Menopause Flashcards

Question

What are the routes of HRT and the pros and cons of each?

Answer 1

1. Transdermal 2.Oral 3. Intrauterine 4. Intravaginal Transdermal oestrogens:patches/gel - Provides direct access to systemic circulation, therefore more estradiol enters circulation compared to oral. - avoids gut and hepatic first pass effect therefore the serum E2:E1 ratio is near unity compared to the 1:4 ratio with the oral route - avoids bolus first pass effect on liver & subsequent increase in hepatic globular synthesis and coagulation factors - does not affect lipoprotein profile CONS: Expensive; sensitivity to the patch adhesive or the alcohol in the gel Oral oestrogens - cost effective, hence usu first choice -acceptable route of admission -beneficial effect on HDL, LDL and total cholesterol CONS: all tablets contain lactose, increases triglycerides, high doses required to achieve good blood levels, variation in absorption and metabolism, increases hepatic protein synthesis (SBHG, coagulation factors) Subcutaneous E2 pellets - good for persons who cannot tolerate oral or transdermal preparations. CONS: placement requires a surgical procedure, cannot be quickly removed if an adverse reaction, associated w/ tachyphylaxis (symptoms of estrogen deficiency w/high serum levels). Vaginal E2: tablets, cream, pessary * pessaries are hard plastic impregnated with E2 and are generally not well tolerated. - Vaginal E2 is indicated for genitourinary symptoms (dryness, dyspareunia, urgency and recurrent cytitis) and is beneficial as 1. very little reaches the systemic circulation ➡️ reducing potential adverse systemic effects. 2. Endometrial protection is not required

Answer 2

- the clinical situation - patient preference - poor symptom control w/ a particular route - side effects (nausea w/ oral treatment) - lactose sensitivity (oral pills) - allergic rxn to adhesive or alcohol in gel - preexisting medical conditions - bowel d/o that affects absorption - hypertriglyceridaemia - Risk of stroke/VTE - enzyme inducing meds e.g antiepileptic drugs

Answer 3

Decreases the risk by a third.

Answer 4

Decreases risk of fragility fractures by 30% WHI showed that HRT reduced the risk of osteoporosis fragility fractures in the spine, hip and other areas. Because oesteogen restores bone loss due to oestrogen deficiency by suppressing osteoclastic activity and stimulating osteoblastic activity. Trabecular bone is strengthened.

Answer 5

Weight bearing exercises Calcium and Vit D supplementation Stop smoking Reduce alcohol intake

Answer 6

Maximal improvement by 1-3 months. In some, may take up to a year. Symptoms usu. return shortly after stopping treatment. So long term treatment is usually required.

Answer 7

1. Vasomotor symptoms improve - w/in 4 weeks. This is the benchmark of a successful HRT regimen. 2. Improved mood/sleep disturbances - improved vasomotor symptoms improves sleep, which w/ improved vasomotor symptoms improves her QOL, making her happier. 3. Improved genitourinary symptoms (vaginal dryness/soreness, superficial dyspareunia, urinary frequency/uti) 4. Improved libido - refer to points 3 as Improved vag dryness/dyspareunia may restore libido 5. Improves osteoporosis and reduces risk of fragility fractures 6. Decreased risk of colon ca

Answer 8

HRT should not be provided primarily for this function as its role remains uncertain. Coronary Heart Disease WHI study: - increased risk with combined therapy >10years post menopause, especially ages 70-79yrs - Women <60yrs on oestrogen-only tx w/in 10yrs of menopause - no sig. reduction but they had a 30% lower total mortality from stroke/CHD. Stroke - Older women starting HRT have a higher absolute risk since risk of stroke increases w/age. - WHI study: Oestrogen-only: no increased risk Continuous combined HRT was compared to baseline risk (11.3cases/1000 women) over 7.5yrs - showed increased risk by 6 more cases/1000 women. - LIFT study (long-term intervention on fractures with tibolone) showed a 2.2 times increased risk of stroke, mainly ischaemic, especially for >60yrs.

Answer 9

100-200 cases per 100,000 woman/ years

Answer 10

1.6-2.7 OCPs: 7.5 fold increased risk of DVT 5.3 fold pulmonary embolism

Answer 11

Age Obesity Cigarette smoking Varicose veins Personal/family h/o varicose veins Disease affecting coagulopathy/fibrinolytic function - factor V Leiden, protein c deficiency

Answer 12

Risk peaks in the first 1-2 years now use then drops to natural risk afterwards.

Answer 13

- No as more studies/data is required hence HRT should.not be started solely for this purpose. - Observational studies show that HRT started in early menopause may reduce or delay the onset of AD. - medroxyprogesterone actetate has been found to increase neuronal plasticity and neurotransmission. - The Women's Health Initiative Memory Study/WHIMS looked at the impact of HRT on AD in women 65 and older - concluded that combined oestrogen and progesterone therapy increased the risk of probable dementia if started after the age of 65.

Answer 14

WHI study: - no sig. increase w/ combined HRT. Million Women Trial: A 5yr course of HRT may cause one extra case of ovarian cancer in every 2,500 users.

Answer 15

3 months, 6 months then yearly. Aim: 1.to assess response to treatment; 2. determine if medication needs to be adjusted or changed 3. Observe for adverse effects - AUB Advise to do 3 yeary pap smear and 3 yearly mammogram after age 50.

Answer 16

Oestrogen only HRT or tibolone (once no h/o breast cancer)

Answer 17

Oestrogen only or Tibolone (once no h/o breast ca)

Answer 18

FSH>30 iu/L on 2 separate occasions These pts can be started on HRT

Answer 19

Vaginal estrogen - cream, tablets/inserts/ pessary (unpopular choice due to patient discomfort)

Answer 20

35% Patients should be advised to continue with treatment for at least 3 months, because MOST adverse effects resolve with increased duration of use.

Answer 21

Black cohosh Ginseng Red clover Contain phyto-oestrogens

Answer 22

- continous combined HRT has been associated with increased risk of recurrence. Evidence shows that progestational agents play a role in mammary carcinogenic. Daily oral estrogen with shorter courses of progesterone (cyclical sequential combined HRT) have been shown to have a insignificant decrease in breast cancer recurrence, as evidenced by the Stockholm Trial. Further to this point Tibolone was found to increase the risk of breast cancer in the Liberate Study. - other alternative to HRT include non-hormonal therapy (red clover, black cohosh, ginseng) but the FDA warns that phyto-oestrogens can interfere with tamoxifen therapy. If the patient has severe symptoms of oesgrogen deficiency, then HRT can be started under specialist supervision and After the possible risks have been carefully explained to the patient and informed consent has been obtained. - Liberate study: Tibolone increases recurrence of breast ca. Thus implicating progestational agents in breast ca. Stockholm Trial reduced progesterone exposed and avoid ccHRT. They used oral oestradiol and short courses of progesterone (cyclical sequential combined HRT). Results however an insignificant decrease in breast ca recurrence. Habits Trial showed recurrence of breast ca by 3 fold wishing 2.1years

Answer 23

There appears to be very little risk associated. With oestrogen therapy after endometrial cancer. Patients with endometrial stromal sarcoma should be counselled at there is a lack of data about recurrence on HRT and that only she can decide of the risk of recurrence is acceptable in order to achieve symptom relief.

Answer 24

1. Yes, transdermal therapy may be a better option. 2. Stop the HRT.and treat treat VTE. If HRT needs to be continued after treatment, consider lifelong thromboprophylaxis.

Answer 25

1. To exercise and avoid a sedentary exercise. Weight bearing exercise (with light weights) is beneficial. 2. Increase dietary intake of calcium 3. Commence calcium and vitamin D supplementation. 4. Bisphosphonates 5. SERMS e.g Raloxifene (preferred over tamoxifen, no effect on uterus)

Answer 26

-Bisphosohonates are used to treat osteoporosis in the postmenopausal woman and other metabolic diseases. - They bind strongly to the bone matrix and inhibit osteoclastic activity, thereby preventing bone loss. - They are classified as Nitrogen and Non-nitrogen containing bisphosphonates. - NBPs inhibit farnesyl diphosphate synthase and is more POTENT. - They stimulate osteoblast activity and differentiation E.g. zoledronic acid - NNBPs induce the production of toxic analogs of adenosine triphosphate.

Answer 27

**Moa: inhibits farnesyl diphosphate synthase; increases osteoblastic activity and differentiation Benefits: -Increases bone mineral density -Suppresses bone turnover -Reduces incidence of vertebral and nonvertebral fragility fractures S/Es: - oesophagitis - gi discomfort ( most common cause of discontinuation) - acute phase rxn - hypocalcaemia - uveitis

Answer 28

False. HRT use for 5-10yrs doesn't provide enough protection to prevent fragility fractures. Treatment is lifelong

Answer 29

False. Sequential combined is associated with a higher risk of endometrial cancer. * think of it this way. Continuous administration of progesterone prevents endometrial proliferation, thus decreasing risk of endometriosis ca

Menopause Flashcards

(53 cards)