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Repro Week 4 > ICL 17.3: Hormonal Changes and Their Sequelae > Flashcards

ICL 17.3: Hormonal Changes and Their Sequelae Flashcards

1
Q

51 year old woman present to your office with concerns that she is not sleeping well at night. she’s assoaciting this with night time hot flashes. what do you recommend first?

A

try lifestyle modifications first!

  1. avoid spicy food
  2. wear light clothes and cool bedding
  3. avoid caffeine and alcohol
  4. weight loss if obese
  5. smoking cessation

anything that will lower sympathetic response and vasodilation!

consider timing: perimenopause vs. menopause! if it’s perimenopause then you should wait because they’re fluctuating so much and OCPs (much higher doses than HRT) are the preferred treatment instead of hormone replacement therapy

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2
Q

how do OCPs differ from HRT?

A

OCPs are much more potent and higher doses

ethinyl estradiol is 4-10x more potent than HRT estrogens

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3
Q

what is the standard of care for menopausal symptoms?

A

hormone replacement therapy

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4
Q

what are common menopausal symptoms?

A
  1. vasomotor symptoms (hot flashes)
  2. genitourinary symptoms
  3. osteoporosis risk
  4. CVD/CHD

osteoporosis is maybe helped by HRT but you do NOT use HRT to reduce CVD risk because it may actually be detrimental

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5
Q

how do you treat vasomotor symptoms?

A

hot flashes and night sweats require systemic HRT!

it is effecting their sleep and ADLs

if they have a uterus you need estrogen + progestin and the progestin can be continuous of cyclical

if they don’t have a uterus you dont have to give progestin

there are many different formulations but use the lowest dose possible in either scenario and wait 12 weeks to see the full effect of the medication

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6
Q

which systemic HRT products are available?

A

orally, ells, emulsion packs, femring, patches, spray

be sure to look at the indication!

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7
Q

what are compounded products and bioidenticals?

A

there’s not evidence of increased safety or efficacy of bioidenticals aka like natural estrogens or herbs

compounded products are not regulated for quality control and there are variable absorption/effects

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8
Q

how does HRT effect CHD?

A

combined estrogen and progesterone risk is neutral but may be increased if 10+ years post menopause

neutral effects with just estrogen HRT

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9
Q

how does HRT effect VTW?

A

increased especially in the 1st year of use especially with oral > transdermal

increased risk with just estrogen too

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10
Q

how does HRT effect stroke/TIA risk?

A

increased risk for both combined and just estrogen HRT

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11
Q

how does HRT effect breast cancer risk?

A

increased risk with more duration for those on combined HRT

neutral risk for estrogen only

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12
Q

how does HRT effect endometrial cancer?

A

neutral risk with combined HRT

neutral risk with estrogen only HRT unless given alone with intact uterus

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13
Q

how does HRT effect colon cancer?

A

decreased risk with both types of HRT!

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14
Q

how does HRT effect fractures?

A

decreased risk with both types of HRT!

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15
Q

what are the absolute contraindications for HRT?1\

A
  1. undiagnosed abnormal genital bleeding
  2. active endometriosis
  3. known or suspected breast cancer history
  4. known or suspected estrogen or progesterone dependent neoplasia
  5. h/o DVT. PE or MI, stroke, atherosclerotic disease
  6. liver dysfunction or disease especially with oral medications that need first pass metabolism
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16
Q

how do you monitor HRT for estrogen efficacy?

A

estrogen dose should be helping with:

  1. hot flush/sleep disturbance persistance
  2. breast tenderness
  3. mood swings
  4. nausea
  5. water retention/bloating
17
Q

what progestin side effects can be seen with HRT?

A
  1. headache
  2. nausea
  3. premenstrual-like symptoms
18
Q

51 year old female with hot flashes and trouble sleeping. what questions do you have for her?

A
  1. when was your last menstrual period to tell if she’s in menopause or perimenopause
  2. is she taking anything to help with symptoms?
  3. past medical history: cancer, DM, CVD, DVTs, liver disease
  4. any other symptoms? like vaginal or uritogenital symptoms?
  5. history of migraines?
  6. gastric bipass history which can effect medical absorption
  7. any breast surgery or endometrial ablation or hysterectomy
  8. any possible drug interactions that could be causing the hot flashes? aka ask for her medication list
19
Q

51 year old female with hot flashes and trouble sleeping. what recommendations do you have for her?

A
  1. lifestyle and behavioral changes like using cooler blankets and lowering the AC
  2. has she considered HRT?
  3. discussions with the patient about risk/benefit of HRT and what the timeline would look like for the medication to kick in with full effects
20
Q

what are the genitourinary symptoms of menopause?

A
  1. vulvovaginal atrophy = vaginal dynes, burning, itching, discomfort, dyspareunia
  2. lower urinary tract symptoms = urethritis, urinary urgency, frequency
21
Q

how do you treat genitourinary symptoms of menopause?

A

HRT local therapy!

they minimize systemic absorption, more effective than systemic therapy

22
Q

what are the local treatments available for genitourinary sytmptoms of menopause?

A
  1. estrace cream
  2. estring
  3. invexxy vaginal tablet
  4. vagifem vaginal tablet
23
Q

how do you treat people who have both vasomotor and genitourinary symptoms?

A

vasomotor = systemic

genitourinary = local

so sometimes the systemic treatment will help with some genitourinary function but sometimes you also need local therapies too if needed

24
Q

what is the risk/benefit conversation associated with HRT?

A

what works best for the patient and do they want to take it? how is their quality of life being effected?

25
Q

how long do you keep someone on HRT?

A
  1. for systemic HRT, there isn’t a specific rule but you want to use the shortest duration necessary

trial every 3-6 months to decrease dose is reasonable for most patients after 1 year of therapy

it is SO important to taper off after the 1st year

  1. low-dose loca/vaginal estrogen can be continued indefinitely
26
Q

what are SERMS?

A

selective estrogen receptor modulators

they dont treat photoflashes as well as HRT but are great for other stuff like osteoporosis

  1. bazedoxifene + estrogen (duavee)
  2. ospemifene (osphena)
  3. raloxifene (evista)
27
Q

what is duavee?

A

bazedoxifene + estrogen that is a SERM

3rd generation SERM combined with seteorgen to treat vasomotor symptoms and osteoporosis prevention

bazedoxifene antagonized estrogen effect on endometrium to prevent endometrial hyperplasia so you dont need a rpgoesterine too

antagonistic activity on breast tissue and agonist activity on bone tissue

28
Q

what is ospemifene (osphena)?

A

used for vulvogainal atrophy and painful intercouse

decreases dyspareunia and improves vaginal structure and ph

it’s a 3rd generation SERM that has agonist activity on vaginal tissue

avoid in patients with history of thrombosis

may cause hot flashes

29
Q

what is evista?

A

raloxifene is a SERM with agonist activity on bone tissue and antagonist activity on breast tissue

used to prevent postmenopausal osteoporosis only

30
Q

what is the non-hormonal pharmactotherapy for vasomotor symptoms?

A
  1. SSRIs/SNRIs
  2. gabapentine/pregabalin
  3. clonidine
31
Q

how do SSRIs work for menopause?

A
  1. decreases hot flashes by increasing serotonin in CNS and decreasing LH

also helps treat depression and anxiety during menopause

great if HRT is contraindicated

32
Q

how does gabapentin work for menopause symptoms?

A

affects thermoregulatory process of pituitary hypothalamic region through calcium curren modulation

effect adrenergic and serotonergic pathways

decreases severity and frequency of hot flashes at high doses so you have to titrate up which is annoying

33
Q

how does clonidine work for menopause symptoms?

A

decreases small vessel response to stimuli centrally and peripherally

however lots of side effects and rebound HTN…

patch is preferred over a patch if you use this medication

34
Q

what is the homeopathic treatment for vasomotor symptoms?

A

not recommended really

  1. black cohosh
  2. soy
  3. primrose oil

Repro Week 4 (16 decks)

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