Hormone replacement therapy

Question 1

What is perimenopause

Answer 1

Onset of menstrual irregularity-12 months after LMP

Question 2

What is menopause

Answer 2

permanent cessation of menses caused by loss of ovarian follicular activity

Question 3

In menopausal women, bleeding is

Answer 3

cancer until proves otherwise

Question 4

What happens when ovarian function ceases

Answer 4

Ovaries no longer are primary site of estradiol and progesterone synthesis
Serum FSH reaches >40

Question 5

Menopause is characterized by

Answer 5

10-15x increase in circulating FSH
4-5x increase in LH
>90% decrease in estrogen and progesterone

Question 6

Perimenopause is characterized by

Answer 6

FSH fluctuates between normal and postmenopausal ranges (so don’t use FSH to Dx perimenopause!)
-You can still get pregnant in perimenopause!

Question 7

Leading up to menopause, most women have

Answer 7

4-8 years of heavy, irregular cycle changes which is mostly caused by anovulatory cycles (can also be 2/2 thyroid abn, hyperPRL, or PCOS)

Question 8

What are symptoms of menopause

Answer 8

Vasomotor Sx (hot flashes, night sweats) 
slep disturbances 
mood changes 
problems with concentrating and memory 
vaginal dryness and dyspareunia

Question 9

What lab tests can you get to diagnose menopause and perimenopause

Answer 9

Peri: FSH on day 2 or 3 of cycle >10-12 IU
Meno: FSH >40 IU
-Can also get thyroid tests, iron stores, and a lipid profile

Question 10

FDA approved therapy for these 4 indications

Answer 10

Vasomotor symptoms (hormonal Tx is A1)
Prevention of bone loss
Hypoestrogenism
GU Sx

Question 11

How can estrogen be given to postmenopausal women

Answer 11

W/ a uterus: estrogen + progesterone (or estrogen agonist-antagonist)
Had a hysterectomy: unopposed estrogen

Question 12

What is MHT

Answer 12

menopause hormone therapy
individualized based on severity of Sx and risk of CVD, breast cancer, osteoporotic Fx, and VTE
DO NOT use to reduce risk of CVD

Question 13

In what way does MHT increase the risk of breast cancer

Answer 13

With progesterone added to estrogen therapy!

Breast cancer risk is not higher in women taking unopposed estrogen

Question 14

Recently postmenopausal women are at an increased risk for

Answer 14

fracture!

May use systemic estrogen to prevent osteoporotic Fx when alternate Tx are CI or have excess ADE

Question 15

Per USPSTF, should post menopausal women use hormone therapy as primary prevention for chronic diseases

Answer 15

No! It is a grade D recommendation that if with a uterus you NOT use estrogen+progesterone, and if without a uterus you NOT use estrogen

Question 16

Absolute contraindications to using MHT are

Answer 16

undiagnosed genital bleeding 
known or suspected Hx of breast cancer 
Known or suspected E/P  dependent neoplasia
Active or Hx of DVT or PE 
Active or recent MI or CVA
Liver dysfunction or disease

Question 17

What lifestyle modifications can help relieve vasomotor symptoms

Answer 17

Wear layered clothing
lower room temperature
decrease intake of spicy food, caffeine, or hot beverages
exercise

Question 18

Does HRT provide contraception?

Answer 18

NO

Question 19

What is the estrogen transdermal patch

Answer 19

17 b-estradiol

Question 20

Different formulations of estrogen include

Answer 20

topical emulsion, gel 
topical transdermal spray 
implanted 
vaginal ring 
intravaginal products (to Tx urogenital Sx)

Question 21

What are the oral types of progsterone

Answer 21

Medroxyprogesterone acetate
Micronized progesterone
Norethindrone acetate

Question 22

Why do women typically not like progesterone

Answer 22

Because it messes with your menses, and can cause your periods to return

Question 23

Commonly used oral hormone replacements are

Answer 23

Conjugated equine estrogen + MPA

Ethinyl estradiol + Norethindrone acetate

Question 24

Commonly used topical hormone replacements are

Answer 24

Estradiol + Norethindrone acetate patch

Estradiol + Levonorgestrel patch

Question 25

What can you use other than estrogen to treat hot flashes

Answer 25

- Venlafaxine: may cause nausea, HA, dizzy, constipation, HTN - Desvenlafaxine: may cause same as above but no HTN - Paroxetine: may cause same as above but no HTN - Megestrol acetate: progesterone can be linked to breast cancer - Clonidine: may cause drowsiness, dizzy, hypotension, dry mouth - Gabapentin: may cause dizzy, mental confusion, ataxia

Question 26

What therapy is becoming more widespread

Answer 26

therapeutic use of testosterone (androgens) | even though it is unclear if there is a true androgen deficiency!

Question 27

What effects do androgens have in women

Answer 27

Act directly via androgen receptors in bone, skin, hair follicles, and sebaceous glands Act indirectly via aromatization of T-to-E in ovaries, bone, brain, adipose, and other tissues

Question 28

Symptoms of androgen insufficiency include

Answer 28

diminished well being persistent, unexplained fatigue decreased libido, sexual receptivity, and pleasure

Question 29

What androgen treatments are available

Answer 29

Methyltestosterone + Esterfied estrogens Testosterone pellets Transdermal testosterone system Oral tablet Flibanserin (came out for women)

Question 30

What are phytoestrogens

Answer 30

Plant compounds with bioactivity like estrogen (but weak estrogen receptor binding) that have a physiologic effect in humans

Question 31

What are the 3 main classes of phytoestrogens

Answer 31

Isoflavones: Genistein and Daidzein (active components)- found in soybeans Lignans- found in cereal, oilseeds, flaxseeds Coumestans- found in alfaalfa sprouts

Question 32

What is Black Cohosh

Answer 32

an herbal supplement that acts through the serotonergic system, but does not have strong estrogenic properties Relatively safe but has been linked to hepatotoxicity May not offer a lot of relief of hot flashes

Question 33

Never put transdermal products on

Answer 33

The breasts!!

Question 34

After prescribing HRT, follow up

Answer 34

in 6 weeks to discuss patient concerns, and evaluate Sx relief, ADE, and patterns of withdrawal bleeding

Question 35

How long should hormone therapy be used

Answer 35

only as long as Sx control is necessary; usually 2-3 years

Question 36

ADE of estrogen are

Answer 36

Breast tenderness! Reduce the estrogen dose, or switch to transdermal (If hot flashed persist, raise estrogen dose)

Question 37

ADE of progesterone are

Answer 37

Bloating PMS-like Sx -switch to a different progesterone

Question 38

What does ACCE NOT recommend

Answer 38

Use of bioidentical hormone therapy

Question 39

Part of the general statement on HRT put out by NAMS

Answer 39

- Benefits >risks for women <60, w/in 10 years of menopause - HRT should be individualized - VMS and GSM prevent bone loss and fracture

Question 40

What are bioidentical hormones

Answer 40

Natural forms of estrogen, progesterone, and testosterone | carry the same risks as traditional hormone therapy!

Question 41

If women only have vulvovaginal Sx, how do you treat

Answer 41

Mild: vaginal moisturizer/lube | Mod-Severe: vaginal estrogen at lowest dose

Question 42

If women have only vasomotor Sx, how do you treat

Answer 42

Mild: Non-pharm therapy | Mod-severe: If not CI, use estrogen +/- progesterone. If CI, use SNRI, SSRI, clonidien, or gabapentin

Question 43

If a woman has vasomotor and vulvovaginal Sx, how do you treat

Answer 43

Basically combine the two !