MenopauseSH1 Flashcards
Menopause
Patients are losing estrogen leading to menopause. Usually 45 to 55 years old. Avg 51 y/o
Hot flashes, vulvovaginal arophy, including vaginal dryness and dyspareunia
HRT relieves sx. Most pt stop within 2 years of HRT
HRT
Estrogen
Safe in healthy patients, within 10 years of menopause or < 60 years old who dont have contraindications ( hx breast cancer, CHD, stroke, active liver disease )
HT linked to certain cancers
-breast cancer
-endometrial cancer
• add a progestin for women with an intact uterus.
If pt has had hysterectomy then we DONT have to worry about giving progestin and not worry about risk of endometrial cancer
Say patient is on prempro ( estrogen + progestin ) and has hysterectomy what do you change?
D’C prempro and now add ( estrogen only Premarin )
Hormone combinations used for HRT
Prempro : estradiol + Medroxyprogesterone
Premphase: estradiol + Medroxyprogesterone
Activella: Estradiol + NE
Angeliq: estradiol 0.5 mg + Drospirenone 0.25 mg
ClimaraPro: estradiol + levonorgestrel ( weekly ) patch - climbing the mountain just once ( once weekly patch )
CombiPatch : estradiol + NE ( twice per week ) ( REFRIGERATE)
Estratest ( generic ) / Covaryx : Estradiol + methylestor
Prefest : Estradiol + norgestimate
Bijuva : Estradiol + progesterone
Estrogen alone ( ok to give is patient has already had hysterectomy )
Estrogen PO : Premarin , estrace
Estrogen Vaginal Cream: Premarin cream, estrace cream. Premarin cream 0.5 grams daily; reduce to twice per week.
Estradiol Vaginal Ring: Estring, Femring ( estradiol acetate ) ( replace after 90 days )
Estradiol vaginal tab: vagifem
Estradiol Vaginal soft gel insert: Imvexxy ( 2xqw)
Estradiol transdermal patch : Climara ( QW) , FEMpatch : Vivelle: Vivelle Dot ( QW)
Alora, Minivelle ( BIW)
Estradiol Transdermal spray ( Evamist )
Estradiol transdermal gel: divigel, estrogel, elestrin
Estrogen / Bezedoxifene
Duavee
SERM : selective estrogen receptor modulator ( works on the estrogen R but also gives you SE of estrogen )
SE: clots
Contraindication: stroke, MI, clotting probs.
Indications: hot flashes, post menopausal osteoporosis. Q
Painful sexual intercourse due to vaginal atrophy
1 ) recommend lube
Vaginal therapy : because system absorption is LOW, vaginal estrogens generally do not relieve vasomotor sx ( hot flashes)
Vagifem ( vaginal tab )
Estring ( ring replaced every 90 days )
Vaginal creams ( Premarin, estrace )
Ospemifene ( osphena ) a SERM
Prasterone ( Intrarosa ) ( qhs vaginal insert ) - DHEA which is converted in vaginal tissues to estrogens and androgens
Dyspareunia ( pain with intercourse )
Ospemifene ( Osphena )
Indication: menopausal related dyspareunia
MOA: SERM. ( has estrogenic effects on vaginal tissue while Raloxifene and tamoxifen do not. Like other SERMS, osphena can cause hot flashes and bloot clots)
Preg X
Dose 60 mg QD with food exactly like Raloxifene and tamoxifen.
Yeast infection
Itching , thick white cottage cheese discharge. no smell to it.
Not sexually transmitted.
More likely in women who are pregnant, diabetic.
Make sure you keep area dry.
Yeast infection OTC tx
Rx
Clotrimazole ( gyne-lotrimin )
1% cream: insert applicatorfull QHS x7days, may also apply externally BID for 7 days for itching and irritation
Always tell patient to use inserts at night bc it can leak throughout day.
Miconazole ( monistat )
Tioconazole ( vagistat )
Butoconazole ( Gynazole )
Most products will give small tube of cream to use externally. Inserts used at night.
Rx Oral: fluconazole ( diflucan ) 150 mg single dose
Bacterial Vaginosis
Common cause of abnormal vaginal discharge
Grayish white vaginal discharge, a bothersome fishy odor & ↑pH
Bacterial vaginosis Tx
Metronidazole 500 mg oral BID x7days
Metronidazole gel intravaginally QD x5days
Clindamycin 300 mg PO BID for 7 days
Clindamycin 2% cream intravagially QHS x 7 days
Alternative :
Secnidazole ( solosec ) 2 g packet PO single dose
Tinidazole 2 g PO x7days OR
Tinidazole 1 gram PO QD x5days
Endometriosis
when tissue that makes up the uterine lining is present on other organs
Can cause severe pain.
Endometriosis tx
NSAIDs, COC, GnRH analogues
GnRH analogues:
Nafarelin ( synarel ) ( intranasel )
Leuprolide ( lupron ) - recall we use this for prostate cancer stop testosterone, for endometriosis we use to stop cycle ( IM )
Goserelin ( zoladex ) SQ-
Triptorelin ( IM )
Danazol : oral. Increases free testosterone levels.
Cyp3a4 inhibitor. Contraindicated with statins like simvastatin
Max 20 mg / day of lovastatin with danazol
Pregnancy Termination
Mifepristone ( RU-486 )
Misoprostol ( cytotec ) : also used for cervical ripening
Dinoprostone ( Cervidil, Prepidil ): also used for cervical ripening
