PHARM: Menopause

Question 1

What are some non-pharmacologic therapies for hot flashes?

Answer 1

Avoid smoking
Moderating alcohol
Dressing in Layers
Low ambient temperature
Consume cool drinks
Exercise

Question 2

List the SSRIs that work centerally to treat vasomotor symptoms of menopause.

Answer 2

Paroxetine
Fluoxetine (off-label)
Escitalopram (off-label)

Question 3

List the SNRI used to treat vasomotor symptoms of menopause.

Answer 3

Venlafaxine (off-label)

Question 4

List the anti-hypertensive drug used to treat vasomotor symptoms of menopause.

Answer 4

Clonidine (off-label)

Question 5

List the anti-convulsant used to treat vasomotor symptoms of menopause.

Answer 5

Gabapentin (off-label)

Question 6

What is the ROA of the following estrogens:
• 17β- Estradiol
• Ethinyl estradiol
• Conjugated estrogen

Answer 6

oral

Question 7

How else can 17β- Estradiol be administered in HRT?

Answer 7

Transdermally: patch, gel, spray, emulsion
Vaginally: cream, tablet, ring

Question 8

What is the ROA of the following progestins:
•	Medroxyprogesterone acetate
•	Norethindrone acetate
•	Drospirenone
•	Micronized progesterone

Answer 8

oral

Question 9

What are the two progestins that can be given transdermally?

Answer 9

• Norethindrone acetate

* Levonorgestril

Question 10

What drug is a combination of estrogen and selective estrogen receptor modifier (SERM). Can act as an agonist or antagonist in different estrogen-sensitive tissues.

Answer 10

Bazedoxifene

Question 11

What population can benefit from co-therapy with bazedoxifene?

Answer 11

In women who are post-menopausal on estrogens—helps reduce endometrial growth.

Question 12

TOXICITY: Nausea, HA, insomnia, possible sexual dysfunction

Answer 12

SSRIs:
Paroxetine
Fluoxetine
Escitalopram

Question 13

TOXICITY: N/V, dry mouth, anorexia, possible sexual dysfunction

Answer 13

Venlafaxine

Question 14

TOXICITY: Dry mouth, insomnia, drowsiness, skin reactions to patch. Lowers peripheral vascular reactivity and raises sweating threshold (possible action in thermoregulatory center)

Answer 14

Clonidine

Question 15

TOXICITY: Dizziness, unsteadiness, drowsiness

Answer 15

Gabapentin

Question 16

TOXICITY: Breast tenderness and uterine bleeding. Vomiting, HA, weight change, rash and pruritus, cholecystitis

Answer 16

Hormonal therapies

Question 17

What is is the MOST effective treatment for VMS and urogenital atrophy?

Answer 17

Estrogen ± progestogen

• Relief occurs within one month (reduce symptoms by 80-90%)

Question 18

What form of estrogen is preferred for HRT?

Answer 18

transdermal

Question 19

What is CEE?

Answer 19

conjugated equine estrogens from horse urine; most common estrogen replacement used in USA

Question 20

What drug is used in HRT to protect against endometrial proliferation?

Answer 20

progesterone

Question 21

What can be given to increase libido in post-menopausal women?

Answer 21

testosterone

Question 22

Which has a more pronounced hypercoagulable effect (from liver protein synthesis): oral or transdermal HRT?

Answer 22

oral (and increases synthesis of C-reactive protein and fibrinolytic markers)

Question 23

Why does transdermal estrogen not affect liver protein synthesis as much as oral estrogen therapy?

Answer 23

bypasses liver metabolism

Question 24

Does oral or transdermal estrogen have a greater effect on HDL to LDL ratio?

Answer 24

oral

Question 25

Does oral or transdermal estrogen have a greater effect on triglycerides?

Answer 25

transdermal

Question 26

Does oral or transdermal estrogen have a greater effect on testosterone levels? How?

Answer 26

oral (Increases hepatic Sex Hormone Binding Globulin which lowers testosterone availability compared with transdermal delivery)

Question 27

Does oral or transdermal estrogen have a higher incidence of weight gain?

Answer 27

oral

Question 28

True or false: after stopping HRT, all risks rapidly decline.

Answer 28

FALSE: all risks decline rapidly EXCEPT for increased risk of breast cancer—risk persists for several years after!

Question 29

In what percentage of patients do VMS recur after you stop treatment with HRT?

Answer 29

50%

Question 30

What is the major thing to take into consideration when you balance the risks and benefits of HRT in a patient?

Answer 30

age and time since last menopause are HIGHLY related with adverse effects (younger women typically do not have as high an incidence of adverse effects as older women)

Question 31

Does solo estrogen therapy increase risk of breast cancer?

Answer 31

no! only in combination with progesterone

Question 32

What reasons may a young woman have for starting HRTs?

Answer 32

approve appearance; prevent osteoporosis, vaginal moisture (and somewhat libido), overall health maintenance, brain function (may play a role in prevention of dementia), CV protection (heart disease is the number 1 killer of women).

Question 33

List the absolute contraindications for HRT.

Answer 33

undiagnosed abnormal genital bleeding
history of breast cancer
estrogen-dependent neoplasia
DVT, PE, thromboembolic disease (stroke or MI)
liver disease
hypersensitivity
known or suspected pregnancy

Question 34

List the conditions that warrent caution when administering HRT.

Answer 34

dementia
gallbladder disease
hypertriglyceridemia
prior cholestatic jaundice
hypothyroidism
fluid retention + cardiac/renal dysfunction
severe hypocalcemia
prior endometriosis
hepatic hemangiomas

Question 35

If a woman is NOT a candidate for HRT, what is your first step in management?

Answer 35

you MUST do DEXA scans

Question 36

How long does Dr. Young give a patient who is a candidate for HRT (no risk factors) HRT?

Answer 36

until around 10 years before predicted death