Menopause

Question 1

Natural menopause

Answer 1

The time of a person’s final menstrual period
* Diagnosed after no periods for 12 consecutive months

Question 2

Induced menopause

Answer 2

Experience (before natural menopause) with bilateral oophorectomy (removal of both ovaries) ablation of ovarian function with chemotherapy or pelvic radiation

Question 3

Perimenopause

Answer 3

• Most often begins between 45 and 55
• Starts at onset of menstrual irregularity and ends 12 months after final menstrual period
• Abnormal uterine bleeding

Question 4

Abnormal Uterine Bleeding

Answer 4

• Characterized by a deviation of regularity, frequency, duration, or volume of menstrual fluid
• Most often caused by the increased frequency of anovulatory cycles

Question 5

What are some vasomotor symptoms?

Answer 5

• Hot flashes
• Night sweats

Question 6

What are some symptoms of genitourinary syndrome of menopause?

Answer 6

• Vaginal atrophy leading to dryness, burning, irritation
• Dyspareunia (sexual discomfort or pain)
• Urinary urgency, dysuria, incontinence, and recurrent UTIs

Question 7

What are some psychological symptoms?

Answer 7

• Depression and anxiety
• Sleep disturbance

Question 8

What are postmenopausal women at an increased risk for?

Answer 8

• Osteoporosis
• Bone fractures
• CHD
• Increased memory loss
• Other cognitive difficulties

Question 9

How do you diagnosis menopause?

Answer 9

• Elevated FSH level is NOT required
• In patients with uterus/ovaries under age 45, rule out other causes of menstrual cycle dysfunction
• In patients with hysterectomy without bilateral oophorectomy, elevated FSH and low estradiol concentrations may support diagnosis

Question 10

What are some non-pharmacological treatments?

Answer 10

• Smoking cessation
• Exercise
• Avoid hot, spicy foods
• Avoid caffeine
• Layer clothes

Question 11

Menopausal Hormone Therapy

Answer 11

• Estrogen replacement therapy
• Effective for vulvovaginal symptoms
• Effective for moderate to severe vasomotor symptoms

Question 12

What MHT are you using if the patient had a hysterectomy?

Answer 12

1. Estrogen + Progesterone
2. Estrogen + Bazedoxifene
3. Low-dose vaginal estrogen

Question 13

Intravaginal estrogen products are preferred when?

Answer 13

In patient with only genitourinary symptoms
* No need to give with progestogen
* Local action, except with Femring, which achieves systemic levels

Question 14

What are the adverse effects of estrogen?

Answer 14

• Nausea
• Breast tenderness
• Increased risk of migraine
• Headache
• Thromboembolic events
• Gallbladder disease
• Hypertriglyceridemia
• HTN
• Increased the risk of endometrial cancer
• Small increase in risk of breast cancer and cardiovascular events

Question 15

Progestin

Answer 15

• Prevent estrogen-induced endometrial hyperplasia and cancer when co-administered when estrogen
• Can be used continuously or cyclically
• At least 12-14 days of progestogen therapy per month is required

Question 16

Conjugated equine estrogen (CEE)

Answer 16

• Administer 21 days on and 7 days off
• Vaginal estrogen

Question 17

Estradiol cream (Estrace)

Answer 17

• Vaginal estrogen
• 2-4 g daily for 2 weeks, then half-dose daily for 2 weeks; maintenance 1 g 1-3 times per week

Question 18

Estradiol tablets (Vagifem)

Answer 18

• Once weekly for 2 weeks, then twice weekly

Question 19

Estring (intravaginal ring)-estradiol

Answer 19

• Intravaginal estrogen
• 90 days

Question 20

Femring (intravaginal ring)

Answer 20

• Intravaginal estrogen
• 90 days

Question 21

Topical emulsion (Estrasorb)

Answer 21

Apply to legs
* topical estradiol

Question 22

Topical gel (EstroGel metered-dose pump)

Answer 22

• Apply from wrist to shoulder
• Topical estradiol

Question 23

Topical gel (Elestrin metered-dose pump)

Answer 23

Apply to upper arm
* Topical estradiol

Question 24

Topical gel (Divigel)

Answer 24

• Apply to upper thigh
• Topical estradiol

Question 25

Transdermal spray

Answer 25

* Apply to inner forearm * Topical estradiol

Question 26

Does cyclic regmines of progestins cause withdrawal bleeding?

Answer 26

Yes

Question 27

What are the common adverse effects of progestin?

Answer 27

* Breast soreness * Some experience "premenstrual-like" symptoms such as mood swings and bloating * Vaginal bleeding iwth cyclic progestin and in the early months of continuous estrogen-progestin (if newly menopausal) * Risk of CHD with MPA use

Question 28

What are the contraindications of MHT?

Answer 28

* Unexplained vaginal bleeding * Active liver disease, liver failure * Prior estrogen-sensitive breast or endometrial cancer * History of CHD or stroke * History of or high risk for VTE * Untreated HTN

Question 29

When is transdermal estrogen preferred over oral estrogen?

Answer 29

* Hypertriglyceridemia * Active gallbladder disease * Thrombophilia such as factor V Leiden * Migraine headaches with aura

Question 30

What is the risk vs benefits of having cardiovascular disease when taking MHT?

Answer 30

* Reduced when estrogen-only used in newly menopausal patient * No increase if estrogen + progestin therapy initiated within 10 years of menopause * Increased risk if initiated more than 10 years since menopause

Question 31

What is the risk vs benefits of having breast cancer when taking MHT?

Answer 31

* Increased risk when estrogen + progestin therapy if used > 10 years * Use of estrogen alone may decrease risk

Question 32

What is the risk vs benefits of having osteoporosis when taking MHT?

Answer 32

* Estrogen therapy reduces bone turnover and increases bone density * Standard-dose MHT reduces postmenopausal osteoporotic fractures

Question 33

What is the risk vs benefits of having ischemic when taking MHT?

Answer 33

Increased risk with estrogen only and estrogen + progestin

Question 34

What is the risk vs benefits of having VTE when taking MHT?

Answer 34

* Increased risk of with personal risk factors including obesity, previous history of VTE, presence of Factor V Leiden mutation

Question 35

Bazedoxifene

Answer 35

* FDA-approved for use in severe vasomotor symptoms and prevention of osteoporosis * Antagonist in breast and uterus * Must be used with estrogen

Question 36

What are the side effects of Bazedoxifene?

Answer 36

* Muscle spasms * Nausea * Diarrhea * Dyspepsia

Question 37

Ospemifene

Answer 37

* FDA-approved for the treatment of moderate-to-severe dyspareunia from menopausal vulvar and vaginal atrophy * Nearly full estrogen agonist effect in the vaginal epithelium; antagonist in breast and uterus

Question 38

What is the side effect of ospemifene?

Answer 38

* Hot flashes * Vaginal discharge * Muscle spasms

Question 39

Prasterone (Intrarosa)

Answer 39

* Once daily vaginal insert * DHEA * FDA-approved for treatment of moderate-to-severe dyspareunia * Local effect = decrease vaginal dryness * Does NOT carry boxed warning for VTE or endometrial hyperplasia like other estrogen-containing products

Question 40

What are some side effects of Prasterone (Intrarosa)?

Answer 40

* Vaginal discharge and abnormal Pap smear (atypical squamous cells of undetermined significance)