ICL 17.3: Hormonal Changes and Their Sequelae Flashcards
51 year old woman present to your office with concerns that she is not sleeping well at night. she’s assoaciting this with night time hot flashes. what do you recommend first?
try lifestyle modifications first!
- avoid spicy food
- wear light clothes and cool bedding
- avoid caffeine and alcohol
- weight loss if obese
- smoking cessation
anything that will lower sympathetic response and vasodilation!
consider timing: perimenopause vs. menopause! if it’s perimenopause then you should wait because they’re fluctuating so much and OCPs (much higher doses than HRT) are the preferred treatment instead of hormone replacement therapy
how do OCPs differ from HRT?
OCPs are much more potent and higher doses
ethinyl estradiol is 4-10x more potent than HRT estrogens
what is the standard of care for menopausal symptoms?
hormone replacement therapy
what are common menopausal symptoms?
- vasomotor symptoms (hot flashes)
- genitourinary symptoms
- osteoporosis risk
- CVD/CHD
osteoporosis is maybe helped by HRT but you do NOT use HRT to reduce CVD risk because it may actually be detrimental
how do you treat vasomotor symptoms?
hot flashes and night sweats require systemic HRT!
it is effecting their sleep and ADLs
if they have a uterus you need estrogen + progestin and the progestin can be continuous of cyclical
if they don’t have a uterus you dont have to give progestin
there are many different formulations but use the lowest dose possible in either scenario and wait 12 weeks to see the full effect of the medication
which systemic HRT products are available?
orally, ells, emulsion packs, femring, patches, spray
be sure to look at the indication!
what are compounded products and bioidenticals?
there’s not evidence of increased safety or efficacy of bioidenticals aka like natural estrogens or herbs
compounded products are not regulated for quality control and there are variable absorption/effects
how does HRT effect CHD?
combined estrogen and progesterone risk is neutral but may be increased if 10+ years post menopause
neutral effects with just estrogen HRT
how does HRT effect VTW?
increased especially in the 1st year of use especially with oral > transdermal
increased risk with just estrogen too
how does HRT effect stroke/TIA risk?
increased risk for both combined and just estrogen HRT
how does HRT effect breast cancer risk?
increased risk with more duration for those on combined HRT
neutral risk for estrogen only
how does HRT effect endometrial cancer?
neutral risk with combined HRT
neutral risk with estrogen only HRT unless given alone with intact uterus
how does HRT effect colon cancer?
decreased risk with both types of HRT!
how does HRT effect fractures?
decreased risk with both types of HRT!
what are the absolute contraindications for HRT?1\
- undiagnosed abnormal genital bleeding
- active endometriosis
- known or suspected breast cancer history
- known or suspected estrogen or progesterone dependent neoplasia
- h/o DVT. PE or MI, stroke, atherosclerotic disease
- liver dysfunction or disease especially with oral medications that need first pass metabolism
how do you monitor HRT for estrogen efficacy?
estrogen dose should be helping with:
- hot flush/sleep disturbance persistance
- breast tenderness
- mood swings
- nausea
- water retention/bloating
what progestin side effects can be seen with HRT?
- headache
- nausea
- premenstrual-like symptoms
51 year old female with hot flashes and trouble sleeping. what questions do you have for her?
- when was your last menstrual period to tell if she’s in menopause or perimenopause
- is she taking anything to help with symptoms?
- past medical history: cancer, DM, CVD, DVTs, liver disease
- any other symptoms? like vaginal or uritogenital symptoms?
- history of migraines?
- gastric bipass history which can effect medical absorption
- any breast surgery or endometrial ablation or hysterectomy
- any possible drug interactions that could be causing the hot flashes? aka ask for her medication list
51 year old female with hot flashes and trouble sleeping. what recommendations do you have for her?
- lifestyle and behavioral changes like using cooler blankets and lowering the AC
- has she considered HRT?
- discussions with the patient about risk/benefit of HRT and what the timeline would look like for the medication to kick in with full effects
what are the genitourinary symptoms of menopause?
- vulvovaginal atrophy = vaginal dynes, burning, itching, discomfort, dyspareunia
- lower urinary tract symptoms = urethritis, urinary urgency, frequency
how do you treat genitourinary symptoms of menopause?
HRT local therapy!
they minimize systemic absorption, more effective than systemic therapy
what are the local treatments available for genitourinary sytmptoms of menopause?
- estrace cream
- estring
- invexxy vaginal tablet
- vagifem vaginal tablet
how do you treat people who have both vasomotor and genitourinary symptoms?
vasomotor = systemic
genitourinary = local
so sometimes the systemic treatment will help with some genitourinary function but sometimes you also need local therapies too if needed
what is the risk/benefit conversation associated with HRT?
what works best for the patient and do they want to take it? how is their quality of life being effected?
