Block 5: Menopause

Question 1

What is perimenopause?

Answer 1

Time before menopause and menstrual pattern changes from decreasing estrogen and ovarian function decrease

Question 1

What are the sx of perimenopause?

Answer 1

1. Anovulation
2. Dysfunctional uterine bleeding
3. Extended menstrual intervaals
4. Hot flashes
5. Oligomenorrhea

Question 2

What are the labs and primary sx of peri and menopause?

Answer 2

Question 3

What are tx options for perimenopause?

Answer 3

1. Progestins
2. Low dose COC

Question 4

What is DUB?

Answer 4

Anovulatory bleeding from vagina

Question 5

Tx for DUB?

Answer 5

Investigate other possible causes first
1. Progestin only IUD
2. Systemic progestin therapy
3. COC

Question 6

What is menopause?

Answer 6

1. Permanent cessation of menses(at least 1 year) following the loss ofovarian follicular function
2. FSH levels are > 40 IU/L.
3. Estrogen has decreased by > 90%
4. 40-58

Question 7

What are sx of estrogen deficiency?

Answer 7

Vasomotor:
1. Hot flashes
2. Night sweats

Vaginal:
1. Burning, drynesss, itching, irritation
2. GU atrophy
3. Impaired sexual function
4. Lubrication difficulty

Urinary:
1. Urgency
2. Dysuria
3. Recurrent UTI

Question 8

What are GSM?

Answer 8

Both vaginal and urinary sx of menopause

Question 9

What is the tx for GSM?

Answer 9

1. Local urinary estrogen (creams, tablet, ring) Only menopausal sx
2. FemRing (vaginal ring): vulvovaginal candidiasis, vaginal bleeding, breast pain, nausea
3. Ospemifene (SERM): for painful intercourse and no cancer risk

Question 10

How do you counsel on local vaginal estrogen use?

Answer 10

Therapeutic response after 2 weeks of daily use

Maintenance dose is decreased to 2-3 times per week

Question 11

What are the advantages of local estrogen?

Answer 11

1. Minimizes systemic absorption
2. More effective than PO
3. No progesterone necessary with low dose vaginal estrogen

Question 12

What are the medical concerns associated with perimenopause/menopause?

Answer 12

CV health:
1. Estrogen is cardioprocective
2. After menopause -HDL down, LDL up, total cholesterol up

Bone health:
1. Decline in bone health

Question 13

How do you assess for menopause?

Answer 13

1. Complete med hx
2. CV exam
3. Thyroid assessment
4. Breast/pelvic exam
5. Assess the baseline risk of breast cancer and CVD, and consider risk when making recommendation

Question 14

How do you treat mild vasomotor and vulvovaginal sx?

Answer 14

Nonpharmacologic

Question 15

How do you treat moderate/severe vasomotor and vulvovaginal sx?

Answer 15

1. Menopausal hormone therapy
2. Systemic estrogen (w/ progesterone if women has a uterus)
3. Estrogen agonist/antagonist

Question 16

How do you treat moderate-severe GSM sx?

Answer 16

Local vaginal estrogen - progesterone therapy not recommended with low dose vaginal estrogen

Question 17

What are the non-pharm therapy for menopause?

Answer 17

1. Limit alcohol
2. Low fat-diet
3. Limit spicy foods
4. Use cold therapy
5. Practice relaxation techniques
6. Massage
7. Loose Clothes/ layered clothing
8. Exercise
9. Lubricants

Question 18

What are the uses of black cohosh? ADR?

Answer 18

Hot flaskes and additive effect with tamoxifen

Use should NOT exceed 6 months

1. HA
2. Rash
3. DZ
4. Weight gain
5. Cramping

Question 19

What are the OTC menopausse products?

Answer 19

1. Remifemin
2. Estroven
3. Black cohosh

Question 20

Indications HRT?

Answer 20

Hormonoe therapy alleviates vasomotor and vaginal sx
1. Menopausal sx
2. Osteoporosis prevention

Question 21

How can use HRT?

Answer 21

Women with a uterus = estrogen + progesterone
Women without a uterus = estrogen only

Question 22

How long can HRT be used?

Answer 22

<5 years and lowest dose

Question 23

What are the ADRs of estrogen?

Answer 23

N, HA, breast tenderness, and heavy bleeding

Question 24

What are HRT products?

Answer 24

1. Conjugated estrogens (Premarin®) 2. Conjugated estrogens and medroxyprogesterone acetate (Prempro®): Continuous progestin = no menstruation 3. Conjugated estrogens (Premarin®) vaginal cream (2g/dose or lowest effective dose)

Question 25

What are BBW of estrogen?

Answer 25

1. Endometrial cancer risk 2. CV risk (VTE, stroke) 3. Dementia risk

Question 26

Function of transdermal estrogne?

Answer 26

Micronized 17-beta-estradiol that delivers estradiol at a continuous rate 1. Lower risk for estrogen ADR 2. Oral estrogen should be avoided in women with hypertriglyceridemia, liver disease, and gallbladder disease 3. Should be applied to lower abdomen below the waistline, should NOT be applied to breast

Question 27

What are examples of progesterone products?

Answer 27

1. Medroxyprogesterone (Depo-Provera, SC/IM) 2. Micronized progestins(e.g. Prometrium)

Question 28

What are examples of combo regimens?

Answer 28

1. Continuous Cyclic Estrogen/Progestogen 2. Continuous- Combined Estrogen/Progestogen: Reserved for women 2 years post menopause 3. Continuous Long-Cycle Estrogen/Progestogen: Decreases incidence of uterine bleeding, but heavier bleeding 4. Intermittent-Combined Estrogen/Progestogen: Lower incidence of uterine bleeding

Question 29

What does dosing of Phemphase look like?

Answer 29

Days 1 - 14 = Conjugated estrogens Days 15 - 28 = Conjugated estrogens + medroxyprogesterone Monthly withdrawal bleeding often occurs

Question 30

HRT dosage forms?

Answer 30

**Estradiol vaginal rings – Replace every 3 months** 1. Femring® 2. Estring ® **Estradiol transdermal patch – Replace twice weekly** 1. Alora ® 2. Estraderm ® 3. Vivelle Dot ® **Estradiol transdermal patch – Replace weekly** 1. Climara ® 2. Combipatch ® (estradiol + norethindrone) with uterus may be used on days 14-28 = withdrawal bleeding

Question 31

What are the indications for androgen products? Examples?

Answer 31

Improve loss of sexual desire and bone density more than estrogen alone Methyltestosterone + Estrified estrogen

Question 32

What are the CI of androgen therapy?

Answer 32

**Absolute:** Pregnancy/lactation, androgen-dependent neoplasia **Relative:** : Concurrent use of CEEs, low sex hormone binding globulin levels, moderate to severe acne, clinical hirsutism, androgenic alopecia

Question 33

Risks of estrogen and progestin use?

Answer 33

1. Invasive breast cnacer 2. Coronary disease events 3. PO 4. Stroke 5. Decreased hip fracture 6. Decreased colorectal cancer

Question 34

How should you counsel patients on MHT?

Answer 34

1. Discussion of risks and benefits 2. Patient should be reassessed every 6-12 months and discontinuation of therapy should be considered 3. Follow-up appointment in 6 weeks after initiating HRT 4. If d/c HRT, make sure to taper so vasomotor symptoms do not reoccur

Question 35

What are absolute CI of MHT?

Answer 35

1. Abnormal genital bleeding 2. Hx of breast cancer 3. Estrogen- or progesterone-dependent neoplasia 4. DVT, PE 5. Liver dysfunction or dx

Question 36

What are relative CI of MHT?

Answer 36

1. Elevated BP 2. HTG 3. Impaired liver function 4. Hypothyroidism 1. Fluid retention 1. Severe hypocalcemia 1. Ovarian cancer 2. Exacerbation of endometriosis

Question 37

Evista | Brand, MOA, ADR, CI

Answer 37

Raloxifene **MOA:** bind to estrogen receptors and function as tissue-specific estrogen antagonists or agonists * Prevents bone loss and spinal fractures; invasive breast cancer **ADR:** exacerbate vasomotor sx, increases risk for VTE **CI:** thrombosis hx

Question 38

Duavee | Brand, Indication, ADR

Answer 38

Conjugated estrogens and bazedoxifene **Indication:** treatment of moderate to severe vasomotor symptoms and prevention of osteoporosis **ADR:** Muscle spasms, NV, throat, neck and/or upper abdominal pain, and indigestion

Question 39

Ospenifene | Brand, Indication, ADR

Answer 39

Osphena **Indication:** women with a uterus may require a progestin, moderate to severe dyspareunia (vulvular and vaginal atrophy) **ADR:** Hot flashes, muscle cramps, vaginal discharge, hyperhidrosis

Question 40

Prasterone | Brand, Indication, ADR, CI

Answer 40

Intrarosa **Indication:** Moderate to severe dyspareunia, related to menopausal vulvar and vaginal atrophy **MOA:** Inactive endogenous steroid that is converted to active androgens and estrogens **ADR:** Vaginal discharge, abnormal pap smear **CI:** Undiagnosed abnormal genital bleeding, Current or past history of breast cancer

Question 41

Bremelanotide | Brand, Indication, Counseling, ADR

Answer 41

Vyleesi **Indication:** Hypoactive sexual desire disorder (HSDD) in premenopausal women **Counseling:** * Inject Vyleesi under the skin of the abdomen or thigh at least 45 minutes before anticipated sexual activity  * Patients should not use more than one dose within 24 hours or more than eight doses per month.  * Patients should discontinue treatment after eight weeks if they do not report an improvement in sexual desire and associated distress **ADR:** NV, HA, nasal congestion

Question 42

What is bio-identical HRT?

Answer 42

Identical to the individual’s endogenous hormones (E1, E2, E3, and P4): Increased estrone levels are linked to increased risk of estrogen receptor (ER) positive breast cancer

Question 43

What is the difference between progesterone and progestogens?

Answer 43

**Progesterone:** molecule identical to endogenous products **Progestogens:** natural or synthetic products that act like progesterone in uterus

Question 44

What is first line if MHT is CI? ADR?

Answer 44

**SSRI:** Paroxetine, Fluoxetine ADR: HA, N, weight gain **Venlafaxine:** ADR: Dry mounth, N, decreased appetite

Question 45

What are other therapies for hot flashes besides MHT and SSRI?

Answer 45

1. Megestrol acetate: linked to breast cancer 2. Clonidine: dry mouth, drowsiness 3. Gabapentin: somnolences, DZ