Treatment of Menopause and Perimenopause

If a patient decides to use a transdermal route of estrogen and they divide to use a estradiol transdermal spray what are some counseling types to provide the patient?

1. Avoid children or pets touching the skin 2. Want to spray from the wrist to the forearm 3. Don't want to have contact with treated skin 30 minutes after application 3. After 2 minutes than the women can wear a garment that covers the treated skin 4. If contact occurs with children than we need to was the child's skin with soap and water immediately 5. Watch for signs of estrogen effects (nipple swelling and breast enlargement)

What are examples of commonly compounded BHT?

1. Bi-est which is 80% estriol and 10% estrone 2. Tri-est which is 80% estriol, 10% estradiol, and 10% estrone

What are some common ADRs for using estrogens?

1. Bleeding 2. Breast tenderness 3. Bloating 4. Premenstrual-Like symptoms 5. Nausea 6. HA

What are some common ADRs for using progestins?

1. Breast Tenderness 2. Weight Gain 3. Edema 4. PMS-like symptoms 5. Depression 6. Irritability

How should we counsel a women on how to treat vasomotor symptoms?

1. Dress in layers 2. Avoid hot and spicy foods as well as alcohol and caffeine as these may exacerbate hot flashes 3. Deep breathing/ stress reduction techniques

What are absolute contraindications for Hormonal Replacement Therapy?

1. Endometrial cancer 2. Breast cancer 3. Undiagnosed vaginal bleeding 4. Recent Venous Thromboembolism 5. Active liver disease

What is a regimen for treating androgen deficiency?

1. Esterified estrogen + 1.25 or 2.5mg of Methyltestsoterone

What is the regimen for continuous therapy?

1. Estrogen + progestin everyday

What are the 4 types of estrogens that are bioidentical?

1. Ethinyl Estradiol 2. Micronized Estradiol 3. 17beta-estradiol 4. Esterified Estrogens

A women comes in complaining of insomnia due to her menopause. What are some things you can tell her to help treat this symptom?

1. Exercise earlier in the day 2. OTC sleep aids 3. Hot shower or bath immediately before bed 4. Milk products

Androgen deficiency can occur in menopause. What are the symptoms that a women might have estrogen deficiency?

1. Fatigue 2. Decrease sense of well being 3. Sexual function changes

65% of women stopped HRT in 2002, but 1 in 4 started to come back to this type of therapy. Why?

1. Has the best relief of symptoms 2. Patients are willing to take the benefits over the risks 3. The follow-up reports regarding WHI, brought uncertainty about the results

What are the most common menopausal symptoms?

1. Hot flashes 2. Amenorrhea 3. Decrease BMD 4. Urogenital Atrophy

What are the ADRs of Evista?

1. Hot flashes 2. Migraines 3. Leg cramps 4. Weight gain

What are some common adverse reactions of women taking progestins?

1. Irritability 2. Depression 3. Headache

What are considered to be under phytoestrogens?

1. Isoflavones 2. Lignans 3. Coumestans

What is the case that is against promoting BHT as safer and more efficacious than MHT?

1. Manufactured Hormone Therapy is approved by the FDA as safe and effective 2. The quality and purity is in the hands of manufacturers that are federally regulated 3. There are many studies and publications on MHT

What are the counseling points for Ospemifene?

1. Need to take once daily with food 2. Boxed warning for endometrial stimulation due to being an endometrial agonist 3. Could lead to DVT and stroke

A patient wants to take a Home Menopausal test to measure their FSH levels to determine if they had went through menopause. What are some counseling tips?

1. Need to use first morning urine 2. Need to retest in 1-2 weeks due to fluctuations in pre-menopausal women 3. Followup with physician to determine other important signs of menopause

Do we need to add progestins if estrogen is used through the vaginal route?

1. No if using a low dose micronized beta-estradoil 2. Yes if we use CEE vaginal creams or other products that may stimulate uterine proliferation

What are some examples of non hormonal therapies that can be used to treat vasomotor symptoms?

1. SNRI--Venalfaxine 75mg 2. SSRI--Paroxetine 7.5mg at bedtime 3. Gabapentin--high dose (900mg) 4. Clonidine--.1-.2mg 5. High dose MPA--20mg/day; ADRs not really tolerated by patients

What are lifestyle modifications that you can counsel a women going through menopause

1. Smoking cessation since it increases the symptoms associated with menopause 2. Decrease caffeine and alcohol intake 3. Increase exercise

If treating someone going through perimenopause what are the steps that need to be taken?

1. Start on a low dose COC 2. After 1-2 years, if severe hot flashes continue than need to switch to cyclic HT 3. If there is excessive bleeding than need to restart the patient on COC for an additional year and then switch to HT (if they patient is still bleeding than she hasn't gone through menopause yet)

There were many issues surrounding the WHI that make results less accurate. What were they?

1. The average study population used in WHI was 63 years and usually the average onset of menopause is about 51 2. Only 1:6 patients were within 5 years of menopause 3. Most patients did not show signs of having symptoms of menopause at all 4. The only products that were used was Prempro (estrogen +progestin) 0.0625/2.5mg and Premarin(estrogen only) (0.625mg)

What are the serious ADRs that come from taking HT?

1. There could be an increase risk of endometrial cancer 2. Venous Thromboembolism 3. Gallbladder Disease

What are selective estrogen receptor modulators?

1. These are estrogens that bind to estrogen receptors and can function as an agonist or antagonist at certain tissues

What is the case that is for promoting BHT as safer and more efficacious than MHT?

1. These are natural products that are preferred over synthetic products 2. They are chemical identical to hormones in the body 3. They are custom made with a broad selection of doses and combinations 4. High touche therapy meaning the patients are well educated and monitored on this type of therapy

The use of oral Hormone therapy is associated with an increase risk of what two disease states?

1. Venous Thromboembolism 2. Ischemic Stroke

When is menopause usually diagnosed?

12 months from the last period when the person crosses over from perimenopausal to postmenopausal.

What bioidentical hormone is not orally effective and has to be given transderamally?

17B-estradiol

What is used to treat post-menopausal dyspareunia?

A SERM known as Ospemifene to treat dyspareunia caused by vulvovaginal atrophy

What are the two main reasons that the WHI was stopped?

An increase risk of breast cancer(HRT) and stroke(ERT)

What is the top selling natural product for treating menopause?

Black Cohosh because it showed to be equal to a low dose patch for hot flashes

What natural product effects dopamine and acetylcholine levels and might help in PMS symptoms?

Chasteberry

Premarin or Prempro is considered to be what kind of estrogen?

Conjugated Equine Estrogens that come from a pregnant mares urine

What are common ADRs of using phytoestrogens?

Constipation, bloating, and nausea

What is another advantage of COCs besides a decrease in bleeding and vasomotor symptoms?

Contraception

What natural product must be not ever recommend?

Dong Quai

This hormone is a major contributor to bone health and during menopause is most likely reason for a decrease in bone mass density

Estrogen

When is ERT appropriate and when is HRT appropriate?

Estrogen only therapy is appropriate for women who has had a hysterectomy and estrogen + progestin therapy is appropriate for women who still have their uterus

This hormone is increased at menopause.

FSH

T/F: Hormone replacement therapy is a high enough hormone to keep the patient from ovulating.

False

T/F: If a women is using a transdermal estrogen product the will not need a progestin to go with it if they have an intact uterus

False--still need to have progestin

When is local low-dose estrogen therapy preferred?

For women whose symptoms are limited to vaginal dryness or associated discomfort with intercourse

Most patients usually start on a low dose estrogen (about .45mg-.3mg) except in what case?

If that patient has had surgically induced early menopause than we can start them on a higher dose

When should a patient be placed on continuous therapy?

If the patient is experiencing irregular bleeding for 6-12 months

When should we refer to a patient to be checked for possible endometrial cancer?

If the patient starts bleeding after a period of amenorrhea, if the patient has heavier than normal bleeding or bleeding that is not expected

When is a patient considered to be perimenopausal?

If they are still menstruating and experiencing vasomotor symptoms

Why is FSH levels so high when a person is undergoing menopause?

In menopause the womens eggs are no longer functional and there is not ovulation. FSH stimulates the eggs to develop that produces estrogens. Since the women in menopause is not producing a mature egg each month and there is no estrogen produced than there is no negative feedback at the pituitary, thus FSH levels remain high

Can wild yam be used for menopausal symptoms?

It has been shown to be converted to synthetic estrogens in the lab, but not in the human body

What is the first line treatment for Perimenopause?

Low-dose combined oral contraceptives to suppress the menstrual cycling and decrease the bleeding; should only be used safely in women up to age 55

What types of patients should be started on cyclic therapy?

Newly diagnosed patients or patients with bleeding problems.

Is the use of bioidentical hormone therapy recommended for the treatment of menopause?

No

What medication is approved for treating moderate-to-severe dyspareunia (painful intercourse)?

Ospemifene

What is the typical FSH levels pre-menopausal and post-menopausal?

Pre-menopausal its 5-25 mIU/ml and post-menopausal its greater than 40 mIU/ml

DHEA?

Probably too soon to recommend for menopausal symptoms

What is the regimen for long cycle therapy?

Progestin added to estrogen every other month for 12-14 days; decreases the number of periods, but periods could be heavier

What is the regimen for an intermittent cycle therapy?

Pulse therapy of 3 days of estrogen followed by 3 days of estrogen + progestin

What are the 2 main goals of pharmacologic therapy?

Should be short term and lowest effective dose

What are examples of natural products used in bioidentical therapy?

Soy and Yams

What are the common dosage forms of bioidentical hormones?

Suppositories, troches, transdermal, and vaginal capsules

What happens if we start HT while the patient is still menstruating or they are recently menopausal?

That might lead to unpredictable estrogen levels, irregular bleeding and risk of pregnancy

What was the purpose of the Womens Health Initiative?

The purpose was to define risks and benefits of intervention to decrease heart disease, breast, and colorectal cancer, and osteoporotic fractures in postmenopausal women

What are Phytoestrogens?

These are estrogens that come from plant sources like yams and sorry and are commonly found in food

What is the MOA of Phytoestrogens?

They bind to estrogen receptors and they can have either an agonist or antagonist effect, but they are not as potent as naturally occurring estrogens

What is Duavee?

This is a combination of CEE and bazedoxifene, a SERM that reduces the risk for endometrial hyperplasia that is used for the treatment of vasomotor symptoms in women with a uterus

What is bioidentical hormone therapy?

This is hormones that are identical to naturally produced hormones; the source of estrogen is a natural product and its usually made through compounding; usually individualized therapy

What is the regimen for cyclic therapy?

This is taking an estrogen + progestin for 12 days minimum (estrogen is given alone for a month with progestin added in for 12 days)

What is significant about red clover when patients want to use this for hot flashes?

This may be additive to warfarin and increase the risk of bleeding

What does Raloxifine (Evista) do?

This medication decreases bone loss (agonist at bone), has no effect on the endometrium (antagonist at the endometrium), and has estrogenic action on lipids, but does carry a risk for VTE

T/F: Duavee can be used to prevent osteoporosis in women with significant risk factors?

True

What is the most serious symptom for women that are going through menopause?

Vasomotor symptoms or hot flashes

When would HRT therapy most likely outweigh the risks?

When the women is less than 60 years old and within 10 years of menopause

An increase in breast cancer is primarily due to what?

When you have an addition of progestin to estrogen therapy and the duration of hormone use

Can a higher dose of vaginal estrogen give a systemic effect?

Yes

Is systemic Hormone Therapy recommended in patients with premature ovarian insufficiency (premature menopause)?

Yes at least until the average age of natural menopause

Is transdermal therapy risks greater, the same, or less than oral HRT?

less than

What is the safest recommendation for using phytoestrogens?

use food sources and not high dose supplement products