Menopause and Perimenopause

Low dose COCs can be used for ___years in non-smokers for the treatment of perimenopause

1-2 years

Progestins must be used a minimum of __ days/month

10-14 (Patient DOES NOT need to take them every day of the month to get protection)

Are phytoestrogens weaker or stronger than estrogen?

100-10,000 times weaker Can act like SERMS or estrogen

What is the average age for menopause?

51

What we the positive results from WHI data at 5 years?

6 fewer cases of colorectal cancers 5 fewer hip fractures

The continuos regimen will cause irregular bleeding for first ____

6-12 months, this is why they start patients on cyclic generally then switch you to continuos

What are the common compounded BHRT strengths and combinations?

Bi-est- 80% estriol ad 20% estradiol Tri-est- 80% estriol, 10% estradiol, and 10% estrone

Definition ___- contains hormones identical to naturally produced hormones

Bioidentical

What are some common ADRs associated with estrogens?

Bleeding- return of regular periods Breast tenderness Bloating Pre-menstrual symptoms N/HA

What are some Serious ADRs associated with HRT?

Breast cancer Endometrial cancer Gallbladder disease VTE CVD and dementia?

What are some common ADRs associated with Progestins?

Breast tenderness Weight gain Edema PMS Depression Irritability

If you switch perimenopause patient to HRT and excessive bleeding occurs, restart patient on __ for how long then switch to HRT

COC For additional year

What kinds of things may alter FSH level test results?

COCs HRT, ovarian and pituitary tumors

What are risk of using HRT?

CVD Breast cancer Endometrial cancer VTE

Can wild yam be converted to hormones?

Can be converted in the lab, but NOT in the body

___ is a herb promoted for menopause. It affects DA and ACh; may help with PMS symptoms

Chasteberry

What are some of the common ADRs to phytoestrogens?

Constipation, bloating, nausea

What type of dosing regimen generally has better compliance for patients on progestins?

Continous Take both estrogen and progestin every day

What type of regimen are newly diagnosed patients or patients with bleeding problems typically proscribed for taking progestins?

Cyclic - They may have withdrawal bleeding but it will be lighter and predictable and go away after some time

Chasteberry effect __ and __ . May be helpful with PMS symptoms

DA ACh

What is your reccomendation to using DONG QUAI?

DO NOT TAKE IT, may contain carcinogens, not shown effective

What are some ADRs of Ospemifene (Osphena)?

DVT, Stroke - lower risk than estrogen along Hot flashes also possible

What is important to note about the dosage forms of BHRT?

Dosage forms avoid oral absorption and gastric acid, These compounds are not orally acitve they will be broken down Dosage forms: Supp, Troches, Transdermal, vaginal, capsules

What are some lifestyle modifications that would help with vasomotor symptoms?

Dress in layers Avoid hot and spicy foods, alcohol and caffiene, deep breathing/stress reduction, meditation

What are some absolute contraindications to using HRT?

Endometrial cancer Breast cancer Undiagnosed vaginal bleeding Recent VTE Active liver disease

What is the common regimen for androgen deficiency during menopause?

Estrified estrogen + 1.25 or 2.5mg methyltestosterone

What estrogens are safer?

Ethinyl estradiol Micronized estradiol 17 Beta estradiol Esterified estrogen -Much more similar to what the female normally produces

What is a risk of estradiol transdermal spray?

FDA advisory was issued -Childern age 3-5 were exposed -Nipple swelling and breast enlargement resulted Can occur from touching medicated skin Problems resolved when exposure stopped

Deficiency of androgens may occur in menopause. Symptoms include?

Fatigue Decrease sense of well-being Sexual function changes

What are the relative contraindications to HRT?

Fibroids Migraines Seizures Hypertriglyeridemia History of liver disease Gall-bladder disease

__ is the number one reason that patients seek treatment for menopause

Hot flashes

What are some common menopause symptoms?

Hot flashes, amenorrhea, decreased BMD, urogenital atrophy

What are some ADRs associated with Evista?

Hot flashes, migraines, leg cramps, weight gain (Related to antagonists side)

What progestin regimen has the least progestin side effects?

Intermittent

__,__, __ and __ have estrogenic effects but are not shown to be effective for menopause

Kudzu, alfalfa, Hops, licorice

What are some therapeutic treatment options for menopause?

Lifestyle modification Hormonal therapies Symptomatic relief Alternative products

What progestin dosing regimen decreases the number of periods but period may be heavier

Long Cycle

What are some treatment options for perimenopause?

Low dose OC (Unless the patient is a smoker or obese)

Herbs and supplements may/may not be safer?

MAY NOT

What are some things do you need to know to assist a patient in her decision for treatment?

Medical Hx Family Hx Social Hx Physical Exam Test Results Lab Results Share pros and cons of HRT

Are SERMs steroidal?

NON-Steroidal compounds

Which of the non-hormonal therapies is more effective then estrogen for treating vasomotor symptoms?

None of them

What is the newly approved drug for postmenopausal Dyspareunia?

Ospemifene (Osphena)

___ is characterized by fluctating changes in menstrual cycle due to the fact that as ovaries are getting older the patient will not ovulate eahc month and leads to different hormone levels

Perimenopause

What are the most common natural products for menopausal symptoms?

Phytoestrogens Herbs Bioidentical Hormones

What are the remedies to avoid exposure to estradiol transdermal spray?

Prevent contact with treated skin for 30 minutes after application Wear garment that covers treated area (after 2 mins)

Describe the Long Cycle regimen to taking progestins?

Progestin added to estrogen every other month for 12-14 days

__ are used for women with an intact uterus.

Progestins

The Ideal SERM would have what characteristics?

Protect against osteoporosis No effect on breast, endometrium No menopausal like ADRs (No SERM currently meets these needs)

Describe the Intermittent regimen to taking progestins?

Pulsed therapy of 3 days estrogen followed by 3 days of estrogen and progestin

Name a SERM?

Raloxifene (Evista)

What are some other herbs that are promoted for menopause?

Red clover Flaxseed Black cohosh Dong quai Chasteberry DHEA

If post-menopausal woman is receiving HR and if with no cause she starts to have vaginal bleeding. What should you do and why?

Refer to doctor to check for endometrial cancer. Serious ADR of HRT

What are some of the benefits to using HRT?

Relief of vasomotor symptoms Protect from osteoporosis Protect from colon cancer Relief of mood disorder, vaginal dryness, incontinence, insomnia

If a patient has decided to try Black Cohosh what product should you recommend to them. Do not confuse with?

Remifemin (study demonstrated effectiveness equal to low dose patch for hot flashes) Blue or white Cohosh- TOXIC

Menopause is diagnosed ___

Retrospecitvely After 12 months of amenorrhea

Name some non-hormonal therapies for vasomotor symptoms?

SNRI- Venlafaxine SSRI- Paroxetine and fluoxetine Gabapentin-High dose (900mg) Clonidine-bothersome ADRs High dose MPA (These are all Off-Label Uses)

Lifestyle modification for menopause?

Smoking cessation Increase exercise OTC vaginal lubricants and moisturizers

__ or other ____ MAY help MODERATELY. What sources are preferred

Soy Phytoestrogens Food sources preferred

Since WHI report, 1 in 4 women have returned to HRT, Why?

Still offers best relief of symptoms Willing to take the risk Follow-up reports of WHI

IF child is exposed to estradiol transdermal spray?

Wash child's skin with soap and water immediately Watch for signs of estrogen effect

DHEA may increase risk of __ cancer. May raise __ levels and cause __ ADRs

breast testosterone androgenic

The HRT arm of the WHI study was terminated in 2002 due to increase cases of ___

breast cancer

HRT is NOT recommended as a sole or primary indication for ____ in women of ANY age

coronary protection

After 1-2 years of perimenopause treatment with low dose COCs, if patient is still experiencing severe hot flashes, switch to ___

cyclic HRT

Evista ___ bone loss, __ effect on endometrium, estrogenic actions on ____, __ risk of VTE similar to ___

decreases no lipids increased CEE

Ospemifene (Osphena) has what black boxed warning?

endometrial stimulation (It is an imperfect SERM)

BHRT are manufactured products containing __ and __

estradiol progesterone

Describe Cyclic dosing of Progestins?

estrogen + progestin for 12 day minimum. Then the rest of the month you just take estrogen

Transdermal delivery avoids ___ and you do not stimulate ____. Thus it may be better for patients at risk for ____

first pass metabolism clotting factors thrombotic effects

The purpose of the WHI was to define risk and benefits of interventions to decrease ___, __ and __ in postmenopausal women

heart disease breast and colorectal cancer osteoprotic fractures

Perimenopause occurs at what age?

in late 40s

The Current Recommendations HRT in the ______dose with endometrial protectin is recommended in menopausal and postmenopausal women for ___, __, and ____ and cardiovascular protection in younger women aged ___ years

lowest effective vasomotor symptoms, vaginal atrophy, and bone loss prevention 50 to 59

Decision to use HRT is __ choice in conjunction with ___

patient health professional

Period of time prior to actual menopause is called ___

perimenopause

Phytoestrogens are ___

plant estrogens- isoflavones, lignans, coumestans

What are the goals of therapy for treating menopause?

relive menopausal symptoms Enhance QOL Reduce morbidity/mortalility assocaited with sex-hormone deficiency -> Bone loss,CV disease, and DM

FSH levels ___ at menopause due to ____

rise relief of negative feeback (no estrogen to feedback so more and more is made)

Natural products used to make BHRT include __ and __

soy yam

The ERT arm of the WHI was terminated in 2004 due to increased risk of ___

stroke

HRT in menopausal and postmenpausal women is NOT reommended for __, cardiovascular protection in women older than ___, treatment of ___, prevention of __ decline or ___, or prevention of __ gain.

stroke prevention 50 depression cognitive or dementia weight

Vaginal can have a __ or __ effect depending on what?

systemic or local Depending on the dose used

Starting HRT will still menstruating or recently menopausal (within 6 months) leads to ____, __, and risk of ___

unpredictable estrogen levels irregular bleeding pregnancy

What is the sagest recommendation with regards to phytoestrogens?

use food sources not high dose supplements

Dyspareunia is caused by what in menopausal women?

vulvovaginal atrophy