Ex. 4 L1 - MHT 1 (35)

Question 1

When menopause is diagnosed

Answer 1

Confirmed after 12 consecutive months of amenorrhea (absence of menstruation)

Question 2

Premenopause

Answer 2

The time period of endocrine changes BEFORE cessation of menstruation

Question 3

Perimenopause (Climacteric)

Answer 3

The period of endocrine changes SURROUND the menopause

Question 4

Menopause Median age of onset US

Answer 4

51 years (40-58)

Question 5

Postmenopause

Answer 5

The time period of endocrine changes AFTER cessation of menstruation

Question 6

Women spend _% of their lives postmenopausal

Answer 6

40%

Question 7

Premature menopause

Answer 7

AKA “premature Ovarian Insufficiency” (POI)
Occurs before age 40
Hysterectomy, radiation therapy, chemotherapy
1% of women develop premature ovarian failure before 40
Increase risk of mortality and morbidity

Question 8

Symptom statistics

Answer 8

Worst symptoms occur during first 1-2 years
Symptoms last 7+ years for most women

Question 9

Causes of menopause

Answer 9

Physiologic
-Extensive deterioration of the follicular cells and ova w/aging
-Decrease estrogen and progesterone levels -> increase FSH and LH level
Surgery
-Removal of ovaries (oophorectomy)
Chemotherapy
-Breast cancer chemotherapy
Radiation therapy

Question 10

Clinical presentations of menopause: Vasomotor

Answer 10

Hot flashes
Night sweats
(50-87% of symptoms)

Question 11

Clinical presentations of menopause: Mix

Answer 11

Irregular Menses
Episodic Amenorrhea
Sleep Disturbance
Mood changes (depression, irritability)
Fatigue
(generally lower number due to embarrassment of reporting)

Question 12

Clinical presentations of menopause: Genitourinary

Answer 12

Vulvovaginal atrophy (vaginal dryness, dyspareunia)
Urinary tract dysfunction
Sexual dysfunction
Urinary frequency, urgency
(27-84%)
Lower incidence of reporting due to embarrassment

Question 13

Long term consequences of menopause

Answer 13

CV disease
Bone loss
Osteoarthritis
Body composition
Skin changes
Balance

Question 14

Treatment of Menopausal symptoms: Nonpharmacologic therapies: recommended

Answer 14

Weight loss
Cognitive behavioral therapy
Clinical hypnosis
Stellate ganglion block

Question 15

Treatment of Menopausal symptoms: Nonpharmacologic therapies: NOT recommended

Answer 15

Lifestyle:
-cooling techniques
-Avoid triggers
-Yoga/exercise
-Dietary modifications
Mind body techniques
-Mindfulness-based interventions
Paced respiration
Dietary supplements
-Soy foods and soy extracts, soy metabolite equol
Supplements/herbal remedies
-cannabis
Others:
Acupuncture, calibration of neural oscillations, chiropractic intervention

Question 16

Indications for menopausal hormone therapy

Answer 16

Vasomotor symptoms
Vulvovaginal atrophy
Osteoporosis prevention (not main tx for osteoporosis)

Question 17

Contraindications to MHT: ABSOLUTE

Answer 17

Any contraindications = stop immediately
Unexplained vaginal bleeding
Pregnancy
Estrogen-dependent malignancies
-Endometrial cancer
-Breast cancer
Stroke
Active thromboembolic disorders (or prior history)
Active liver disease

Question 18

Contraindications to MHT: Relative

Answer 18

Contraindications = patient’s choice to continue/discontinue
Uterine leiomyoma
Migraine headaches with aura
Seizure disorders
Diabetes
Hypertriglyceridemia (>400mg/day)
Active gallbladder disease
High risk for heart disease
Family hx of breast cancer

Question 19

Estrogen monotherapy is only for women (with/without) a uterus

Answer 19

Without

Question 20

Estrogen monotherapy products: Oral

Answer 20

Premarin (conjugated estrogens)
Menest (esterified estrogen)
Estrace generics (micro ionized estradiol)

Question 21

Estrogen monotherapy products: topical

Answer 21

Topical Gel (EstroGel, Divigel, Elestrin)
Topical Spray (Evamist)
IF other family members handle these, can cause S.E. (ex. gynecomastia)

Question 22

Estrogen monotherapy products: IM injections

Answer 22

Estradiol cypionate (Depo-estradiol)
Estradiol valerate (Delestrogen)
not typically used
Used more so in gender changing therapy

Question 23

Estrogen monotherapy products: Transdermal

Answer 23

Preferred
Climara
Lyllana
Menostar
Minivelle
Vivelle-dot
Dotti

-17B estradiol
Put patch on: continuous delivery of estrogen
Bypassing GI tract: avoid first pass, lower incidence of stroke, clots, dyslipidemia etc.

Question 24

Estrogen monotherapy products: intravaginal

Answer 24

Vaginal cream (Estrace, Premarin)
Vaginal Insert (Imvexxy)
Vaginal tablet (Vagifem, Yuvafem)
Vaginal Ring (Estring, Femring)
EXCEPTION:
Estring - does not have high amount of systemic absorption (localized)
Femring: Delivers appropriate amount for symptoms
Ring is bigger than string

Question 25

Topical vaginal products should be prescribed for women

Answer 25

Exclusively experiencing vulvovaginal atrophy (Local)

Question 26

Women with an intact uterus: When to use estrogen?

Answer 26

Should be prescribed a progestin **IN ADDITION TO** estrogen in order to decrease the risk of **endometrial hyperplasia and endometrial cancer**

Question 27

Women's Health initiative study:

Answer 27

15 yr research program **Address most common causes of death, disability and poor quality of life in postmenopausal women** Clinical trials + observational study Effects of hormone therapy, diet modification and Calcium/vitamin D **With uterus:** Conj. estrogen: 0.635 mg/day + medroxyprogesterone 2.5mg/day **W/o uterus:** Conj. estrogen 0.625

Question 28

Major clinical outcomes of WHI study: Estrogen and Progesterone

Answer 28

**Increase**: CV: heart attacks, stroke and venous thromboembolism Invasive breast cancers **Decrease**: Colorectal cancers Hip fractures

Question 29

Major clinical outcomes of WHI study: Estrogen alone

Answer 29

**Increase**: Strokes Venous thromboembolism **Decrease:** Hip fractures **No difference** CHD Invasive breast cancers Colorectal disease

Question 30

Estrogen only: Age groups

Answer 30

-50-59 years favorable risk benefit profile -60-69 increase risk of CHD and stroke -70-79 highest risk of CHD and stroke

Question 31

Estrogen and Progestin age groups

Answer 31

-50-59: lowest risk -60-69: Increasing risk -70-79: Highest risk

Question 32

The women's health initiative showed estrogen + progestin increased the risk of all of the following EXCEPT

Answer 32

Fracture (decreases)

Question 33

The WHI showed estrogen alone increased all of the following except:

Answer 33

Heart attack (age <60 within 10 years of menopause) Fractures Risk of breast cancer