Menopause Flashcards by Kim Nguyen

Menopause definition

permanent cessation of menses following the loss of ovarian follicular activity; occurs 1 year after last menses, FSH ≥40 IU

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Perimenopause definition

immediately prior to menopause and 1st year after menopause begins , characterized by anovulatory bleeding

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Postmenopausal definition

period greater than 1 year after menopause occurs

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Non-hormonal factors that can contribute to menopause

Age, surgery (bilateral oophorectomy/hysterectomy), chemotherapy, pelvic radiation, smoking

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Two categories of menopause symptoms

Vasomotor symptoms (VMS) and Genitourinary syndrome of menopause (GSM)

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VMS Sx

Hot flashes, night sweats, occur 12-24 months after last menstrual period

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GSM Sx: Genital

dryness, burning, irritation

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GSM Sx: Urinary

dysuria, urgency, recurrent UTI Sx

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GSM Sx: Sexual

dryness, dyspareunia

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Other symptoms associated with menopause

Menstrual irregularity, sleep disturbances, mood changes, difficulty with memory and concentration, osteoporosis

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Types of estrogens for HT

Conjugated equine estrogen (CEE), 17-beta estradiol, bioidentical hormones

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Where does CEE come from?

Pregnant mare’s urine, natural product

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17-beta estradiol

Synthetic product

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Bioidentical hormone information

Compounded preparations which are said to provide a unique mix of estradiol, estrone, and estriol at dosages specifically designed for each woman but aren’t FDA regulated

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Systemic estrogen routes of administration

PO, TD patch, TD emulsion, TD spray, TD gel, vaginal ring, implanted pellet

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Vaginal/local estrogen routes of administration

Vaginal cream, vaginal tablet, vaginal ring

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Common ADEs of estrogen

N/V, headache, breast tenderness, heavy bleeding

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Serious ADEs of estrogen

CHD, stroke, VTE, breast cancer, gallbladder disease

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Role of progestogen in combination HT

Mitigation of endometrial hyperplasia

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Who do you give progestogen to?

Women with an intact uterus (aka no hysterectomy)

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Progestogen dosing

Given a minimum of 12-14 days/month

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Progestogen ADEs

irritability, depression, headache

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Types of progestogen products

MPA, norethindrone, micronized progesterone

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Preparations of progestogen

Systemic/oral

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For cyclic use, how often must the progestogen be taken?

Minimum of 12-14 days per month

For a woman with a Hx of hysterectomy, is use of progestogens indicated?

For women with endometriosis with a Hx of hysterectomy, would you use progestogen?

Yes, if combined with estrogen it may minimize endometriosis exacerbations

Continuous cyclic treatment regimen

Estrogen daily, progestogen given the last 12-14 days of every cycle to give scheduled withdrawal bleeding 1-2 days after the last progestogen dose

Continuous combined treatment regimen

Estrogen and progestogen daily, associated with absence of vaginal bleeding

Who is the continuous combined treatment regimen reserved for?

Women 2 years post menopause

Continuous long-cycle treatment regimen

Estrogen daily, with progestogen given 12-14 days EVERY OTHER MONTH, bleeding periods may be heavier and longer than withdrawal bleeding

Intermittent combined treatment regimen

3 days of estrogen alone, followed by 3 days of combined estrogen and progestogen repeated without interruption

Undiagnosed or abnormal bleeding: absolute or relative CI

absolute

Known, suspected Hx of breast cancer: absolute or relative CI

absolute

Known or suspected estrogen or progesterone-dependent neoplasia: absolute or relative CI

absolute

Active or Hx of VTE: absolute or relative CI

absolute

Active or recent arterial thromboembolic disease like MI or stroke: absolute or relative CI

absolute

Liver dysfunction or disease: absolute or relative CI

absolute

HTN: absolute or relative CI

relative

High TGs: absolute or relative CI

relative

Impaired liver function: absolute or relative CI

relative

Hypothyroidism: absolute or relative CI

relative

Fluid retention: absolute or relative CI

relative

Severe hypocalcemia: absolute or relative CI

relative

Ovarian cancer: absolute or relative CI

relative

Exacerbation of endometriosis: absolute or relative CI

relative

Exacerbation of asthma, DM, SLE, epilepsy, porphyria, or hepatic hemangioma: absolute or relative CI

relative

WHI results for the group who received estrogen and progesterone vs. placebo

Increased risk of MI, stroke, breast cancer, blood clots Decreased risk of colorectal cancer and fractures

WHI results for the group who received estrogen only vs. placebo

No difference in risk of MI or breast cancer Increased risk of stroke and blood clots Decreased risk of hip fractures

WHI benefits of HT

Relieved Sx of VMS and GSM, decreased hip fracture and osteoporosis and colon cancer

What did the WHI do for HT?

FDA safety warning labels were added to all estrogen and progestogen products for increased risk of MI, stroke, breast cancer, endometrial cancer, thromboembolism Use the lowest effective dose possible!

Indications for HT therapy

Moderate-severe VMS +/- GSM Sx, moderate-severe GSM Sx alone for vaginal therapies

What should all patients be reviewed for before starting HT?

Contraindications and they should all be offered a discussion on the risks and benefits of HT so they can make an informed decision

HT for VMS length of therapy

<5 years, goal should be cessation within 5 years

HT for GSM

Vaginal products only Low dose vaginal estrogen usually doesn't require progestin but long-term use may require intermittent progestin

Length of therapy for GSM HT therapy

Usually require prolonged therapy

Contraception during menopause

All good to use as long as age ≥40 years old

Nonpharm Tx for VMS

Cognitive behavioral therapy, hypnosis, mindfulness-based stress reduction, weight loss (limited evidence of benefit) Cooling techniques, avoidance of triggers, yoga (insufficient evidence)

Nonpharm Tx for GSM

Nonhormonal vaginal lubricants and moisturizers (1st line for GSM only!)

Herbals for menopause

Black cohosh and phytoestrogens No evidence for herbals

Androgens for menopause

Methyltestosterone and esterfied estrogens, testosterone; administer with or without concurrent estrogen therapy

ADEs of androgens

Acne, hirsutism, lowering of voice, lipid and liver function changes

SERMs for menopause

Raloxifene (Evista), ospemifene (Osphena), CEE and bazedoxifene (Duavee)

Raloxifene indications

Prevention and treatment of osteoporosis

Ospemifene indication

Severe dyspareunia

CEE and bazedoxifene indications

moderate-severe Sx of VMS in women WITH A UTERUS, prevention of osteoporosis

Raloxifene dosing

60mg PO QD

Ospemifene dosing

60mg PO QD

Duavee dosing

0.45mg CEE, 20mg bazedoxifene

Duavee has an increased risk for...

VTE and CVA

Duavee ADEs

leg cramps, hot flushes, sweating, GI Sx

SSRI for menopause

Paroxetine mesylate (Brisdelle), used for VMS

Paroxetine mesylate dosing

7.5mg PO QD

Paroxetine mesylate ADE

GI Sx

Paroxetine mesylate BBW

Suicidality

Who do you consider paroxetine mesylate in?

Patients with concomitant depression, CIs to HT, or those who don't wish to take HT

SNRIs for menopause

Desvenlafaxine, venlafaxine (off-label); effective for VMS

Prasterone (Intrarosa) indication

Dyspareunia due to menopause

Prasterone dosing

6.5mg intravaginally QHS daily

Clonidine and gabapentin

Off-label uses for VMS

Patient counseling for HT

Systemic HT is highly effective in alleviating VMS +/- GSM Using the lowest effective dose and limiting therapy to <5 years removes nearly all risk HT is indicated for healthy women with significant VMS <60 years old and within 10 years of menopause onset

Discontinuation of HT

Tapered to limit recurrence of hot flashes, slowly D/C over 3-6 months after 4-5 years of therapy

What should women experiencing menopause prior to age 45 do regarding HT?

Use HT until the natural age of menopause (~51 years old in the US)

Menopause Flashcards

(83 cards)