Week 6 Menopause, Breast Changes, & Osteoporosis

Question 1

In postmenopausal women, estrogen levels increase with decreasing weight. True or False?

Answer 1

False

Question 2

Which of these is NOT listed as a recommended dosing option for estrogen/progesterone therapy? Continuous Monophasic Sequential

Answer 2

Monophasic

Question 3

Provera is an option for transdermal hormone therapy. True or false

Answer 3

False

Question 4

Alendronate (Fosamax) and riserdronate (Actonel) are examples of calcitonin. True or false

Answer 4

false

Question 5

Galactorrhea can persist for months or years after breastfeeding. True or False

Answer 5

True

Question 6

Which of these procedures allows clinicians to distinguish between invasive and noninvasive cancer?

Answer 6

core needle biopsy

Question 7

Mammograms help differentiate among malignant, benign, or cystic fibroids. true or false

Answer 7

false

Question 8

Which of these screening procedures is reserved for those at very high risk for cancer?

Answer 8

MRI

Question 9

Women with a parent, sibling. or child with BRCA-1 or BRCA-2 mutation should have an MRI and a mammogram every other year. True or false

Answer 9

false

Question 10

Bisphosphonates

• Aldronate (Fosamax)
• Risedronate (Actonel, Atelvia)
• Ibandronate (Boniva)

Indication

MOA

Contraindication

Answer 10

1st line osteoporosis

MOA: inhibit bone resorption by reducing osteoclast #

Contraindication

• Upper GI disease
• Hypocalcemia
• Renal disease
• MUST TAKE WITH WATER

Question 11

Zoledronic acid (Reclast)

Indication

Contraindication

Answer 11

osteoporisis

IV

Contraindication: Hypocalcemia

Question 12

Raloxifine (Evista)

Indication

MOA

side effect

Contraindication

Answer 12

Indication: Osteoporosis (spine)

MOA: selective estrogen receptor modulator (SERM)

Side Effect

• Hot flashes

Contraindication:

• not recommended if on estrogen therapy or EPT
• Hx VTE

Question 13

Calcitonin

Indication

Caution

Contraindication

Answer 13

Indication

• Not first line for osteoporosis
• Analgesic effect on osteoporotic fractures

Caution:

• Consider malignancy risk
• admin = nasal spray
• Use <6 months

Contraindication

• Allergy to calcitonin- salmon

Question 14

What increases a patient’s modifiable risks for osteoporosis?

Answer 14

• BMI <21
• Hypogonadal states (anorexia, turner & kleinfelters)
• Nulliparity
• Lifestyle (smoking, sedentary)
• Medications (thyroid, steroids, PPIs, SSRI)
• Chronic disease

Question 15

What are the non modifiable risk factors for developing osteoporosis?

Answer 15

• Age
• Female
• Race (white)
• Family history
• history fracture as adult
• 1st degree relative
• Genetic disease
• Hematologic disorder
• Autoimmune

Question 16

What are the diagnostic criteria for osteoporosis?

Answer 16

Bone mineral density score

T score -2.5 or higher = osteoporosis

Question 17

What are the physiological changes that occur with menopause? What questions should you be asking your patients?

Answer 17

Follicles less responsive to FSH

Ovaries produce less estradiol, progesterone, and androgens

Question 18

Describe

Estradiol (E2)

Estriol (E3)

Estrone (E1)

Answer 18

Estradiol (E2)

• most potent
• Main estrogen in reproductive years
• low post menopausal

Estriol (E3)

• by product of estradiol and estrone

Estrone (E1)

• Weak
• Primary estrogen in post menopausal women
• Produced by adipose

Question 20

What are non hormonal treatment options for vasomotor symptoms? 3 and their side effects

Answer 20

Clonidine: weekly patch

• Side Effect dizzy, dry mouth

Gabapentin:

• Side Effect: anorgasmia

SSRI (Venlafaxine or Fluoxetine)

• SE: sexual dysfunction

Question 21

What are the only FDA approved prescription for treating hot flashes in women with high risk breast cancer or people who have had breast cancer?

Answer 21

Paroxetine

Question 22

When will vasomotor symptoms resolve within _____ after initiation of hormone therapy but return in _____ % of women

Answer 22

2 to 6 weeks

50%

Question 23

how long do vasomotor symptoms last?

Answer 23

up to five years and sometimes up to 10 years

Question 24

What is the diagnostic criteria for Female Sexual Arousal Disorder

Answer 24

Complete lack or reduction in sexual interest/arousal associated with 3+ below for 6 months

Absence or reduction in

• interest
• erotic thoughts
• desire to initiate sex
• sense of excitemnt during sex
• response to sexual cues
• decreased sensation during sex

Question 25

Medications for sexual arousal disorder

Answer 25

Flibanserin Bremelanotide Brupopion Testoserone

Question 26

Flibanserin MOA Side effect

Answer 26

For sexual arousal disorder MOA: dopamine activation "female viagra" Side Effect: Syncope esp with ETOH

Question 27

Bremelanotide Side Effect

Answer 27

Sexual arousal disorder PRN autoinjector Side Effect: Nausea

Question 28

What is the breast cancer screening recommendations for the average women without risk factors?

Answer 28

45 to 74

Question 29

What is the USPSTF screening recommendations for average risk women breast cancer?

Answer 29

Mammography Q 2 years Ages 50 to 74

Question 30

What does the american cancer society recommend for breast cancer screening for women with high risk

Answer 30

MRI and mammogram yearly starting at 30

Question 31

What does the ACOG recommend for higher risk breast cancer individuals

Answer 31

MRI yearly starting at 25 Mammogram yearly starting at 30

Question 32

When would you order an ultrasound? Benefits of US

Answer 32

* When radiation is to be avoided if aged \<30 * pregnant * Dense breasts * palpable breast lumps As an adjunct to mammography!!! **Benefits** * Differentiate cysts v solid mass * guide fine needle aspiration of breast cysts \*\*cannot differentiate between malignant or benign solid masses

Question 33

Management for breast lump \<30 \>30

Answer 33

\<30 = Ultrasound alone \>30 = US & Mammogram

Question 34

Causes of galactorrhea

Answer 34

* Hyperprolactinemia * Pituitary prolactin secreting tumors - adenoma * Medications (COC, antidepressant) * Hypothyroidism * Neurologic disorder * Stress

Question 35

What diagnostics do you check for galactorrhea?

Answer 35

Pregnancy Prolactin in AM before breast stimulation ( + = CT pituitary) TSH Mammogram if \>30 US

Question 36

What are the screening recommendations for osteoporosis?

Answer 36

All women \>65 years Women \<65 with risk factors Men \>70 Men \<50 if previous broken bone

Question 37

How do you screen for osteoporosis?

Answer 37

DEXA scan Q2 years osteoporosis = T score of -2.5 SD or lower Osteopenia = t shore -1.1 to -2.4 SD Z-score -2 or less

Question 38

What is the FRAX tool?

Answer 38

determines 10 year risk for fracture

Question 39

What are the benefits of Raloxifene (Evista) Disadvantages?

Answer 39

Selective Estrogen Receptor Modulator (SERM) * Decreases bone resorption * Increases BMD at spine only/reduce risk vertebral fx * Protection against breast cancer **Disadvantages** * May cause hot flashes * Increased risk DVT * Lose bone immediately after stopping

Question 40

When would you stop Bisphosphonates after 5 years? When would you continue meds over 5 years?

Answer 40

* No fracture hx or low risk for fracture * hip BMD \>-2.5 = drug holiday reassess in 2 to 3 years **Continue** if * Hx fracture before or during treatment * BMD is -2.5 or less or at high risk fracture Reassess every 2 to 3 years

Question 41

Raloxifene (Evista) ## Footnote Who is this for? BBW

Answer 41

Who: Postmenopausal women at risk for breast cancer; people with bisphosphonate contraindications BBW: DVT, endometrial/uterine cancer, increased risk of stroke death