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Flashcards in HRT Deck (19):
1

menopause vasomotor effects how many women?
How many of those are severe?
Median symptom duration?
How is it diagnosed?

80%
20%
4 years but up to 12 years in 10%
clinically based on typical symptoms 1 year of amnorrhea after 50 years of age.

2

What is premature menopause?
What is early menopause?
What is most common age of menopause?

< 40 years of age
< 45 years of age
51 years old

3

HRT what must you do?
What must you NOT do?

Fullyr mn, informed on the risk benefits of treatement
Do NOT start in women over 60 years of age.

4

What are common signs of menopause?

What are common symptoms of menopause?

Signs
decreased estrogen production from ovaries
low levels of testosterone
erratic levels of estrogen and progesterone
low levels of estrogen
thinner vaginal walls

Symptoms - decreased levels and erratic levels
hot flashes
night sweats
decreased libido
irregular periods
mood swings
vaginal dryness

5

What causes normal menopause transition?

What are other causes of menopause transition?

demise of follicular cells and the immature ova
estrogen levels fall
FSH and LH increase then decrease after final menses

other reasons: chemotherapy, radiation, pelvic vessel embolism, bilateral oophorectomy

6

What are the benefits of HRT?

Most effective treatment of vasomotor symptoms
sleep, mood by 3 months
urogenital symptoms (sexual functions, UTIs)
reduce osteoporosis
reduce risk of CHD (start within 10 years of menopause)
Possible reduced risk of colorectal cancer

7

What are the risks of HRT?




effect of transdermal vs oral (systemic)

How does combined HRT effect breast cancer, breast density and mammogram?

How is breast cancer risk effected?





effects of estrogen only HRT?

effects on Ovarian ca?

effects on CHD?

Risk free until natural menopause
Ven Thrombo Embo: low in healthy women under 60
Stroke: (not increased in women under 60)

Lower risk with transdermal vs system estrogens effect may be dose related.

Breast cancer (debated) none within 5 years time
(time of use -risk goes up after 60)

Absolute risk is 1 breast ca per 1000 women/year
(similar to obesity, nulliparity, late menopause/ drinking 2-3/day) return to non use risk within 5 yrs of cessation

increases density and increased risk

risk of endometrial ca

conflict but only RCT says none

CHD increase but only in women starting AFTER 60
some suggest benefit if prior to 60

8

HRT for total hysterectomy?
Uterus with some periods
Post menopausal

estrogen only
cyclic HRT
continuous combined HRT

9

Monitoring HRT
follow up at 3 months?
Common effects 3-6 months
If heavy bleeding on Cyclic HRT?
What are progesterone SE
What can be done for progesterone SE?

symptoms, bleeding, BP weight gain
erratic bleeding common 3-6 months - investigate if bleeding persists after this time frame.
double progesterone
fluid retention, weight gain, mood swings,
reduce dose 1/2, reduce duration to 7-10 days

10

Monitoring HRT?
Stopping HRT?

reassess annually
assess FSH. . . symptom free for 1-2 years
wean rather than reduce abruptly especially if high dose

11

Pharmocotherapy for HRT
What are available routes?

estrogen alone or with progestin
oral, transdermal patch, gel and spray. Intranasal and Buccal used outside united states.

12

Describe a newer regime for HRT

what is a serm?

Estrogen and bazedoxifene (SERM)
Selective estrogen receptor modulator (mixed agonist/antoagonist)
intact uterus and short course (how short)
For moderate to severe VMS
provention of osteoporosis

13

What is FDA use for testosterone

NO FDA monotherapy approval, but combines with HRT.

14

What are advantages of non oral forms of HRT?

avoid 1st pass metabolism
FOR moderate risk category

15

What is moderate risk category for HRT?

nausea, liver disease, malabsorption, thrombosis,
enzyme-inducing drugs (p450 system)

16

Can OCP be used with HRT?

yes if under 50, no OCP if over 50.

17

What are alternatives to HRT for urogenital symptoms of menopause
What for VMS such as flushing?

topical estrogen cream - first line NOT systemic
then tablet, cream, pessary or vaginal ring
Clonidine but causes dry mouth, wean down to stop and can cause hypotension. -
dose 0.1 mg daily

18

Alternatives to HRT for vasomotor symptoms

low dow SNRI (Serotonin and norepinephrine reuptake inhibitors) such as vanlafaxine
low dose SSRI (selective serotonin reuptake inhibitors ) brisdelle,
paroxetine 7.5 mg daily similar SE to higher doses
gabapentin lacking FDA (600-900 daily)

19

HRT window 1
HRT window of opportunity 2
other important questions?

What are the contraindications?

must be less than 60
must be no more than 10 years since last period
intact uterus? still having a period?

undiagnosed vaginal bleeding
VTE
active or recent angina
suspected/current/past breast ca
endrometrial or other estrogen-dependent ca
Active liver disease with abnormal LFTs
uncontrolled HTN
pregnancy or breastfeeding
all of these refer to a specialist.