PR3152 IC18 (main) Flashcards
describe the menopause progression to perimenopause
variable length (≥7days) difference in the menstrual cycle ==> interval of >60 days of amenorrhea AND vasomotor symptoms
FSH, AMH, inhibin start to change (FSH increase, AMH, inhibin decrease)
AMH for foliculogenesis
what is the 4 clinical presentations of menopause
- Vasomotor symptoms (VMS) eg hot flushes & night sweats
- Genitourinary syndrome of menopause (GSM)
- Psychological / cognitive
- Bone fragility
what are the vasomotor symptoms during menopause (and how it happens)
thermoregulatory dysfunction at the hypothalamus level due to estrogen withdrawal. symptoms include
- feeling of heat on face/flushing/reddened face
- anxiety
- sleep disturbance
- sweating/cold sweats
- irregular/increase HR
what are the symptoms of genitourinary syndrome of menopause (GSM) (and how it happens)
decreased oestrogen = changes in the labia, urethra, vagina, vestibules, bladder
causing:
- decreased libido/impaired sexual function/painful intercourse/lubrication difficulty during sex
- vaginal irritation/burning/dryness
- recurrent UTI
- dysuria
- urinary urgency
describe the mechanisms causing GSM
the vaginal lining becomes thin and dry
less secretions produced during sexual intercourse
vaginal elasticity decreases
the urethra shortens and narrows
what are the psych/cognitive symptoms of menopause?
(and how it happens)
likely multifactorial: stress and hormonal fluctuations
- depression, anxiety, mood swings, poor concentration/memory
what are the bone fragility problems caused by menopause
decreased estrogen = bone fragility = increased risk of osteoporosis, fractures, joint pain
what are some dietary supplements for vasomotor symptoms in menopause?
Isoflavones
- classified as a phytoestrogen
- Food sources: Soybean products, Legumes (lentils, chick pea)
Black Cohosh
- Herb native to North America
- No significant DDI
- Possible serotonergic activity at hypothalamus
what are some non-pharmacological methods to menopause symptom resolution? (include the indication)
mild vasomotor:
- layered clothing easily removable
- lower room temp
- avoid spicy food/caffaine/hot drinks
- more exercise
- consider dietary supplements
mild vulvovaginal
- nonhormonal lubricant or moisturisers
what is the indication to oestrogen therapy in menopause?
MODERATE to severe symptoms or unresponsive to non-phx
what are the types of phx therapy in MHT?
1) estrogen only: in the form of oral, topical, local vaginal (pessaries, etc)
2) COCs
rationale for adding progestin to menopausal hormone therapy
for women with intact uterus to stabilise the endometrial lining and prevent overgrowth and reduce risk of endometrial cancer
when can estrogen only treatment be recommended in menopausal hormone therapy?
1) no intact uterus
2) local vaginal estrogen only
reduce risk of endometrial cancer without progestin to stabilise the end
what is the difference between MHT and COC in terms of formulations used and dosage?
Replace/supplement endogenous estrogen to alleviate symptoms and risks of lower estrogen production
10-15 mcg VS 20-50 mcg
17 beta estradiol OR Conjugated equine estrogens VS Ethinylestradiol OR estradiol
pros and cons of systemic tablet for MHT
PRO
Relatively inexpensive
CON
Highest dose required –> higher risk of side effects
Potential for missed doses –> irregular bleeding
pros and cons of local vaginal (pessary, cream) for MHT
PRO
Lowest estrogen dose –> no need concomitant progestin
Continuous estrogen release
CON
Inconvenient/uncomfortable
Vaginal discharge
Only for localized urogenital atrophy** (NOT FOR VASOMOTOR SYMPTOMS)**
pros and cons of systemic topicals (patch/gel) for MHT
PRO
Lower systemic dose than oral
Convenient
Continuous estrogen release
CON
Expensive
Skin irritation (rotating sites helps)
Gel has more variability in absorption
counselling for systemic patches for MHT
Replaced twice a week
–> lower back, abdomen, thigh or buttocks –> rotate sites
counselling for systemic gels for MHT
Ruler provided to measure dose of gel –> apply over arms or thigh daily –> let gel dry –> rotate sites
counselling for systemic tablets for MHT
Take same time everyday –> once finished with a pack, start a new one right away
counselling for vaginal cream for MHT (HOW TO APPLY)
wash hands
squeeze cream on applicator
lie down with knees facing you
insert applicator into vagina and press plunger
if applicator reusable, wash with mild soap and warm water
counselling for vaginal pessaries
Inserted twice a week –> insert tablet just before bedtime to minimize movement
what are the risks associated with oestrogen only therapy
increased risk of breast cancer, VTE, endometrial cancer, CHD, stroke.
increased endometrial cancer risk can be mitigated with progestin add on.
appears to have some benefit to fracture risk
what are the two regimens for combined MHT and compare the benefits/disadvantages
1) continuous cyclic
2) continuous-combined
continuous cyclic may cause some withdrawal bleeding when progestin is stopped. is useful to regulate menses
continuous combined (no withdrawal bleeding) but might cause some breakthrough bleeding at the start. eventually will cause amenorrhea
what is the regimen for continuous cyclic MHT
initiated 1st or 15th day of the month, continued for 11-14 days
what is the regimen for continuous combined MHT
progestin and oestrogen daily
types of progestin available for MHT
Types available: Dydrogesterone, norethisterone, medroxyprogesterone, micronized progesterone, norgestrel, levonorgestrel, gestodene, desogestrel, norgestimate
counselling for MHT
understand the risk vs benefits
note that will take 2-3 months for vast improvement
follow up is important
50% patients will have symptoms once stopped
what are the follow up required for MHT
1) Annual mammography
2) Endometrial surveillance
- Unopposed estrogen: any vaginal bleeding
- Continuous cyclic: if bleeding occurs when progestin is still on
- Continuous combined: if bleeding is prolonged, heavier than normal, frequent, persists after >10 months after treatment started
other pharmacological management other than MHT
what are some other available drugs for use
Antidepressants
- Serotonin and norepinephrine reuptake inhibitors (SNRIs) esp venlafaxine
- Selective serotonin reuptake inhibitors (SSRIs) esp paroxetine
Gabapentin
- Night sweating
- Sleep disturbances
Tibolone ($$$)
- Synthetic steroid with estrogenic, progestogenic and androgenic effects
- Improves mood, libido
- Protects against bone loss, menopause symptoms, vaginal atrophy (less than estrogen)
- Risk of stroke, breast CA recurrence, endometrial cancer
- Only indicated in postmenopausal women ≥ 12 months since last natural period
