Pharm: Hormone Replacement Flashcards
Define perimenopause
- The period immediately prior to menopause and the first year of menopause.
- Characterized by menstrual cycle irregularity due to the increased frequency of anovulatory cycles
Define menopause
- Usually defined as 12 consecutive months of amenorrhea.
- Menopause is the loss of ovarian function and subsequent hormonal deficiency.
Vasomotor sx
- Hot flushes and night sweats- primarily characterized by the perception of sudden, intense heat (hot flash) in the face, neck and chest and subsequent cooling by cutaneous vasodilation (skin flushing), perspiration, and chills.
- May include HA, dizziness, palpitations, and sleep disturbances
- Sx usually last 1-5 minutes and worse in
- Worse early morning and evening
Atrophic vaginitis/GU sx
- Dryness, burning, dyspareunia, loss of vaginal secretions, and vulvar pruritus.
- Over time, lack of vaginal lubrication may lead to sexual dysfunction and emotional distress.
- Urinary symptoms include urethral discomfort, frequency, dysuria, stress incontinence, and increased urinary tract infections.
CI to hormone (E&P) therapy
- Unexplained vaginal bleeding
- CVD, Stroke, TIA, MI, PE, VTE
- Breast or endometrial cancer
- Active liver disease
- Caution: DM, high TG, active GB dz, high risk breast or endometrial cancer, migraine with aura
Best candidate for Duavee
- vasomotor sx d/t menopause
- estrogen related breast tenderness
- higher risk of breast cancer
- cannot tolerate progestins
(downside is increases risk of VTE)
Duavee MoA
- Estrogen agonist effect on bone
- Estrogen antagonist effect on endometrium
Why is progestin not needed when using Duavee which contains estrogen
Bazedoxifene prevents estrogen-induced endometrial hyperplasia
What are the three systemic dose forms of estrogen
Oral
Transdermal
Dermal
Downside to oral estrogen
- Greater effect on liver, increases hepatic production of other hormone (thyroxine, etc.) binding globulins which reduces the other hormone availability.
- Also increases TG, HDL, cholesterol, and clotting factors
What are the two types of oral estrogens? How do they differ in efficacy?
- Conjugated equine estrogens: estrone mostly
- Micronized 17β estradiol – absorbed via lymph system like fats
- equally effective
Two examples of oral estrogen
- Premarin: conjugated equine estrogen
- Estrace: micronized 17β estradiol
**also come in cream form
What is the preferred route of estrogen therapy? why?
- Transdermal
- lower risk of thromboembolism and stroke, less effect on lipids
- just as effective as oral for preserving bone density
Example of transdermal estrogen
Vivelle-dot
Two examples of dermal applications, how to use
- Gel: Divigel.
Apply to unbroken skin daily - Spray: Evamist
Metered dose pump, apply to inner surface of arm daily
*both are flammable like 151 rum :)
Vaginal hormone therapy doses/usage
- Used in very low doses to treat vaginal atrophy
- Higher doses can be used to treat vasomotor sx. Do not use high dose to treat vaginal atrophy only!
- If use higher dose, progestin must also be used
Three examples of vaginal therapy
- Premarin and Estrace cream (also PO form)
- Estring – ring
- Vagifem - tablet
What is the most appropriate progestin to Rx with estrogen? what is the most commonly used ?
- Prometrium is best option (100 mg daily or 200 mg 12 days a month).
- Preferred bc it protects endometrium but does not seem to increase risk of breast cancer or CVD
- Most commonly used is medroxyprogesterone acetate (MPA).
- Associated with increased risk of breast cancer and CVD
Best non hormonal therapy for vasomotor sx dt menopause
SSRI or SNRI
- Paroxetine is only FDA approved for hot flushes
- Citalopram is alternate
Best non hormonal therapy for vasomotor sx dt menopause AND breast cancer
Citalopram
Alternative non-hormonal therapies for vasomotor sx dt menopause
- gabapentin
- Alt for pt who cannot tolerate or fail SSRI/SNRI
- Low dose at bedtime. Sedating so helps sleep and return to sleep if hot flash awakens
- Pregabalin or clonidine
- Lifestyle: may try before drug therapy
First line therapy to treat atrophic vaginitis
- vaginal moisturizing agents
- used alone for mild sx
- used in combo with estrogen for moderate-severe
Therapies for atrophic vaginitis during intercourse
water based lubricants
What might be needed to treat significant atrophic vaginitis d/t menopause?
- local or systemic estrogen therapy
- intravaginal cream, tablet, or ring
- once control severe acute dryness with cream, can transition to ring or tablets for maintenance therapy
What is the indication for osepemifene
- moderate to severe dyspareunia dt menopause
- Consider for pt with sx who doesn’t want to consider vaginal estrogen
- Same CI as estrogen therapy
Purpose of progestin therapy
Helps protect against endometrial hyperplasia and cancer
When to use progestin therapy
- if there is a uterus, progestin should be used in combo with estrogen
- Except, probably not needed to protect when using low-dose preparateions (Estring, vagifem)
- Systemic absorption of vaginal creams is difficult to quantify, conservative approach is to treat with progestin
What should always be co-administered with androgen therapy?
Estrogen
