Menopause Flashcards

Question

HRT Precautions

Answer 1

``` Type I DM active gallbladder disease > 1ppd smoker obesity FMH breast Cancer Fibroid uterus hx of peripheral vascular episode migraines elevated triglycerides ```

Answer 2

Newly menopausal (within 5 years) Good health No risk factors for heart disease or breast CA (no first degree relative and neg fmx for BRCA1 or 2) Non smoker, Non-obese Normal Blood sugar and blood pressure Moderate to severe vasomotor s/s or menopausal s/s (Relief of Hot flashes/flushes, irritability, mood changes, sleep disturbances ? Can you function in your day to day activities. Relief of atrophy, vaginal dryness, dysparunia)

Answer 3

Blood Clots Gall Bladder Disease Breast Cancer < 4yr no increase risk 4-10 years questionable > 10 year increase risk Increased cardiac events in 1st year use with patient with prior heart disease – HERS II (Goal of therapy, less than 5 years use, that’s what we tell patients Instability of blood vessels)

Answer 4

``` E2/Progesterone arm halted after 5.2 years 8 More will develop breast cancer >4yrs 7 more will have heart attack 8 more will have stroke 8 more will have blood clot in lungs 3yr 5 fewer will have hip fractures overall harm outweighs the benefits ```

Answer 5

15 year study looked at the common cause of death, disability and impaired QOL in PM women – had 3 arms ert, ert/prog, nothing The Women’s Health Initiative (WHI) study in 2002 showed that oral horse estrogens and progestins (Prempro) increased the risk of breast and ovarian cancer and heart disease and strokes. Many experts feel the study design was flawed because they used older women (average age 62) some of whom had been on no HRT for 20 years so they were more likely to already have disease. Furthermore, many of these risks may be from the use of oral estrogen. Another possible explanation for the risks in WHI may arise from using synthetic hormones instead of the natural hormones. Premarin comes from horse estrogen and the synthetic progestin, medroxyprogesterone (Provera) is substituted for progesterone. WHI utilized a specific product, Prempro, that combines Premarin and Provera in one pill that’s taken daily. So the adverse effects could be caused from the use of oral estrogens, synthetic hormones or from the unique combination of two synthetic hormones.

Answer 6

Cardiac protection-counsel on other methods Osteoporosis prevention- ok, but other alternatives available Short term use for Vasomotor S/S 1-4 years Long term use for Vasomotor S/S-creams, mood elevators, sleeping pills Estrogen with Progesterone 5 years use ok Estrogen alone can be used up to 7 years (Cardiac – diet, exercise, cholesterol lower meds, Ca, vit D, vasomotor)

Answer 7

``` Conjugated estrogen – Premarin (0.3/0.45/0.625,0.9,1.25mg/d) Esterified estrogen – Menest (0.3/0.625,1.25,2.5mg/d) Transdermal estrogen – Vivelle dot-, never on the breast tissues, Vivelle, Estraderm, Alora, Climara, Esclim, Menostar, FemPatch **avoids liver effects and less effect on triglycerides and lipids compared to oral formulations. Micronized estrogen – Estradiol 1.0mg/d ```

Answer 8

*****MUST be used in ALL patients intact uterus Provera or Prometrium Cyclic – taken the first 10-15 days of the month with estrogen Continuous – taken everyday that estrogen is taken, usually 2.5-5.0 mg qd of MPA Combined products – Prempro, Premphase, FemHRT, Activella, Ortho-Prefest, CombiPatch

Answer 9

Cyclic will bring on menses Continuous no menses, may have btb for up to 6 months on products, is still btb can increase progesterone – ex, if start on 2.5 prempro then increase to 5.0 prempro Prometrium – natural progesterone, peanut oil based, check allergies to peanuts 100-200mg/day Discuss if you haven’t how estrogen works on the uterus and how progesterone counteracts that.

Answer 10

BTB or withdrawal bleeding Progesterone: breast tenderness, fluid retention, wgt gain, depression, irritability increase fibroids allergic reaction to patch Virilization with testosterone products (If BTB on cyclic progesterone increase progesterone dose)

Answer 11

``` Proper way to take meds Report bleeding SBE exercise and calcium 1000 mg/qd Preventative health measure (pap,mammo,fobt, colonoscopy) S/S of danger signs (CVA, MI, Endo CA) ```

Answer 12

``` Improve sleep habits Melatonin Gabapentin - 300mg 1-2 hours before bedtime, some patients may need 600mg Lunesta - 2mg qhs Ambien - 5mg qhs (no longer 10mg) ```

Answer 13

Sleep Hygiene-cool temperature room, avoid naps, exercise, no etoh or caffeine, regular sleep wake cycle, dark and quiet, limit beverage no tob SE of gabapentin- drowsiness, dizziness, spacy feeling usually goes away after about 1 month should be taken before bed half life 5-7 hours Eszopiclone-Lunesta can use long term SE Drowsiness and impairment even in am so use lowest dose Zolpidem-Ambien least expenseive also comes in ER ER approved for long term SE same as above recommended dose lowered high blood levels in the morning and impaired activities

Answer 14

Venlafexine- venlafaxine ER 37.5 qd x 1 week then 75mg once a day or Immediate release 37.5mg qd x 1 week then 37.5 mg bid Gabapentin- 600mg q hs or 300mg TID depending on when the flashes take place (Hot flashes or night sweats) Clonidine – 50-75 mcg/day SSRI some effect+/- Paroxetine 25mg qd Fluoxetine 20mg qd Sertraline 50mg qd (Effexor: SNRI reduced HF 33% Neurontin: Reduced HF 35-38% but varying doses from 900mg to 2500mg SSRI: paxil, prozac, zoloft) Effexor- (Gabapentin- hot flashes, night sweats SSRI best to manage hot flashes, low dose, usually no SE, if already on it, increase up to 40, follow up, 3 mos follow up, check to make sure if doing ok)

Answer 15

May be effective - Estroven, Black Cohash, Soy, Vitamin E | No evidence – Dong quai, acupuncture, yoga, Evening primrose, Ginseng, Kava, Red Clover, Flaxseed

Answer 16

(Soy: Asian-menopausal symptom relief but contain phyto-estrogen Isoflavones which is under investigation for cancer risk. Dietary soy binds more readily to estrogen receptors in the body and safety with use in women with estrogen dependent tumor is unclear. Red Clover: 40mg not enough 80mg reduced hot flashes, side effect:breast tenderness, wgt gain, menstrual changes. Increases endometrial lining with use with soy (1 study) Black Cohosh: reduces hot flashes with very little know side effects or adverse events. No long term studies. May alter the serotonin level as MOA. Hops: Estrogenic Flavonoids. Risk of unopposed estrogen and cancer. Evening primrose: Only one study, with no effect on hot flashes when compared with placebo. Increased N/D and H/A. drug interactions-anti-inflammatory drugs, siezure meds, Beta blockers, corticosteriods, anti coagulants and antipsychotics. Dong Quai: No study to prove benefit but photosensitivity and excessive bleeding with anticoagulants. Ginseng: estrogenic properties. Side effects: insomnia, diarrhea, vaginal bleeding, mastaglia, increase labido. Caution with HTN, DM or Caffeine intake. Flaxseed: estrogenic, antiestrogenic, steriod like activities.may delay absorption of other drugs that are taken simultaneously. No SE.)

Answer 17

85 million women > 50 years of age in 2014 10-40% experience VVA=16 million women/600,000 new cases each year Women on aromatase inhibitors 2 x as likely to develop VVA Only 25% seek help FDA Local Vaginal Preparation is recommended

Answer 18

Vaginal Creams or suppository Premarin cream 0.625, Ogen1-2 appl QD for 2 weeks then 2 x week Estrace 2-4 grQd x 2w, 1-2 gr qd x2w, then 1 gr 1-3 x week *****Estring vaginal ring continuous release for 90 days, needs replacement q 90 days *******Caplet Vagifem 10ug qd x 2wk then 2 x week Osphena – 60mg QD – estrogen receptor modulator

Answer 19

``` OTC lubricants – Ky Jelly, Astroglide OTC vaginal moisturizers – Lubrin, KY longlasting, Replens Vaseline, Aquaphor, Vit E oil – externally Mild soaps (Dove unscented bar soap), warm soaks with baking soda ```

Answer 20

B. Fluoxetine

Answer 21

A. ovaries usually 2-3 cm- evaluate, ultrasound

Answer 22

Porous bone characterized by low bone mass and deterioration of bone tissue, which leads to increase risk for fracture Effects 52 millions Americans, 80% women 1:2 women and 1:4 men over 50 will have a osteoporosis fracture in their life time Responsible for 2 million fractures/year Costs: 19 billion/year *****In the 5-7 yrs following menopause, a woman can lose up to 20% of her bone density.

Answer 23

- history of fracture, advanced age >50, low E2, women, caucasian, FMH, Wgt< 127 lbs - Secondary r/t meds or medical conditions - Glucocorticoids, thyroid Rx, anticonvulsants, cigarettes, excessive ETOH - 1/3 will enter LTC within 1year of fracture - Vertebral FX-Increase mortality, LT pain,

Answer 24

A woman’s risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian and uterine cancer combined. And a man age 50 or older is more likely to break a bone due to osteoporosis than he is to get prostate cancer. (Educate both men and women about the risk and give teaching about healthy diet)

Answer 25

``` Should be done on patients at risk >65yo Family history small frame smoker, ETOH, gluccocorticoid use post-menopausal women not on HRT Low activity early menopause Hx of rib, hip, forearm, or vertebral fracture ```

Answer 26

USPSTF – Aged 65 and older should be screened routinely, or at age 60 if increased risk for osteoporotic fracture Repeat study based on results and treatment *****DEXA screening – dual energy x-ray absorptiometry is the most widely used. It is quick and rx exposure is one tenth of standard chest x-ray. Measures hip, spine, wrist

Answer 27

Normal – BMD within 1 SD of a young normal adult; Tscore – above -1.0 (research retest 10-15 yrs) Osteopenia – BMD between 1 and 2.5 sd below that of a young normal adult; Tscore -1.0 to -2.5= retest 2-5yr Osteoporosis – BMD between 2.5 sd or more that of a young normal adult; T-score at or below -2.5=retest 1yr after RX If osteopenic or normal with risk factors use preventative treatment If osteoporotic use treatment regimens If results show osteopenia/ostoeporosis a FRAX test may be ordered. This test uses BMD results and additional info to predict risk of breaking a bone in 10 yrs.

Answer 28

Calcium Requirement Women on HRT 1000mg Calcium with 400-800 Vitamin D No HRT 1500 mg Calcium with 400-800 Vitamin D Men 1000 mg of calcium with 400-800 vitamin D Over 65 -1500mg Calcium and 400-800 Vitamin D, both men and women with or without HRT

Answer 29

Treatment and prevention of osteoporosis in postmenopausal women increases bone mass and prevents hip, wrist and spine fractures 50% ****P: Fosamax 5 mg QD; 35 mg Qweek ****T: Fosamax 10mg QD; 70mg qweek ****Strict dosing regimen – empty stomach, Water, upright for 30 minutes Contraindicated: Hypocalc,esophageal disease, inability to follow dosing rules (Long term use > 5 years may have an increase in atypical subtrochantic fracture (femur shaft) 13% of occuring vs. 24 % of typical trachanter neck fracture. Benefits still outweight the risk. If stop biphosphonate after 5years, will only prevent 1 atypical subtrachanter fx. FDA on going. Jaw- proper dental care needed) (FIRST THING IN THE MORNING, DO NOT LAY DOWN FOR 30 MIN, ONCE A WEEK DOSE MORE TOLERABLE BONIVA- NEEDS UPRIGHT FOR 60 MIN TO PREVENT STOMACH UPSET)

Answer 30

Treatment and Prevention of osteoporosis Suppresses osteoclast activity Actonel 35mg qweek Same dosing rules, contraindications and SE 41% reduction in Vertebral fx and 39% reduction in non-vertebral fxs.

Answer 31

Treatment and prevention of osteoporosis in post menopausal woman Boniva 2.5mg QD or 150mg Q Month Take 60 minutes before first food or drink/or any vitamins/calcium Same dosing instructions as other biphosphonates If missed dose and next > 7 days take missed pill and resume regular schedule. If < 7 days don’t take missed pill, continue on. (Evista- helps to preserve bone mass Estrogen- up to avarage age, not for tx of osteoporosis Calcitonin spray- Tscores in the spine, nasal spray Endocrinology will manage the parathyroid hormone Prevvention, won’t build back, just for prevention of vertebral fractures Cont calcium and Vit D- encourage to continue, exercise is the best thing,)

Answer 32

Prevention & treatment of osteoporosis in post-menopausal women decreases bone turnover and bone resorption which increase bone density – acts like estrogen Evista 60mg/QD Contraindication: Thromboembolic disease ******SE: Leg cramps and hot flashes****** DVT most risky with in first 4 months and with immobilization -should D/C 72 hours + effect on Chol, no risk breast/uterus

Answer 33

Treatment for women greater than 5yrs post-menopausal, decreases vertebral fx36% Inhibits bone resportion, suppresses osteoclast activity Miacalcin Nasal Spray 200IU/day one spray/day alternate nostrils daily contraindication: allergy to med or salmon SE: rhinitis, athralgia, back pain, HA, epitaxis

Answer 34

C Total 800-2000 IU of vitamin D every D for 50 yo and older Secodn questions- do not worry about thromboembolic with biophosphonates

Answer 35

B | Second questions- do not worry about thromboembolic with bisphosphonates

Menopause Flashcards

(60 cards)