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Menopause Flashcards

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1
Q

What is the brand name of Ospemifene?

A

Osphena

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2
Q

What is the only ORAL agent for Vulvovaginal Atrophy/Uregenital systems?

A

Ospemifene

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3
Q

Why Ospemifene controversial?

A

Controversial whether a progestin should be used

Its dose is 60mg daily

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4
Q

Name are the treatments for Vulvovaginal Atrophy/Urogenital symptoms?

Estrogens

A 
Premarin (Conjugated equine estrogen cream)
Estrace
Vagifem
Estring
Femring
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5
Q

What are some comments for Vulvovaginal Atrophy/Urogenital symptoms?

A

DOC for patients with vaginal symptoms only

With low dose (LD) , no progestin necessary

Moderate to hight dose requires 10 days of progestin q12 weeks to protect the endometrium.

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6
Q

Name Non-estrogen therapies for menopause?

A

SSRI’s

  • Paroxetine
  • Brisdelle
  • Fluoxetine (Prozac)
  • Ecitialopram (Lexapro)

SNRI’s
Venlafaxine (Effexor), desvenlafaxine (Pristiq)

Clonidine and Gabapentin

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7
Q

Whats the efficacy of Non-estrogen therapies (VMS)?

A

SSRI’s, SNRI, Clonidine, and gabapentin;

All more effect than placebo in reducing hot flashes but less effective than estrogen

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8
Q

What’s Non-estrogen’s place in therapy?

A

Contraindication to MHT

Patient prefers not to use MHT or cannot tolerate MHT

Use after 5 yrs and pts still experience VMS

Mood changes in addintion to menopause symptoms.

–These groups may benefit

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9
Q

Dietary supplements for Menopause: Which Supplement i has a precaution with patients with aspirin or salicylate allergy?

A

Black Cohosh

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10
Q

Dietary supplements for Menopause: Which Supplement does not have estrogenic activity but may effect serotonin?

A

Black Cohosh

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11
Q

Dietary supplements for Menopause:
Pytoestrogens (compounds with week estrogen resceptor properties)

Name all the classes?

A

Pytoestrogens

Isoflavones (soy): (active) genisteiin, daidzein

Lignans:Flaxseed

Coumestans: Alpha sprouts

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12
Q

What are the precautions for Phytoestrogens?

A

Individual or family of hx of breast, endometrial or ovarian Cancer

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13
Q

How should MHT be monitored?

A

Breast exams, and periodic mammograms, assess menopausal symptoms q 3-6 months

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14
Q

Does MHT caused increased Dementia?

A

Yes, EPT therapy show increased risk of dementia (Alzhiemers disease) in post menopause women >65yrs.

Womens Health Initiative Memory Study

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15
Q

How should MHT be discounted?

A

Do not discontiune in all women at age 65.

Discontinuing may cause recurrent VMS in 50% of women.

Tapering or abrupt (no evidence support one or the other)

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16
Q

Which drug was approved for moderate to severe VMS and prevention of osteoporosis in women with intact uterus?

A

Duavee: 0.45mg - conjugated estrogen/20mg bazedoxifene PO Daily

only recommend for Shortest duration possible

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17
Q

EPT (Estrogen + Progestin): what are the Transdermal combo?

A

Combipatch and Climara Pro

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18
Q

EPT (Estrogen + Progestin): what are the continuous oral combo?

A

Prempro, femhrt, Activella, Angeliq, or Activella and Mimvey

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19
Q

EPT (Estrogen + Progestin): what are the intermittent oral combo?

A

Prefest

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20
Q

EPT (Estrogen + Progestin): what are the oral continuous Cyclic combo?

A

Premphase

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21
Q

How do we managed the AE of progestins?

A

Change to another progestin

Change the dosing regimen (Cyclic to continuous)

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22
Q

Progestin: name the oral agents?

A

Provera(common), Aygestin(common), Prometrium

Progestin dose for continous regimen is typically half of cyclic regimens

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23
Q

Progestin: name the intrauterine system?

A

Mirena

Contraceptive used for endometrial protection

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24
Q

What is the brand name of Medroprogesterone acetate?

A

Provera

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25
What is the brand name of Norethindrone?
Aygestin
26
What is the brand name Levonorgestral (intrauterine)?
Mirena
27
What is the brand name of micronized Progesterone?
Prometrium
28
What are the AE of estrogens?
Breast tenderness and Heavy Bleeding?
29
How do we managed estrogens AE?
1. Decrease dose of estrogen 2. Switch the dose (oral ->transdermal), 3. If breast tenderness, don't switch from transdermal to oral 4. Change to different type (women respond differently)
30
Name the "early" symptoms of Menopausal Transition?
Abnormal Bleeding
31
Name the "late" menopausal transition and "early" Post-menopause symptoms?
Vasomotor (VMS): Hotflash/flashes, Night sweats Genitourinary (VVA):Vaginal dryness,itching, Dyspareunia Cognitive: Sleep disturbances and mood changes
32
At what stages is hot flahses most limey to occur?
late" menopausal transition and "early" Post-menopause"
33
What is menopause?
12 months after FMP (Final menstrual period)
34
Mentrual cycle: describe early menopausal transition?
Variale cycle length >7 days different from normal
35
Mentrual cycle: describe late menopausal transition?
> 2 skipped cycles and an interval of amenorreha of > 60 days
36
what are the cause of premature menopause?
Chemotherapy/radiation or Surgery
37
When does FMP (Final mental period occur)?
After Late menopausal transition*
38
Why do women seek medical care for menopause?
Hot-flashes/flashes and night sweat
39
What aggravates or causes hotflahses to occur more frequently in women who have menopause?
Smoking, caffeine, alcohol,spicy foods, Obesity, less physical activity
40
What is Vulvovaginal atrophy (VVA)?
Vaginal dryness and Dysareunia -Painful intercourse Related to estrogen deficency
41
What are the psychologic effects of menopause?
Sleep disturbance (may not be related to night sweats) Mood disturbances Cognitive disturbance
42
Treatment: what are some lifestyle changes which will aid menopause symptoms?
1. Smoking cessation 2. decrease alcohol intake 3. Excercise (mixed results may increase VMS) 4. Avoid: caffeine,spicy food, hot drinks 5. Dress in layer (take it off baby **) 6. Keep cool
43
What does MHT mean?
Menopaual Hormone Therapy
44
What MHT is suggest for women WITHOUT uterus?
ESTROGEN
45
What MHT is suggest for women WITH uterus?
Estrogen + PROGESTIN
46
Why is EPT (Estrogen + PROGESTIN) suggest at MHT for women with uterus?
Progestin is added for endometrial protection Long version: progestin is added to prevent the endometrial lining building up and causing hyperlasia. Want to prevention endometrial hyperplasia and endometrial cancer.
47
When is it "ok" to treat VMS with MHT? Hotflash/flashes, Night sweats
Moderate to severe VMS - its most effective for vasomotor and vaginal symptoms only recommneed for < 5 years
48
How is vagninal symptoms VVA treated? Vaginal dryness,itching, Dyspareunia (whats more effective systemic or local)?
Local Hormone therapy is more effective than systemic in reliving these symptoms
49
What extra benefit does MHT have ?
Osteoporosis prevention and Cardiovascuar health - Osterporoisis increses in women who lose estrogen - many MHT agents are indicated for osteoporosis
50
What were the results of the Women's Health initiative study? (WHI)
Study shows increase risk for Stroke, MI, Breast Cancer, thromboembolism for EPT (Estrogen + PROGESTIN) --Benefit for colorectal cancer and osteoporosis/hip fracture Study shows increase in stroke and thromboembolism, no benefit in MI,Breast cancer, Colorectal caner. --Benefit for osteoporosis/hip fracture Mean age 63 years
51
Meanwhile in Demark, RCT has conflicting results with WHI? What was it and Why?
1. Younger patients (do not use HRT in older women) Mean age 49.7 years
52
What are the contraindication ins MHT (Absolute)?
1. Untreated endometrial hyperlasia 2. Current/past/suspect Breast cancer 3. Arterial thromboembolic disease (MI/Stroke) 4. venous thromboembolic disease 5. (untreated HTN) Smoking is OK (just not advised)
53
timing hypothesis: Whats the suggested Duration of therapy when using ET?
7 years
54
timing hypothesis: Whats the suggested Duration of therapy when using EPT?
3-5 years
55
timing hypothesis: what is it?
MHT will have less CV risk when started 5 years within POST-menopause The average window you can use HRT, when the risk would not increase , the time has to be correct*
56
What should be considered before staring MHT?
Severity of symptoms:moderate or severe (only) Timing (Time hypotheisis ) Risk: VTE, Breast CA, Gallbadder disease, CVD: MI/CAD, PVD,stroke
57
Whats the golden rule for hormonal therapy for menopause? (take home)
MHT should be prescribed for the shortest period of time and at the lowest effective dose.
58
Methods of administration: Intermittent Combined EPT (“Pulsed-Progestin”)
Three days of estrogen alone, then 3 days EPT continuously i. Estrogen everyday, but days 3-6 progestin is added along with the estroge, then days 9-12 we give progestin o Lower dose of progestin results in fewer side effects
59
Methods of administration:Continuous Long Cycle
convenient – 6 periods per year Daily estrogen + 12-14 days of progestin every other month i. We have continuous estrogen, then progestin the last 14 days. However in the second month we have continuous estrogen and no progestin. Therefore you will be able to skip a period every other month. o Bleeding every other month (convenient – 6 periods per year****
60
Methods of administration: Continuous Cyclic (“Sequential”)
Note: women will have predictable monthly bleeding with continuous cyclic regimens (every month)** _make sure she now when to use what drug** ``` Estrogen continuously (estrogen always stays the same in all cycle), minimum of 12 days of progestin (at the end of the cycle) ``` -Withdrawal bleeding 1-2 days after last progestin dose (so the women will get what looks like a period every month)
61
Methods of administration: Continuous Combined
``` EPT continuously (same thing, no change in dose) o Unpredictable bleeding/spotting for the first 6-12 months ``` o If used, this regimen is preferred for women who are at least 2 yrs postmenopause as they are less likely to have unpredictable bleeding (if they use it within the first 6 months-12 months more likely to have bleeding) o Continuous combined EPT is not recommended in the AACE 2011 guidelines. Their rationale: continuous progestin exposure is linked to adverse breast outcomes in recent studies. We need to have a certain amount of progestin for endometrium support but they belive that the EPT combo poses a greater risk to adverse breast outcomes.
62
VMS (ET) menopause therapy: Transdurmal?
Evamist, Estrasorb [thigh] Estrogel, Elestrin, Divigel [ARM] Vivelle-Dot, Alora, Menostar, Estraderm [lower abs]
63
menopause therapy: Transdurmal what are some comments made?
64
menopause therapy: ORAL what are some comments made?
65
VMS (ET) menopause therapy: ORal? NO (EE)
Premarin, Estrace, Femtrace, Enjuvia,Cenestin, Orth-Est, and Ogen
66
What are some serious AE of estrogens?
STROKE VTE CVD Breast Cancer
67
Whats another AE of estrogen not mentioned, but is mentioned by mancono's topics?
Hypothyroidism; can increase T4 requirements (for function??)
68
what are some AE for Progestins?
Irritability, Depression, headache, "Premenstrual like" symptoms.
69
Whats the deal with Bioidentical for menopause treatment?
Plant derived hormones which are said to have identical structure to endogenous hormones. claim improve safety, - some contain commercial products - custom compounding - salivary hormone concentration Safety and efficacy is not supported by clinical trials

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