211 - Menopause and HRT

Question 1

Who should be treated with hormone replacement therapy?

(In the context of menopause)

Answer 1

People with…

• Moderate to severe vasomotor symtpoms that affect their quality of life
• NO contraindications
  
  • Cannot have hormone-sensitive breast cancer, CHD, VTE, Liver disease, unexplained vaginal bleeding
• LMP less than 10 years ago

Question 2

If estrogen hormone replacement therapy is only indiated for perimenopausal people with vasomotor symtoms, what treatments are avilable for patients experiencing vulvovaginal symptoms?

Answer 2

• Topical estrogen
• Lubricant, moisturizer, dilator
• SERM

Don’t start systemic therapy if sx are only local

Question 3

Answer 3

FSH

• FSH is elevated post-menopause
• In the transition period, it will fluctuate; not super helpful to measure

Changes in menstrual bleeding patterns = better predictor of menopausal stage than serum FSH during transition

Heavy periods -> lighter/spaced out -> no more periods

Question 4

List 3 new health problems that are more likely to arise after menopasue

Answer 4

• Depression
• Osteoporosis
  
  • Associated with estrogen deficiency
• CAD/CHD
  
  • Associated with estrogen decline

But estrogen hormone therapy is currently not indicated to prevent CHD (useful in preventing osteoporosis)

Question 5

Answer 5

SNRI

• Estrogen contraindicated in patients with hx of breast cancer
• SSRIs contraindicated in pts on tamoxifen

Question 6

Describe the hormonal changes that occur in perimenopause

Answer 6

• Initially, decreased inhibin B
• -> loss of feedback inhibition, resulting in increased FSH
• -> Temporarily increases estrogen from ovary
  
  • ​-> heavy menstrual periods
• -> Follicle continues to deplete
• -> Can no longer respond to increasing FSH
• -> estrogen falls
• Also - Anti-mullerian hormone diminishes during perimenopause*
• Thank you @Frank!*

Question 7

Describe the vasomotor symptoms associated with menopause

Answer 7

• Flushing
• Increased HR/palpitations
• Sweating followed by chills
• Hot flashes

The menopasue FISH!

Question 8

Which cancer drug is an absolute contraindication for SSRIs?

Answer 8

Tamoxifen

• Typical pt: Hx of breast cancer, on tamoxifen*
• Cannot give estrogen therapy or SSRI; use SNRI (venlafaxine)*

Question 9

What hormones should be used for hormone replacement therapy?

Answer 9

Estrogen is the hormone that will treat vasomotor sx

• If the pt has a uterus, estrogen + progestin
  
  • Unopposed estrogen -> endometrial cancer
• If the patient does not have a uterus, can use estrogen only

Question 10

List the contraindications to hormone replacement therapy (7)

Answer 10

• Vaginal bleeding (unexplained)
• Liver disease (active)
• VTE or PE (previous)
• Thrombophilia
• HTN (untreated)
• Estrogen-dependent neoplasia
• Hx of CHD, Stroke, TIA

Question 11

Answer 11

B: Topical estroen

• Safe in pts with hx of breast cancer
• Don’t need systemic therapy if sx are only local
• Offer vaginal moisturizer if pt wantst to avoid estrogen

Question 12

Answer 12

A

• B is post-menopausal (>1 year since LMP)
• C has primary ovarian insufficiency

Question 13

What changes in menstrual cycles are likely to occur during perimenopause?

Answer 13

• At first, periods become heavier
  
  • As ovarian estrogen is upregulated in response to increasing FSH
• Then, they become lighter and mose spaced out
  
  • Follicle is depleted, can no longer respond to increasing FSH
• Finally, they stop completely

Question 14

Which gonadotropin is most reliably elevated in a post-menopausal female?

Answer 14

FSH

(But may fluctuate wildly during transition!)