Module 1.4 (Menopause) Flashcards

Question

How is diagnsosis of menopause done?

Answer 1

Measuring hormone levels is unhelpful n Diagnosis is via history taking (symptoms & changes in menstruation) n Perimenopause lasts on average 4 to 8 years **One year after the last menstrual period a woman is considered post-menopausal** Symptoms scores can be a useful diagnostic tool Differential diagnosis * Depression, anaemia and hypothyroidism are the most common conditions that mimic menopausal symptoms * SSRIs can cause hot flushes If a patient is taking hormonal treatments it can be difficult to know when menopause is reached \> HRT doesn't provide contraceptive cover. If women still ovulating there is a risk of pregnancy.

Answer 2

Non-pharmacological measure (lifestyle) Menopausal Hormone Treatments (MHT) Non hormone pharmacological treatments Complementary & alternative medicines (CAMs)

Answer 3

* Balanced and nutritious diet * Exercise * Relaxation \> women with healthy lifestyle appear to have fewer symptoms

Answer 4

* Quit smoking * ≤ 2 standard alcohol drinks per day and two alcohol free days per week * Reduce caffeine * Keep cool/wearing layers * Avoiding triggers of VMSs

Answer 5

Aim for 1300mg of dietary calcium Weight bearing physical exercise Adequate Vit D – follow sun exposure guideline Avoid excessive alcohol Stop smoking Avoid excessive caffeine

Answer 6

**oestrogens** * Conjugated oestrogens * Estradiol * Estriol **progestogens** * Medroxyprogesterone n * Norethisterone n * Levonorgestrel IUD n * Micronised progesterone **TSECs** * Bazedoxifene + conjugated oestrogens **tibolone** **testosterone**

Answer 7

Relieves symptoms including VMSs and urogenital atrophy caused by ↓ endogenous oestradiol production

Answer 8

Reduces risk of endometrial cancer associated with unopposed oestrogen

Answer 9

A) * Estrogen taken continuously * Recommended in women post-hysterectomy (no uterus therefore not at risk of uterine cancer) B) * Recommended in a women with uterus * Can be cyclical or continuous * \*Bazedoxifene continuous only \> last menstrual period under 2 years or withdrawal bleeds or spontaenous bleeding. Use daily estrogen and progesterone. C) * Suitable for postmenopausal women and women who have had a hysterectomy * Taken continuously * Alternative when progestogen-containing combined MHT is not tolerated * Also 1st line

Answer 10

A) Risk of VTE and stroke higher than transdermal B) * Levonorgestrel IUD instead of oral progestogen * Minimises systemic adverse effects * Can be prescribed in perimenopause → contraception; controls heavy bleeding C) * Creams, pessaries * Progestogen not usually necessary * Investigate if any irregular, heavy bleeding \> some systemic absorption can occur \> estrogen for urogenital symptoms = 1st line, lowest effective dose, D) * Gel or patch --\> smaller doses of estrogen can be used * Avoids 1st pass effects -- less side effects (e.g. nausea) * Breast cancer risk seems similar to oral * Can cause skin irritation * Risk of VTE and stroke lower

Answer 11

Choice of oestrogen dose depend upon how a woman’s symptoms respond * **Initiate therapy at a low or ultra low dose and then titrate upwards** * Aavailable as tablets, patches, gels and intravaginal

Answer 12

* Malabsorption * Risk or past history of VTE or DVT, migraine, untreated hypertension, significant liver disease, smokers, overweight.

Answer 13

Used in women who symptoms are predominantly genitourinary \> urinary frequency \> dysuria \> vaginal atrophy * Also used in women or whom systemic oestrogen therapy is contraindicated or ineffective. * Safety not assured when used in vaginal dryness and history of breast cancer --\> use non-hormal treatment like replense * Oestradiol \> effect oestriol

Answer 14

12 day course of progestine very 6 or 12 months --\> minimise risk of endometrial hyperplasia

Answer 15

Progestogens

Answer 16

* Cyclical regimens aim for predictable bleeding pattern --\> (10-14 days/month --\> give women predictable monthly bleeding patterns) * Continuous regimens aim for no bleeding --\> been in meopause for 2 years

Answer 17

True \> do ultrasound if longer than this and potentially hysterectomy

Answer 18

Breast tenderness, fluid retention, headache, depression, PMS like syndrome, acne may occur during progestogen phase of cyclical MHT

Answer 19

* Changing the progestogen * Reducing the dose (ensure endometrium is still protected) * Changing the route * Reducing the duration of progestogen to 10 days/month * Changing to a 3-monthly cyclical regimen * Changing to continous combined HRT if postmenopausal

Answer 20

* Mostly taken orally * Norethisterone is the only preparation reliably absorbed via skin and is available in a combined MHT patch **with estrogen** * Micronised progesterone capsules are a form of “natural” or “ body identical” progesterone that is thought to be better tolerated \> more favourable breast safety profile \> neutral with CVD \> does not cause adverse mood effects * Levonorgestrol IUD is an alternative method to deliver progestogen directly to the endometrium

Answer 21

* = SERM (selective estrogen receptor modulator) + oestrogen * E.g. bazedoxifene and conjugated equine oestrogen (Duavive®) SERM exert different effects on different tissues \> agonists in some tissues \> antagonists in others **Effects one endometrium** * First generation SERMs (e.g. clomiphene and tamoxifen) stimulate the endometrium * Newer SERMs (e.g. raloxifene and bazedoxifene) attenuate the proliferative effects of oestrogen on the endometrium

Answer 22

Progestogen not required as bazedoxifene protects endometrium * Alleviates VMSs, ↓ vulvovaginal atrophy, improves BMD at hip and spine * Neutral effects on breast and endometrium **Indication** * May be an option when progestogen MHT is not tolerated * Short term treatment for relief of menopausal symptoms

Answer 23

* New drug and unreported adverse effects or interactions may occur * **Increased risk of VTE has been reported for both oestrogens and SERMs** \> no additive effects observed on risk of VTE with TESC but true risk unknown \> contraindicated in a women with a history of VTE \> avoid in women at high risk of VTE

Answer 24

A synthetic steroid used as an alternative to combined MHT * Oestrogenic → vagina, bone and thermoregulatory centres = helps with hot flushes and bone loss * Anti-oestrogenic and progestogenic → breast and endometrium * Androgenic → ↓ total chol, HDL, LDL and triglycerides \> positive effects seen on mood and libido

Answer 25

Periomenopausal women \> risk of breakthrough bleeding

Answer 26

Relief of menopausal symptoms – short term 2nd line for post-menopausal osteoporosis

Answer 27

* ↑ risk of breast cancer recurring * Doubles risk of stroke in women \>60 years (those with HTN, stroke, AF and diabetes) * History of endometriosis * ? SLE * Surgery (immobilization) * Bleeding that persists \>6 months Avoid tibolone in older women esp \>70 years old and those at increased risk of stroke

Answer 28

* Cerebrovascular disease n * Coronary artery disease n * Breast cancer n * Severe liver disease ## Footnote **2nd lined drug**

Answer 29

**unclear evidence**

Answer 30

Used in women with low testosterone who are experiencing lack or libido, lack of energy and ongoing fatigue * Used with oestrogen most often for lack of libido * No proven link between testosterone levels and symptoms

Answer 31

Oily skin, acne, excessive facial and body hair, scalp hair loss, irritability, aggression **serious side effects:** deepening of the voice, enlarged clitoris (both irreversible), ?breast cancer, ?endometrial stimulation, ?lipids \> No form of testosterone therapy for women is officially approved in Australia by the TGA

Answer 32

1st line - venlafaxine 37.5 to 75mg daily (also desvenlafaxine) 2nd line - paroxetine 10 to 20mg daily (also escitalopram) --\> **interacts with tamoxifen. paroxetine/fluoxtine reduces efficacy of tamoxifen.** 3rd line – gabapentin 100 to 300mg daily 4th line – clonidine 25 to 50mg twice daily \> Consider effectiveness, side effects, potential interactions * SNRIs, SSRIs → sexual dysfunction, drug interactions * Gabapentin → well tolerated * Clonidine → dry mouth, drowsiness and effect on BP

Answer 33

* Vaginal dryness * First line therapy is non-hormonal preparations \> moisturisers e.g. replens and sylk * If non hormonal, topical treatments are ineffective low dose vaginal oestrogens can be prescribed.

Answer 34

**Refers to compounded products marketed as hormones identical to those produced in the body** \> natural estrogen = estradiol \> natural progestin = progesterone * Concerns about safety of MHT saw an interest in bioidentical hormones develop * Lack of studies re safety \> Not endorsed by AMS \> Concern about lack of protection for endometrial hyperplasia and neoplasia \> Unregulated manufacturing conditions \> Salivary hormone testing unreliable

Answer 35

* Topical progesterone creams marketed to reduce osteoporosis * Have inadequate absorption * If used with oestrogen may result in serious unopposed oestrogenic side effects

Answer 36

* Originally marketed as containing progesterone but this is not the case * Contain diosgenin which can be used to synthesise progesterone

Answer 37

Limited and conflicting research * May be useful for hot flushes, ?benefits on bone health, ?lower LDL cholesterol * May take 3 months daily use to ↓ hot flushes

Answer 38

* Adverse effects – myalgia, headaches, prolonged menstrual cycle * In vitro studies suggest that red clover can inhibit CYP1A2, CYP2C8, CYP2C9, CYP2C19, CYP2D6 and CYP3A4 * May inhibit P-glycoprotein → reduces absorption of drugs * Red clover may have oestrogenic activity \> May interfere with hormonal contraceptives \> May ↑ risk of thrombosis due to estrogenic activity \> Methorexate toxicity with red clover?

Answer 39

Affects serotonin and dopamine * May cause improvements in VMSs * Unclear if helps hot flushes in breast cancer patients but no association between black cohosh and ↑ breast cancer risk * May alter efficacy and toxicity of cancer chemotherapy * May take 3 months of daily use to improve menopausal symptoms

Answer 40

May cause liver damage (rare) * Associated with cases of liver failure and hepatitis * **Watch for symptoms of liver damage including: nausea, vomiting, loss of appetite, abdominal pain, diarrhoea, weightloss, tiredness and yellow discolouration of the skin or eyes** * Other adverse effects: GI symptoms, rash dizziness, headache, tiredness, weight gain, breast pain, vaginal spotting, musculoskeletal complaints \> Black cohosh may harm the liver in some individuals. Use under the supervision of a healthcare professional.”

Answer 41

Oestrogen is the most effective treatment available for the relief of menopausal symptoms * Hot flushes * Vaginal dryness * Dypareunia \> need to consider patient individual risks and benefits

Answer 42

Recommended to calculate cardiovascular risk and breast cancer risk prior to commencing therapy * Benefits outweighs risks if initiated for symptomatic women before the age of 60 years or 10 Years after menopause

Answer 43

Oestrogen alone

Answer 44

In patients who have a uterus

Answer 45

**_to relieve menopausal symptoms_** * In the past menopausal hormone treatments (MHT) were used to prevent \> coronary heart disease (CHD) \> osteoporosis **NO LONGER RECOMMENDED for disease prevention** \> due to results of womens health initiative --\> unfavourable risk/benefit profile of MHT for this use

Answer 46

Yes * Need to assess patient CV risk before commencing MHT

Answer 47

* **Risk not increased if MHT commenced under 60 years** * Mortality from CV disease not increased * **_Presence of CV risk factors is not a contraindication to MHT_** * Oestrogen alone therapy is associated with no or ↓ risk of CV disease * Oestrogen + progestogen associated with little or no ↑ risk of CHD * Oral (but not transdermal) oestrogen is associated with a small ↑ in stroke risk (but baseline risk under 60 years is low)

Answer 48

**Oral estrogen is associated with an ↑ risk of VTE (2-4 fold)** Absolute risk is small for women \< 60 years old --\> individuals have different risk factors * Transdermal estrogen is preferred for women at increased risk of VTE, i.e. smokers, obese \> bypasses first pass metabolism

Answer 49

The baseline risk of breast cancer for women around menopausal age varies from one woman to another * MHT with oestrogen alone is associated with little or no change in the risk of breast cancer * HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer and in women without hystrecetomy * **Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping MHT.**

Answer 50

Menopausal symptoms can arise because * Cancer treatments induce menopause * **MHT is stopped with the diagnosis of cancer** * Endocrine therapies commenced (eg tamoxifen, aromatase inhibitors) \> symptoms similar to natural menopause \> added psychological component of the woman's response to her cancer diagnosis * Non hormone therapies may be helpful however paroxetine should be avoided in patients on tamoxife

Answer 51

Combination, tibolone, TSECS MHT effective in the prevention of bone loss in postmenopausal woman * ↓ risk of hip, vertebral and other osteoporosis-related fractures in post-menopausal women * Only therapy to ↓ risk of fracture in women with low fracture risk (T-scores normal to osteopoenic) * However, ↓ fracture risk is lost a few years after stopping \> this is an issue because patients \>70 need it as fracture risk is higher but wont be on because sx of menopause last until 65.

Answer 52

MHT can be initiated in postmenopausal women at risk of fracture or osteoporosis \<60 years (or within 10 years of menopause)

Answer 53

Benefits dont outweight their risks such as VTE, stroke and breast cancer

Answer 54

* ↑ risk CVD * ↑ risk of osteoporosis * ↑ risk affective disorders and dementia

Answer 55

* ↓ risk of heart disease * Longer lifespan * May prevent Alzheimer’s disease in later life * May improve depressive/anxiety symptoms but antidepressants 1st line

Answer 56

* In women requiring combined MHT, the use of a neutral progestogen such as micronised progesterone or dydrogesterone may be associated with lower risks of breast cancer and VTE * Each women's individual risks and needs should be assessed before initiating therapy * Initiation of menopausal hormone therapy (MHT) a safe option for healthy, symptomatic women who are within 10 years of menopause or younger than age 60 years and who do not have contraindications to MHT CI include * Breast cancer n * Cerebrovascular disease (stroke) or coronary artery disease n * History of thromboembolic disease (VTE) n * Active liver disease n * Unexplained vaginal bleeding \> Estrogen-progestin therapy – intact uterus \> Unopposed estrogen - post-hysterectomy \> Vaginal atrophy symptoms only - vaginal estrogen

Module 1.4 (Menopause) Flashcards

(81 cards)