

Question 33

What dose of calcium is required for children, adolescents, adults, and pregnant women daily?

Answer 33

4-8 years of age =800mg
9-18= 1300mg
18-50= 100mg
50+ = 1200mg

no changes for pregnancy, its just based on their age

Question 34

What are the side effects and precautions associated with Depor Medroxyprogesterone acetate?

Answer 34

IM injection q 12 weeks

side effects: irregular breakthrough bleeding, breast tenderness, nausea, mood symptoms and weight gain

small decreased in bone mineral denisy which is reversible upon DC

Question 35

what is first-line treatment of mild endometriosis-associated pelvic pain and dysmenorrhea?

Answer 35

NSAIDS

Question 36

which medication is more effective at reducing pain in women with rectovaginal endometriotic lesions.

vaginal ring or patch?

Answer 36

the ring

Question 37

What is the first line treatment for endometriosis?

Answer 37

oral contraceptive, cyclic or continuous or progesterone alone

if not effective

then you can try GnrH agonistst + HT

or

LNG-IUS

Question 38

what are the side effects of danazol (Cyclomen) used in the treatment of endometriosis?

Answer 38

• irreversible voice deepening
• decreased breast size
• increased weight and LDL
• hirsutism