Hormone Therapy

Question 1

menopause clinical presentation

Answer 1

• Common symptoms of menopause include vasomotor symptoms (hot flashes and night sweats), vulvovaginal atrophy, vaginal dryness and dyspareunia
• Less common symptoms include mood swings, depression, insomnia, arthralgia, myalgia, urinary frequency, decreased libido, and problems with concentration and memory

Question 2

Risks/benefits

Answer 2

Risks	
•	No benefit for CV disease prevention
•	Increased risk of:
o	CHD
o	VTE
o	Stroke
•	Breast cancer (risk ↑ with use > 2-5 yrs)
•	May  lung CA risk, especially when used > 10 yrs	

Benefits
• Relief of vasomotor symptoms
• Treat vaginal atrophy
• Osteoporosis prevention
• Decrease fasting blood glucose in women with elevated fasting insulin concentrations
• Improvement in mood and well-being primarily in women with vasomotor symptoms and sleep disturbance

Question 3

HRT CI

Answer 3

• History of or active thromboembolic disease
• Breast CA or estrogen-dependent neoplasm
• Pregnancy
• Liver disease
• Undiagnosed vaginal bleeding
• Prevention or treatment of cardiovascular disease, cerebrovascular disease, or dementia

Question 4

Pretreatment assessment prior to HRT initiation

Answer 4

• History consistent with diagnosis of menopause
• Labs: FSH > 40 units/L, pregnancy test, TSH
• Assessment of contraindications
• Discuss the risks and benefits with each patient
• PE including BP and pelvic exam
Results of cervical cytological exam and screening mammography negative for malignancy

Question 5

Nonhormonal therapies

Answer 5

1. hormones
2. SSRI/SNRI - citalopram, fluoxetine, sertraline, paroxetine - SSRI; Venlafaxine - SNRI
3. Gabapentin or Clonidine (antiHTN)
4. Supplements - black cohosh, soy

Question 6

SERMs

Answer 6

Ospemifene

• indicated for vaginal atrophy
• is as effective as topical estrogen, but very expensive and bad AE

Paroxetine
- low dose SNRI/SSRI are not as effective as HRT, but are more effective and better tolerated than gabapentin and clonidine

Question 7

F/U

Answer 7

Six weeks after: check sx relief, AE, and patterns of w/drawal bleeding

Annually:
H&P, breast exam, pelvic exam, routine endometrial CA screen, BP

Question 8

When to d/c

Answer 8

usually after 2-3 years

Taper q4-6weeks to avoid menopausal sxs