Describe vasomotor sx for menopause
- Hormone therapy most effective for moderate to severe sx
- Typically, last 7-8 years
Describe genitourinary sx for menopause
- Vaginal estrogen is best option b/c less systemic effect
- Can still use even if breast cancer hx (if failed non-hormonal tx)
- Non-hormonal tx = vaginal moisturizers
Describe HRT (what to use)
- Always use combo estrogen + progestin unless no uterus -> then use estrogen + SERM (bazedoxifene) (combo used to prevent endometrial cancer)
- Always use lowest possible dose for shortest period of time!
- If last menstrual period < 1 year ago -> cyclic timed to endogenous cycle (minimizes risk of breakthrough bleeding)
- If last menstrual period > 1 year ago -> continuous to avoid monthly withdrawal bleeding
- Topical/transdermal if increased CVD risk, HTN, DM, smoking, obesity, and/or gallstones
Describe risks and AE of HRT
- Risks -> increased risk of breast cancer after 5 years of use, coronary heart disease (if risk factors such as > 60 y/o, menopause > 10 years), thromboembolic events, and stroke
- AE = breast tenderness, headache, mood changes (risk increases w/ increased age)
- SE (progestin) = mood swings, bloating
Describe CI to HRT
- Unexplained vaginal bleeding
- Acute liver dysfunction
- Estrogen-dependent cancer
- Coronary heart disease
- Previous stroke
- Active thromboembolic disease
Describe antidepressant use for menopause
- Used off-label and appear less effective than hormone therapy
- Reduce vasomotor sx by 25-69%
- Paroxetine is most well studied
- Low doses often effective
- AE = GI, headache, insomnia, sexual dysfunction, weight gain
Describe anticonvulsant use for menopause
- Used off-label and appear less effective than hormone therapy
- Initiate at low dose (ex: gabapentin 300 mg HS or pregabalin 50 mg HS)
- AE = dizziness, somnolence, headache, weight gain, rash
Drug interactions w/ menopause drugs
- Estrogen -> levels increased by 3A4 inhibitors
- Paroxetine = CYP 2D6 inhibitor
Red flags for menopause
Unexplained vaginal bleeding
Case specific assessment questions for menopause
- Any changes in your periods? *
- Are you having any hot flashes? *
- Any vaginal dryness or pain or sexual concerns? *
- Any bladder issues or incontinence? *
- How is your sleep?
- How is your mood?
- If yes to any of the first 4 questions -> may be a candidate for tx
Non-pharms for menopause (general)
- Vaginal moisturizers for urogenital sx applied HS 3 times/week
- Weight loss, CBT
- Smoking cessation, healthy diet, exercise, yoga, avoidance of triggers
General monitoring for menopause
- Pt monitor sx -> may take up to 6-8 weeks before modifying regimen
- If experiencing SE from progestin -> decrease dose by ½ or decrease duration by 7-10 days
- If bleeding heavy or erratic on cyclic regimen -> increase progestin dose
General follow up for menopause
- Follow-up in 6 weeks when starting new medication
- Re-assess hormone therapy annually
- Likely recommend tapering off hormone therapy to prevent worsening of VMS
- Useful to screen all menopause px for fracture risk
Describe monitoring for menopause for a new hormone therapy
- Monitor for sx improvement and SE of medication weekly
- Common SE = breast tenderness, headache, mood changes
Describe when to go to a Dr for menopause for a new hormone therapy
- Go to doctor if no sx improvement after 4-8 week trial?
- Any changes in frequency/severity of sx or if new sx occur
Describe when to go to emergency for menopause for a new hormone therapy
- Go to emergency if dramatic mood changes or if sx worsen; severe AE to medication
Describe non pharms for menopause for a new hormone therapy
- Vaginal moisturizer (Replens)
- Weight loss (if overweight)
- CBT, mindfulness-based stress reduction
- Smoking cessation, healthy diet, cooling techniques (carry a fan w/ you, wear loose and light clothing), yoga
Describe follow up for menopause for a new hormone therapy
- I will follow up with you 1 week to discuss adherence, SE management, and sx improvement
- We will be in constant communication because we want you to be on this drug for the shortest possible amount of time
Describe monitoring for menopause for a new non-hormonal therapy
- Monitor for sx improvement weekly and SE of medication daily
- Common SE of antidepressants = GI, headache, insomnia, sexual dysfunction
- Common SE of anticonvulsants = dizziness, somnolence, headache, weight gain, rash; dose HS
Describe when to go to a Dr for menopause for a new non-hormonal therapy
Go to doctor if no sx improvement after 4-week trial; any changes in frequency/severity of sx or new sx occur
Describe when to go to emergency for menopause for a new non-hormonal therapy
Go to emergency if sx worsen, dramatic mood changes
Describe non pharms for menopause for a new non-hormonal therapy
- Vaginal moisturizer (Replens)
- Weight loss (if overweight)
- CBT, mindfulness-based stress reduction
- Smoking cessation, healthy diet, cooling techniques (carry a fan w/ you, wear loose and light clothing), yoga
Describe follow up for menopause for a new non-hormonal therapy
- I will follow up with you 1 week to discuss SE management and adherence
- It takes about 2-4 weeks for this drug (antidepressant) to start working, so after 4 weeks I will follow up with you again and we can reassess if this medication should be continued or stopped.
