Pharm: Hormone Replacement

Question 1

Define perimenopause

Answer 1

• 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

Question 2

Define menopause

Answer 2

• Usually defined as 12 consecutive months of amenorrhea.

- Menopause is the loss of ovarian function and subsequent hormonal deficiency.

Question 3

Vasomotor sx

Answer 3

• 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

Question 4

Atrophic vaginitis/GU sx

Answer 4

• 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.

Question 5

CI to hormone (E&P) therapy

Answer 5

• 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

Question 6

Best candidate for Duavee

Answer 6

• vasomotor sx d/t menopause
• estrogen related breast tenderness
• higher risk of breast cancer
• cannot tolerate progestins
  (downside is increases risk of VTE)

Question 7

Duavee MoA

Answer 7

• Estrogen agonist effect on bone

- Estrogen antagonist effect on endometrium

Question 8

Why is progestin not needed when using Duavee which contains estrogen

Answer 8

Bazedoxifene prevents estrogen-induced endometrial hyperplasia

Question 9

What are the three systemic dose forms of estrogen

Answer 9

Oral
Transdermal
Dermal

Question 10

Downside to oral estrogen

Answer 10

• 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

Question 11

What are the two types of oral estrogens? How do they differ in efficacy?

Answer 11

• Conjugated equine estrogens: estrone mostly
• Micronized 17β estradiol – absorbed via lymph system like fats
• equally effective

Question 12

Two examples of oral estrogen

Answer 12

• Premarin: conjugated equine estrogen
• Estrace: micronized 17β estradiol

**also come in cream form

Question 13

What is the preferred route of estrogen therapy? why?

Answer 13

• Transdermal
• lower risk of thromboembolism and stroke, less effect on lipids
• just as effective as oral for preserving bone density

Question 14

Example of transdermal estrogen

Answer 14

Vivelle-dot

Question 15

Two examples of dermal applications, how to use

Answer 15

• 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 :)

Question 16

Vaginal hormone therapy doses/usage

Answer 16

• 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

Question 17

Three examples of vaginal therapy

Answer 17

• Premarin and Estrace cream (also PO form)
• Estring – ring
• Vagifem - tablet

Question 18

What is the most appropriate progestin to Rx with estrogen? what is the most commonly used ?

Answer 18

• 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

Question 19

Best non hormonal therapy for vasomotor sx dt menopause

Answer 19

SSRI or SNRI

• Paroxetine is only FDA approved for hot flushes
• Citalopram is alternate

Question 20

Best non hormonal therapy for vasomotor sx dt menopause AND breast cancer

Answer 20

Citalopram

Question 21

Alternative non-hormonal therapies for vasomotor sx dt menopause

Answer 21

• 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

Question 22

First line therapy to treat atrophic vaginitis

Answer 22

• vaginal moisturizing agents
• used alone for mild sx
• used in combo with estrogen for moderate-severe

Question 23

Therapies for atrophic vaginitis during intercourse

Answer 23

water based lubricants

Question 24

What might be needed to treat significant atrophic vaginitis d/t menopause?

Answer 24

• 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

Question 25

What is the indication for osepemifene

Answer 25

• moderate to severe dyspareunia dt menopause
• Consider for pt with sx who doesn’t want to consider vaginal estrogen
• Same CI as estrogen therapy

Question 26

Purpose of progestin therapy

Answer 26

Helps protect against endometrial hyperplasia and cancer

Question 27

When to use progestin therapy

Answer 27

• 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

Question 28

What should always be co-administered with androgen therapy?

Answer 28

Estrogen