Women's Health - MHT Flashcards
MHT gets graded D for ___ of disease
prevention
MHT is composed of…
(3)
- estrogen only
- estrogen and progestin
- estrogen and SERM
Indications for MHT
- ___ symptoms
- ____ atrophy
- ___ prevention (not a main reason for MHT)
- Vasomotor
- Vulvovaginal
- Osteoporosis
Absolute Contraindications to MHT
- Unexplained ___ bleeding
- Pregnancy
- Endometrial and ___ cancer
- ___ and thromboembolic
disorders (or prior history) - Active ___ disease
- vaginal
- breast
- stroke
- liver
Estrogen Monotherapy Oral Products
- Premarin® (___ estrogens)
- Menest® (___ estrogen)
- Estrace® generics (___ estradiol)
- conjuagted
- esterified
- micronized
Estrogen Monotherapy Oral Transdermal Products
- Alora®
- Climara®
- Menostar®
- Minivelle®
- Vivelle®
- Vivelle-dot®
Other Estrogen Monotherapy Topical Products
- topical gel (Estrogel, Divigel, Elestrin)
- topical spray (Evamist)
Estrogen Monotherapy Intramuscular Injections
- Estradiol cypionate (___)
- Estradiol valerate (___ )
- Depo-Estradiol
- Delestrogen
Estrogen Monotherapy Intravaginal Products
- vaginal cream (___ , ___)
- vaginal insert (___)
- vaginal tablet (___, ___)
- vagnial ring (___, ___)
- Premarin, Estrace
- Imvexxy
- Vagifem, Yuvafem
- Estring, Femring
Femring needs a progestin (highly absorbed systemically)
Critical factors in determining whether hormone therapy reduces or increases risk of ___:
___ and ___
CHD
* time since menopause
* age of initiation
(E+P) Women with intact uterus was significantly associated with a ___ risk of breast cancer.
(Mono E) Women with prior hysterectomy had significantly ___ risk of breast cancer
- higher
- lower
Menopausal Hormone Therapy: Current Recommendations
Initiation of treatment should be limited to women Age < ___ OR Within ___ years of last period
60
10
Methods of Administration: Combined Estrogen and Progestin
(4)
- continuous cyclic
- continuous combined
- continuous long cycle
- intermittent combined
Continuous Cyclic Therapy
- AKA ___
- Estrogen administered ___
- Progesterone administered at least ___ days out of a 28 day cycle
- scheduled ___ bleeding (90%)
- preferred in ___ menopausal women
- Sequential treatment
- daily
- 12-14
- withdrawal
- recently
Continuous Cyclic Therapy Example 1/2
Premphase
Route: ___
Estrogen Component: ___
Progestin Component: ___
- oral
- conjugated estrogens
- medroxyprogesterone acetate
Continuous Cyclic Therapy Example 2/2
Combipatch
Route: ___
Estrogen Component: ___
Progestin Component: ___
- transdermal
- estradiol
- norethindrone acetate
Continuous Long Cycle
- Rare
- AKA ___
- Estrogen administered ___
- Progesterone administered at least 12-14 days every other ___
- results in ___ scheduled bleeding times per year
- unclear endometerial safety data
- “cyclic withdrawal
- daily
- month
- 6
Continuous Combined
- ___ estrogen and progesterone
- Results in endometrial ___ and absence of vaginal bleeding
- Initial ___ spotting or bleeding which usually resolves within ___months
- Recommended for women ___ years post-final menstrual period
- ___ long-term endometrial protection
- daily
- atrophy
- unpredictable, 6-12
- > 2
- BEST
Continuous Combined Oral Examples 1/5
Prempro
Estrogen Component:
Progestin Component:
- conjugated estrogens
- medroxyprogesterone acetate
Continuous Combined Oral Examples 2/5
Fyavolv/Jinteli
Estrogen Component:
Progestin Component:
- ethinyl estradiol
- norethindrone acetate
Continuous Combined Oral Examples 3/5
Angeliq
Estrogen Component:
Progestin Component:
- estradiol
- drospirenone
Continuous Combined Oral Examples 4/5
Activella/Amabelz/Mimvey
Estrogen Component:
Progestin Component:
- estradiol
- norethindrone acetate
Continuous Combined Oral Examples 5/5
Bijuva
Estrogen Component:
Progestin Component:
- estradiol 1 mg
- micronized progestin 100 mg
bio-identical hormone replacement therapy
Continuous Combined Transdermal Examples (1/2)
ClimaraPro
Estrogen Component:
Progestin Component:
- estradiol
- levonorgestrel
Continuous Combined Transdermal Examples (2/2)
Combipatch
Estrogen Component:
Progestin Component:
- estradiol
- norethindrone acetate
Intermittent Combined
- AKA ___
- ___ days of estrogen, ___ days of estrogen + progesterone
- Pulsing prevents ___ of progesterone receptors
- Long-term endometrial protection: Unknown
- pulsed-progesterone
- 3
- down-regulation
Intermittent Combined Example
Prefest
Route:
Estrogen Component:
Progestin Component:
- oral
- estradiol
- norgestimate
Oral Progestin for Endometrial Protection
Medroxyprogesterone
Brand:
Continous Min Dose:
Cyclic Min Dose:
Provera
2.5 mg
5 mg
Oral Progestin for Endometrial Protection
Norethindrone acetate
Brand:
Continous Min Dose:
Cyclic Min Dose:
Aygestin
5 mg
5 mg
Oral Progestin for Endometrial Protection
Micronized progestin
Brand:
Continous Min Dose:
Cyclic Min Dose:
Prometrium
100 mg
200 mg
BEST (metabollically neutral)
Vaginal/Intrauterine Progestin for Endometrial Protection
Levonorgestrel
Brand:
Continous Min Dose:
Cyclic Min Dose:
Mirena IUM
0.20 mcg
N/A
Vaginal/Intrauterine Progestin for Endometrial Protection
Progesterone gel
Brand:
Continous Min Dose:
Cyclic Min Dose:
Crinone
45 mg
45 mg
Estrogen & SERM
treat both ___ symptoms and prevent ___ loss in women with intact uterus
* AKA ___
* non-___
* agonist: ___
* antagonist: ___
* decrease risk of ___ cancer
- menopausal, bone
- tissue-selective estrogen complex (TSEC)
- hormonal
- bone
- breast, uterus
- endometrial
Estrogen & SERM side effects
- ___ track disorders
- muscle spasm
- ___ and ___ pain
- dizziness
- GI
- neck, oropharyngeal
Estrogen & SERM example
Duavee
Route:
Estrogen Component:
SERM Component:
oral
* conjugated estrogen 0.45 mg
* bazedoxifene 20 mg
What is the preferred regimen?
transdermal estrogen +/- progestin
alternatives to preferred regimen (2)
- Bazedoxifene + Estrogen
- oral estrogen +/- progestin
- systemic vaginal estrogen +/- progestin
alternatives for vasomotor symptoms
herbal/random stuff
- phytoestrogens
- black cohosh
- Dong Quai
- Gabapentin/Pregabalin
- Clonidine
SSRIs/SNRIs for Hot Flashes
SSRIs for Hot Flashes
- Paroxetine (Brisdelle®) 7.5 mg QHS
- Paroxetine (Paxil, Pexeva) 10-20 mg/day
- Paroxetine CR (Paxil CR®)12.5 or 25 mg/day
- Citalopram (Celexa®) 10-30 mg/day
- Escitalopram (Lexapro®)10-20 mg/day
SNRIs for Hot Flashes
- Venlafaxine (Effexor®) 75-150 mg/day
- Desvenlafaxine (Pristiq®) 100-150 mg/day
- Duloxetine (Cymbalta®) 60 mg/day
Side effects: mouth dryness, anorexia, nausea, constipation
Women with high 10-year CVD (>___%) should avoid MHT
10%
if genitourinary symptoms,
consider low-dose vaginal estrogen
First line (non-hormonal) for Genitourinary Symptoms (2)
- Lubricants
- vaginal moisurizers
Second line (non-hormonal) for Genitourinary Symptoms (4)
- cream
- vaginal tablet
- ring
- low dose OC
low dose vaginal estrogen doesn’t require progestin
Treatment of Moderate-Severe Dyspareunia
Ospemifene (Osphena®)
* SERM
* agonist: ___, uterus
* Black Box Warning: ___ cancer, stroke, VTE
* ___ mg once daily in postmenopausal women
* take with ___
* SE: discharge, endometrial hyperplasia, and ___
- vagina
- endometrial
- 60 mg
- food
- hot flashes
Similar precautions to estrogen therapies
Treatment of Moderate-Severe Dyspareunia
Prasterone (Intrarosa)
* Inactive ___ converted to active estrogen and androgen
* ___mg qd qhs in postmenopausal women
* no black box warning
* Contraindications: ___ vaginal bleeding
* Avoid if history of ___ cancer
* SE: vaginal ___
- DHEA
- 6.5mg
- undiagnosed
- breast
- discharge
Estrogen-based regimen remain the first line for vulvovaginal atrophy
Hormone Regimen in Transgender Persons
Oral Estradiol dosage
2.0-6.0 mg/day
Hormone Regimen in Transgender Persons
Estradiol transdermal patch dosage
0.025-0.2 mg/day (New patch placed every 3-5 days)
Hormone Regimen in Transgender Persons
Parenteral Estradiol valerate and
Estradiol cypionate dosage
- 5-30 mg IM every 2 weeks
- 2-10 mg IM every week
