Menopause

Question 1

Definition of menopause?

Answer 1

Permanent cessation of menstrual cycles due to loss of ovarian activity 1 year after last menstrual cycle

Question 2

Symptoms of menopause?

Answer 2

Vasomotor symptoms
Vaginal atrophy

Question 3

What causes vaginal atrophy?

Answer 3

Hypoestrogenic state

Question 4

What are the vaginal changes of menopause?

Answer 4

1. Loss of superficial epithelial cells leading to thinning of vaginal tissues
2. Vaginal tissues are thin and frail leading to tearing and bleeding
3. Loss of subcutaneous fat of labia majora leading to introital narrowing and labia minora fusion
4. Loss of vaginal rugae leading to decreased elasticity and narrowing of the vagina
5. Increased pH causing decrease in normal vaginal flora leading to infection
6. Decreased vaginal secretions leading to dyspaurenia

Question 5

What are the options for management of vasomotor symptoms of menopause?

Answer 5

Systemic hormonal therapy
Nonhormonal therapy

Question 6

What are the systemic hormonal therapy options for vasomotor symptoms of menopause?

Answer 6

Standard or low dose
conjugated estrogen
micronized estradiol
transdermal estradiol

Question 7

What are the non hormonal therapy options for vasomotor symptoms of menopause?

Answer 7

Paroxetine
Clonidine
Gabapentin

Question 8

What is the most effective therapy for vasomotor symptoms of menopause?

Answer 8

Systemic hormonal therapy with estrogen alone or in combination with progestin

Question 9

What systemic hormonal therapy do you use in practice?

Answer 9

Low dose Transdermal estradiol patch 0.025mg/day with or without IUD

Question 10

What non hormonal therapy due you use to treat vasomotor symptoms of menopause?

Answer 10

Paroxetine 7.5mg/day

Question 11

What are the side effects of hormone replacement therapy?

Answer 11

Breast tenderness
Headache
Bloating
Vaginal bleeding

Question 12

What is the dosing and timing recommended for treatment of vasomotor symptoms?

Answer 12

Treating with the lowest effective dose for the shortest duration of time that alleviates vasomotor symptoms

Question 13

What are the risks of systemic hormonal replacement therapy?

Answer 13

Systemic combined= VTE, breast cancer,CHD, Stroke
Systemic estrone alone= VTE

Question 14

What is the Women’s health initiative study?

Answer 14

Randomized trial that looked at healthy postmenopausal women age 50-77 and demonstrated in slight increase risk of breast cancer, coronary heart disease, stroke and VTE and decreased risk of fractures and colon cancer for women using combined HRT for average of 5 years

For women using estrogen alone there was only an increase risk for VTE

Question 15

What is the benefit of transdermal estrogen over oral estrogen for systemic hormone therapy?

Answer 15

Can be associated with lower risk of VTE

Question 16

What should your decision to stop systemic hormone replacement therapy be based on?

Answer 16

Risk benefit ratio of patient and symptoms of menopause

NOT AGE!!

Question 17

Who are the best candidates for systemic hormone replacement therapy?

Answer 17

1. Healthy women
2. No contraindications
3. Within 10 years of menopause
4. Age <60

Question 18

What is an alternative for systemic hormone therapy treatment in women with a uterus as an alternative to progestin?

Answer 18

Conjugated estogen + bazedoxifene

Question 19

Can you use progestin alone for treatment of vasomotor symptoms?

Answer 19

No

No data for safety when used alone
Also risk of breast cancer is thought to be related to progestin

Question 20

What are some herbal remedies women may take for vasomotor symptoms?

Answer 20

St Johns wort
Black cohosh
Ginseng
Ginko

Question 21

What are options to treat vaginal atrophy symptoms of menopause?

Answer 21

Low dose systemic therapy
Localized estrogen therapy with cream, ring or tablet

Question 22

What vaginal estrogen therapy do you use for vaginal atrophy treatment?

Answer 22

Conjugated estrogen Premarin cream 0.5-2g/day

Question 23

What are non hormonal options for vaginal atrophy treatment of menopause?

Answer 23

Vaginal lubricants
Vaginal moisturizers
Estrogen agonist/antagonists

Question 24

What medication is FDA approved for dyspaurenia in postmenopausal women?

Answer 24

Ospemifene

Question 25

What are contraindications to systemic hormonal therapy?

Answer 25

History of breast cancer
History of CHD
History of Stroke
History of VTE
Endometrial cancer
Unexplained vaginal bleeding
Active liver disease